Hand & Wrist Injuries Flashcards
What is dupuytrens contracture?
Thickening of subdermal fascia of palm -> fixed flexion deformity of fingers
What is Dupuytrens contracture?
Thickening of subdermal fascia of palm > fixed flexion deformity of fingers
What causes Dupuytrens and what is the pathophysiology ?
Causes:
Genetic predisposition
Diabetes
Cirrhosis 2ndary to alcohol
Smoking
Repeat trauma
Epilepsy and associated meds
Pathophysiology:
Excess myofibroblast proliferation + altered collagen matrix → thickened palmar fascia
DOESNT INVOLVE TENDONS
What is the presentation of dupuytrens
How is it managed and what are the complications?
Obvious presentation, usually starts as pit nodule -> nghabbou aalik finger
Table top test- unable to flatten hand on table
Managed with conservative stretches or collagenase injections, or surgery (fasciotomy) if very bad
DUPUYTRENS DIATHESIS -> severe form that also involves foot and penis
PIPJ dislocation-
Cause
Presentation
Management
Complications
very common injury
Presents with pain and visible deformity in affected digit- X-ray for possible fracture
Treat via fixation and stabilisation
Must be treated ASAP- delayed treatment will lead to degeneration of articular surface
What is a boxers fracture and what is the common cause
Fracture of the 5th metacarpal neck (pinky)
Clenched fist punching hard object- hence name
How does a boxers fracture present?
How is it investigated?
How is it managed?
Dorsal hand pain, swelling, possible deformity
Possible finger shortening due to anterior displacement
X-ray AP LAT and oblique
managed with buddy strap
What is a Bennett’s fracture and what causes it?
1st metacarpal base fracture
Caused by forced thumb hyperabduction (axial force)
How is a Bennett’s fracture present, and how are they investigated and managed?
Acute pain, tenderness and swelling at thumb base
X-RAY AP and LAT
Surgical reduction and fragment realignment- common to have K wires
What is a key complication of a Bennett’s fracture?
Fracture may extend to 1st carpometacarpal joint
This leads to instability and subluxation of joint- may predispose to arthritis
What is trigger finger
+aetiology
A1 pulley mechanical impingement -> smooth tendon gliding inhibition
More common in females, over 50s
Higher risk in diabetes
Pathophysiology of trigger finger
A1 pulley inflammation and stenosis
Leads to fibrocartilagenous metaplasia (further swelling)
Leads to a nodule which prevents smooth gliding, locking finger in flex position
How does trigger finger present and how is it managed?
pain, clicking, catching
Pain over a1 pulley (MC head)
Finger stuck in flexion, nodule may be palpable
May resolve spontaneously but splinting is good to prevent flexion
Steroid injections highly effective in early cases
What is paronychia, and what causes it?
Nail fold infection, common in younger patients, associated with nail biting
How does paronychia present and how is it managed?
Redness and inflammation around fingertip, possible pus collection
Managed via elevation
Antibiotics
Incision and drainage if needed
What is a flexor tendon sheath infection?
+aetiology
Infection within tendon sheath, tracking up palm + arm
Usually caused by a penetrating wound like a stab
Haematogenous spread- dental infection is common
How do flexor tendon sheath infections present, and how are they investigation, management?
Extreme pain and movement restriction
Kanavels cardinal signs:
-affected finger held in flexion
-fusiform swelling over finger
-painful percussion
Investigated via X-rays, drainage culture
Managed with emergency surgical washout, and antibiotics
What causes flexor tendon injuries, and how are they classified
Usually volar lacerations, classified via zones
Zone 2 is zone between fingertips and lumbricals- called no mans land because its hard to treat
How do flexor tendon injuries present, and how are they investigated and managed?
Loss of active strength and motion in fingers
Plus visible causative injuries
Investigated with X-ray for suspected fractures, and US for soft tissue injury
Managed with conservative wound care and surgical reconstruction if tendons severely affected
What is mallet finger and how is it caused?
Avulsion of extensor tendon of distal phalynx -> inability to actively extend DIPJ (flexion deformity)
Caused by object hitting tip of finger or thumb, force of blow tearing extensor tendon
How would mallet finger present and how is it treated?
Tenderness, bruising, no resisted finger extension on examination
Managed with mallet splint if joint is congruent
If joint is not congruent reduce and fixate (k wires)
Note- non congruent joints will predispose to OA
Chronic -> Dermatotenodesis
What causes an extensor pollicus longus rupture
How does it present
How is it treated
Can occur with RA, or secondary to Colles fracture
Substantial function loss, can’t extend thumb at MCP/IPJ
If preceding synovitis from RA is caught, synovectomy can prevent rupture
If ruptured, tendon transfer is needed
What is carpal tunnel syndrome?
Peripheral neuropathy caused by acute or chronic compression of the median nerve by the transverse carpal ligament
What causes carpal tunnel syndrome?
Women 8x more likely than men
Idiopathic
Can be due to underlying diabetes, hypothyroidism, obesity, RA
Pathophysiology of carpal tunnel
Median nerve innervates first 3 fingers, and LOAF muscles (lateral lumbricals, opponents pollicis, abductor pollicis brevis, flexor pollicis brevis)
Carpal tunnel may compression median nerve
How does CTS present and how is it diagnosed?
Pins and needles
Pain and clumsiness
Numbness and weakness in late stage
Functional issues- driving, using phone, computer mouse, reading
Thenar atrophy and altered sensation
Diagnosed with clinical features and tests-
Tinels test- median nerve percussion
Phalens test- holding wrists flexed exacerbates pain
How is CTS managed?
Splinting
Physio
NSAIDs/Steroids
Surgical decompression if very bad
What is De quervains tenosynovitis
+ aetiology
Inflammation of the tendon sheaths within the first compartment - contains APL and EPB
Spontaneous, tends to affect women 30-50 yrs and associated with pregnancy and RA
How does DQT present and how is it investigated and managed?
Swollen red and painful wrist
finklesteins test- fist made and ulnar deviation exacerbates pain
USS and XR rules out OA due to similar presentation
Managed with rest, splinting, physio, NSAIDs, steroids
Surgical decompression if very bad
Aetiology of a scaphoid fracture
Most frequently fractured carpal bone
Caused by FOOSH
How does a scaphoid fracture present and how is it investigated?
Snuffbox pain
Hard to spot so multi angle X-ray must be taken
Can do repeat X-ray after 10 days, or MRI if pain persists but nothing is found
How are scaphoid fractures managed and what is a potential complication?
Conservative- cast
Surgical- ORIF and screws
Complication-> only half on scaphoid is vascularised, so if it fragments it could result in AVN and non union
What causes distal radius fractures, and how do they commonly present?
FOOSH
Pain and swelling, and deformity in the wrist
Ecchymosis, diffuse tenderness, limited motion
What are the 3 main types of distal radius fracture?
Colles- dorsal displacement, upside down fork like
Smith- volar displacement, spade like
Barton- intraarticular
What investigations are done in a distal radius fracture
X-ray- AP Lat oblique
CT- evaluate intra-articular involvement (which needs surgery)
MRI- evaluates surrounding soft tissue injury
How are distal radius fractures managed?
in most cases Colles and Smith can be managed conservatively ie with a cast
Barton is more severe and often requires ORIF, or wires
What are some complications of a Colles fracture?
Possible median nerve compression or bleeding into carpal tunnel
Some fractures may heal in a poor position which may result in impaired grip strength
