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PHTY3120 > L26: Clinical Reasoning in Examination of the Wrist > Flashcards

L26: Clinical Reasoning in Examination of the Wrist Flashcards

1
Q

What are 6 major pathologies of the wrist?

A
  1. De Quervain’s Tenosynovitis
  2. Skier’s/Gamekeeper’s Thumb
  3. Carpal Tunnel Syndrome
  4. Distal radial fracture
  5. Scaphoid fractures
  6. Carpal instability
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2
Q

What is De Quervain’s Tenosynovitis?

A

Thickening and stenosis of 1st extensor compartment (AbPL, EPB)

  • It is degenerative, not inflammatory
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3
Q

What is the MOI of De Quervain’s Tenosynovitis?

A

overuse thumb E, abd, wrist RD

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4
Q

What are 4 symptoms of De Quervain’s Tenosynovitis?

A
  1. Pain 1st extensor compartment
  2. Awkward positions of wrist/hand
    1. Waiter lifting dish position
    2. Mother lifting baby
    3. Cashier/typer
  3. Catching
  4. +ve Finkelstein’s test
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5
Q

What are 3 other/different diagnoses of DeQuervain’s Tenosynovitis?

A
  1. 1st CMC joint OA
  2. Intersection syndrome: APL, EPB & ECRL & B
    • Pain more central in distal forearm than DeQuervain’s
    • MOID: Repetitive wrist E, thumb E (rowers)
  3. Wartenburg’s Syndrome
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6
Q

What are 8 Conservative Management of DeQuervain’s Tenosynovitis?

A
  1. Rest! Rest! Rest!
  2. Avoid aggravating activity
  3. ADL modification: Address the overuse
  4. Kinesiotape in mild cases
  5. Splintage immobilises wrist & hand to allow rest
  6. Gentle AROM exercises once pain-free
  7. No strengthening exercises, no evidence on eccentric strengthening in the hand
  8. Steroid injection guided by ultrasound facilitates conservative treatment
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7
Q

What are the 2 purposes of Splintage of DeQuervain’s Tenosynovitis?

A
  1. Acute symptoms
  2. Subacute symptoms
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8
Q

What are 3 acute symptoms that splintage of DeQuervain’s Tenosynovitis helps with?

A
  1. Thermoplastic forearm based thumb spica 2/52
  2. Rigid splint progress to soft splint
  3. Needs to rest AbPL & EPB
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9
Q

What are 2 subacute symptoms that splintage of DeQuervain’s Tenosynovitis helps with?

A
  1. Neoprene splints with supports to rest EPB & AbPL
  2. Taping
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10
Q

Thumb splint only is no good for DeQuervain’s Tenosynovitis. Why?

A

because we need to immobilise wrist too

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11
Q

What is surgery for DeQuervain’s Tenosynovitis?

A

Decompression of 1st dorsal compartment

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12
Q

What is decompression of 1st dorsal compartment as Surgery of DeQuervain’s Tenosynovitis?

A
  1. Surgery opens fibrosseous tunnel, slit the tendon sheath to give the tendon more room
  2. People with an extra split tendon have too much bulk in the tunnel, which is often why they failed conservative management
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13
Q

What are 3 post op managements for DeQuervain’s Tenosynovitis?

A
  1. Wound/scar management
  2. Gentle AROM
  3. Strengthening after 6 weeks
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14
Q

What is Skier’s thumb?

A

injury to ulnar collateral ligament of 1st IP joint involving instability

  • Usually from base of proximal phalanx
  • Can involve volar plate, adductor aponeurosis, dorsal capsule and fracture (P1#)
  • Ligament injury is worse than bone fracture because ligament needs surgery to reattach. Bone heals better.
  • Radial collateral ligament injury is less common
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15
Q

What is the acute MOI of Skier’s Thumb?

A

Thumb E + abd > separation of IP joint > ulnar collateral ligament breaks

  • Often sporting injuries
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16
Q

What is the chronic MOI (strain) of Skier’s Thumb?

A
  1. Weak key pinch
    • Allows volar subluxation and rotation of P1 ○ Early degenerative joint disease
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17
Q

What are 4 features in the examination of Skier’s Thumb?

A
  1. History
  2. Compare with uninjured side
  3. Palpation
  4. Stability tests - X-ray
    • If no/minimal displacement (stable), then conservative management
    • If >5 mm or 25% joint space (unstable), then surgery
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18
Q

What are 3 features of Skier’s Thumb Stress Test?

A
  1. Stabilise the metacarpal to prevent rotation
  2. Apply radial stress to the distal phalanx
  3. Looking for increased mobility compared to the other side
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19
Q

What are 3 grades of Skier’s thumb?

A
  1. Grade 1
  2. Grade 2
  3. Grade 3
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20
Q

What is the feature of grade 1 of Skier’s Thumb?

