Hand + Wrist Pathology Flashcards
What do scaphoid fractures result from?
- Common + easily missed on X-ray
- Results from a fall on the hand (FOOSH)
- Contact sports (football + rugby)
How does scaphoid fracture present clinically?
- Tender in ANATOMICAL SNUFFBOX
- Pain along radial aspect of wrist + at base of thumb
- Loss of grip/pinch strength
- Wrist joint effusion
- Pain elicted by telescoping of thumb
- Pain on ulnar deviation of wrist
Which investigations for scaphoid fracture?
- Plain film radiographs → sensitivity in first week only 80%
- CT scan superior to radiograph
- MRI is definitive investigation to confirm/exclude diagnosis → NICE says to use first-line, but it is actually commonly used second-line when radiographs are inconclusive
What is the initial management of suspected or confirmed scaphoid fracture?
- Immobilisation → Futuro splint or standard below-elbow backslab
- Referral to orthopaedics
- Clinical review w/ further imaging should be arranged for 7-10d later when initial radiographs are inconclusive
What is the orthopaedic management of scaphoid fractures?
Dependent on pt and type of fracture:
-
Undisplaced of scaphoid waist →
- cast for 6-8 wks
- union is achieved in > 95%
- certain groups eg. professional sports people may benefit from early surgical intervention
- Displaced fractures → requires surgical fixation
- Proximal pole fractures → require surgical fixation
What is the main complication to worry about from scaphoid fracture?
Avascular necrosis
What is a boxer’s fracture?
- Fracture of the 5th metacarpal neck
- Caused by clenched fist striking hard object
What is Bennett’s fracture?
- Fracture of 1st metacarpal base
- Caused by forced hyperabduction of thumb
- Defined as intra-articular two-part fracture
- Extends to first carpometacarpal joint → instability + subluxation of joint
- Often needs surgical repair
- Rolando fracture is similar but completely intra-articular
What are different types of phalangeal fractures?
- Proximal phalanx → spiral or oblique fractures lead to rotation deformity; corrected with open reduction and fixation
- Middle phalanx → manipulate; splint in flexion over a malleable metal splint strapping finger to neighbour; aim is to control rotation, which interferes with lateral finger flexion
- Distal phalanx → caused by crush injuries; often open; if closed, symptoms may be relieved by trephining the nail
Which tendons may be injured in the hand?
- Flexor digitorum profundus → finger flexion (MCP + IP joints)
- Flexor digitorum supeficialis → finger flexion (PIP joints)
- Flexor pollicis longus → flexes IP joint of thumb
What is the treatment for flexor tendon injuries?
- Primary repair (most are open injuries)
- If loss of tendon substance or delayed presentation → staged repair with silastic implant to keep tendon sheath open, followed by tendon graft
- Intensive hand physio with supervision is essential
Fractures of the distal radius (and/or ulnar) are commonly seen in A+E. Wrist fractures are mostly caused by FOOSH.
What is a Colles’ fracture?
- Extra-articular fracture of distal radius w/ dorsal displacement of distal radius
- Common in females over 50yrs (osteoporosis) following a FOOSH
- Classic dinner fork deformity visible
What is the management of Colles’ fracture?
- Reduction of fracture under regional anaesthesia (Bier’s block) or LA (haematoma block) to reverse deformities
- Area is held in plaster backslab from elbow to metatarsophalangeal joints for 6wks
- Intra-articular involvement, failed reduction or malunion require surgical intervention
What are complications of Colles’ fractures?
- Carpel tunnel syndrome
- Malunion
- Stiffness
- Rupture of extensor pllicis longus
What is a Smith’s fracture?
- Reverse of Colles’ fracture with anterior angulation and tilt
- Uncommon
Tx → manipulation under anaesthesia and a plaster cast above elbow for 6wks
What is Barton’s fracture?
- Intra-articular fracture of wrist
- Causes hand and part of distal raidus to displace proximally
Tx → ORIF
What is a chauffeur’s fracture?
Fracture of radial styloid
What is the commonest cause of hand pain at night?
- Carpal tunnel syndrome
- Due to compression of median nerve as it passes under flexor retinaculum
What are clinical features of carpal tunnel syndrome?
- Tingling or pain felt in thumb, index and middle finger
- When pain at worst, pt flicks or shakes wrist to bring relief
- Pain especially common at night and after repetitive actions
- Wasted thenar eminence + reduced sensation over lateral 3.5 digits
- Lateral palmar sensation is spared as its supply (palmar cutaneous branch of median nerve) does not pass through tunnel
- Phalen’s test → holding the wrist hyperflexed for 1min reproduces the symptoms
Which investigations for carpal tunnel syndrome?
- Usually a clinical diagnosis
- Nerve conduction studies can be helpful in complex or mixed symptoms as well as monitoring responses to surgery
- USS + MRI can help identify lesions
What are associations of carpal tunnel syndrome?
- Hypothyroidism
- Pregnancy / the pill
- Gout + pseudogout
- Diabetes + obesity
- Acromegaly
- Rheumatoid arthritis
- Amyloidosis
What is the management of carpal tunnel syndrome?
- Treat any association
- 1st line → rest, weight reduction, wrist splints
- Splinting in a neutral position alone was sufficient to relieve symptoms + avoid surgery in 37% pts
- Medical → corticosteroid injections (for short-term 10wk pain relief)
- Surgical → carpal tunnel decompression (release of flexor retinaculum)
What are wrist ganglions and their treatment?
- Smooth, multilocular cysts containing jelly-like fluid in communication w/ joint capsules or tendon sheaths
- Treatment not needed unless pain or pressure
- They may appear spontaneously
- Aspiration may work, but surgical dissection gives less recurrence
What is DeQuervain’s tenosynovitis?
Refers to stenosing tenosynovitis (thickening + tightening) of the 1st extensor compartment, abductor pollicis longus and extensor pollicis brevis tendons (at the anterior border of anatomical snuffbox) as they cross distal radial styloid
What is the clinical presentation of DeQuervain’s tenosynovitis?
- Pain is worst when these tendons are stretched (eg. lifting a teapot), and is more proximal than that from osteoarthritis of the 1st CMC joint
- Finkelstein’s sign → pain elicted by gripping the thumb into the palm of the same hand with passive ulnar deviation
- Cause is unknown but symptoms can be exacerbated by overuse of tendons (eg. wringing clothes)
What is the treatment for DeQuervain’s tenosynovitis?
- 1st-line = REST (thumb spica splint) + ICE + NSAIDs
- Corticosteroid injection at tendon site during the first 6 months of symptoms is effective in 90% of patients
- If conservative measures fail, decompression of the tendons is provided by splitting the tendon sheath
What is trigger finger?
- Common condition associated with abnormal flexion of the digits
- Caused by a disparity between size of tendon and pulleys through which they pass
- Associations (idiopathic in most) → women / RA / DM
What are clinical features of trigger finger?
- More common in thumb, middle or ring finger
- Initially stiffness + snapping (‘trigger’) when extending a flexed digit
- A nodule may be felt at the base of affected finger
What is the management of trigger finger?
- Steroid injection is successful in the majority of pts
- Finger splint may be applied afterwards