A

Microscopic tearing, no loss of ligament continuity

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21
Q

What is the management of grade 1 of Skier’s Thumb?

A

Conservative

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22
Q

What is the feature of grade 2 of Skier’s Thumb?

A

Partial tear (30-40%) of the ligament

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23
Q

What is the management of grade 2 of Skier’s Thumb?

A

Conservative

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24
Q

What is the feature of grade 3 of Skier’s Thumb?

A

Complete rupture of the ligament

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25
What is the management of grade 3 of Skier’s Thumb?
Surgery
26
What are the grades, features and management of Skier’s Thumb?
27
What are 3 characteristics in the Conservative Management of Skier's Thumb?
Grade 1 & 2 - conservative management 1. Hand-based thumb spica splint for 6 weeks * Stop thumb load - stop pinching thumb 2. Week 3: Thumb AROM F/E exercises out of splint 3-4x per day 3. Week 6: Gentle PROM * Lateral and palmar pinch strengthening
28
What the hand-based thumb spica splint (conservative management) in the Conservative Management of Skier's Thumb?
29
What are 4 characteristics in the Surgerical Management (post op) of Skier's Thumb?
Grade 3 - surgery Post-op management 1. Hand-based thumb spica splint 6/52 2. ○ 2/52 thumb MP AROM F/E 3. ○ 4/52 General thumb ROM and strengthening 4. ○ 6+/52 modified splint for contact sports/manual
30
What are 5 characteristics of Carpal Tunnel Syndrome?
1. Symptoms in median nerve distribution: Pain, paraesthesia & numbness 2. Nocturnal symptoms & Flick test (gold standard) * Flick test: Need to shake hand in the morning to release irritation 3. Weakness and loss of dexterity in hand 4. Sense of congestion or finger swelling (fingers feel like sausages) 5. Progresses as per nerve compression * Sensory fibres affected first: P&N \> numb * Motor nerves affected later: APB
31
What are 5 Pathogenesis of Carpal Tunnel Syndrome?
1. **Decreased size of tunnel** * Bony abnormality (e.g. Kienbock's disease) * Thickened transverse carpal ligament 2. **Increased contents of tunnel** * Muscle bellies: Lumbricals, FDS * Mass: Ganglia, lipoma * Haematoma 3. **Inflammatory**: RA, infection, gout, overuse 4. **Fluid imbalance**: Pregnancy, hemodialysis, Reynaud's, obesity, hypothyroidism 5. **Neuropathic**: Diabetes, alcoholism
32
What are 5 features of the Diagnosis of Carpal Tunnel Syndrome?
1. Clinical symptoms 2. **Provocative tests**: Phalen’s, Durken’s 3. **Sensibility tests**: Altered sensation (light touch) in median nerve distribution 4. APB muscle power 5. **Nerve conduction tests** (gold standard): Neurologists check sensory & motor conduction proximal and distal to carpal tunnel for latency of nerve impu lse
33
What are 2 provocative tests for the diagnosis Carpal Tunnerl Syndrome?
1. Phalen’s 2. Durken’s
34
What are sensitivity tests for the diagnosis Carpal Tunnerl Syndrome?
Altered sensation (light touch) in median nerve distribution
35
What are nerve conduction tests for the diagnosis Carpal Tunnerl Syndrome?
Neurologists check sensory & motor conduction proximal and distal to carpal tunnel for latency of nerve impulse
36
What is the gold standard of the Diagnosis of Carpal Tunnel Syndrome?
Nerve conduction tests * Neurologists check sensory & motor conduction proximal and distal to carpal tunnel for latency of nerve impu lse
37
What are 3 other/different diagnoses of Carpal Tunnel Syndrome?
1. C6 nerve root injury? 2. Median nerve reduced movement up the chain? 3. Median nerve compressed down the chain?
38
What are 7 Conservative Management of Carpal Tunnel Syndrome?
1. **Work/ADL modifications**: Avoid awkward wrist positions, prolonged/repeated grip, vibration, force 1. Loose rip is better than tight grip 2. Typing in wrist E is better as it releases the carpal tunnel. 3. Wrist F compresses carpal tunnel. 2. **Nocturnal splint** holding wrist in neutral to reduce nocturnal symptoms 3. Median nerve and finger **tendon gliding exercises** 4. **Oedema control**: Gloves to reduce swelling 5. **Lifestyle**: Weight loss, aerobic fitness, stop smoking 6. Assess Cx spine/central component 7. Electrotherapy (no evidence)
39
What are 6 median nerve gliding exercises for Carpal Tunnel Syndrome?
1. A. Fist 2. B. Finger E 3. C. Wrist E 4. D. Thumb E 5. F. OP thumb E
40
What are 5 tendon gliding exercises for Carpal Tunnel Syndrome?
1. Full E 2. Hook 3. Full fist 4. Lumbricals 5. Long fist for FDS
41
What is the surgery for Carpal Tunnel Syndrome?
Carpal tunnel release
42
What are 4 features of carpal tunnel release as surgery for Carpal Tunnel Syndrome?
1. Cut transverse carpal ligament 2. Increase 25% space 3. Forms scar ligament on top 4. Long term biomechanical issues
43
What are 7 features of post op management as surgery for Carpal Tunnel Syndrome?
1. Endoscopic vs. open 2. Wound management 3. Early hand ROM 4. Avoid heavy lifting/pushing for 4 weeks 5. Median nerve and tendon gliding exercises 6. No splinting 7. Scar management
44
What is the incidence of distal radial fractures?
* 15% of all fractures * Mainly females 60-70 yos
45
What is the MOI of distal radial fractures?
FOOSH in old people. High energy injury in younger people.
46
What are 3 types of Distal Radial Fractures?
1. **Colles' fracture**: Non-articular fracture 3-5 cm proximal to the radiocarpal joint * Radius breaks upwards 2. **Smith's fracture**: "Reverse Colles" with volar displacement * MOI: FOOSH on wrist F * Radius breaks downwards 3. **Barton's fracture**: Displaced, unstable articular fracture with carpals subluxation
47
What is a Colles' fracture as a distal radial fracture? What is the MOI?
Non-articular fracture 3-5 cm proximal to the radiocarpal joint * Radius breaks upwards
48
What is a Smith's fracture as a distal radial fracture? What is the MOI?
"Reverse Colles" with volar displacement * MOI: FOOSH on wrist F * Radius breaks downwards
49
What is a Barton's fracture as a distal radial fracture? What is the MOI?
Displaced, unstable articular fracture with carpals subluxation
50
What is radial inclination?
Radius is ~1-2mm longer than ulna
51
What is volar/dorsal tilt?
Dorsal radius slopes down to volar aspect
52
What are 3 features of surgery of Distal Radial Fractures?
1. Obtain a good reduction: Put the bone back to original position 2. Maintain a good reduction 3. Early motion as fracture stability allowsa
53
What are 4 anatomical considerations of reduction of distal radial fractures?
1. **Articular congruity** * Fracture into the joint line \> gap & uneven joint line \> more irritation \> more ongoing pain & arthritis \> bad prognosis 2. **Radial shortening/ulnar variance**: No more DRUJ - cannot do pronation/supination * As you RD/UD, lunate can hit on ulna 3. **Dorsal angulation** * Radius sits in E - easy E, hard to get F 4. **Radial inclination** from radial styloid to DRUJ - affects pain level
54
What are 4 surgical options for distal radial fractures?
1. Immobilisation for nondisplaced fractures 2. Ligamentotaxis: Torn and shifted ligament 1. Closed reduction 2. Pins & plaster 3. External fixation (rare) 3. Percutaneous pinning 4. ORIF +/- bone grafting
55
What are 3 early therapies in the Rehabilitation of Distal Radial Fractures?
1. Oedema control: Elevation & compression 2. ROM of hand, shoulder & elbow 3. Wrist mobilisation as soon fracture healing allows
56
What are 3 wrist AROM in the Rehabilitation of Distal Radial Fractures?
1. Check fracture stability and type of movement required 2. Independent wrist extension: Patients often compensate ECLR & B using EDC - correct it 3. Supination ROM
57
What are 3 wrist PROM in the Rehabilitation of Distal Radial Fractures?
1. Passive stretches 2. Manual therapy 3. CPM
58
What are 3 Rehabilitation of Distal Radial Fractures?
1. Promotion of function: Train ADL 2. Splintage to regain ROM if stiffness occurred * **Dynamic splint** gives prolonged gentle stretch to restore ROM 3. Work hardening: UL considerations of elbow/shoulder
59
What are 5 complications of distal radial fractures?
1. Significant malunion: Stiffness, OA, pain * Check X-ray, further surgery? 2. Carpal tunnel syndrome: Acute CTS is treated by doctors 3. TFCC tears 4. EPL rupture 5. Complex regional pain syndrome type 1
60
What are 3 features post op in the wrist?
1. Scar 2. Swelling 3. Increased hair growth & sweat due to increased SNS activity
61
What is the prevalence of scaphoid fractures?
1. Most common carpal fracture (60-70%) 2. Young males 3. Delayed diagnosis
62
What is the MOI for scaphoid fracture?
* FOOSH with wrist hyperE + RD * Less common MOI: Longitudinal compression - nondisplaced fracture
63
What are scaphoid fractures?
Distal to proximal blood supply: Surface of scaphoid is largely articular. Small portion of scaphoid is accessible for vascular supply from radial artery. * At risk of avascular necrosis
64
What are 3 diagnoses of scaphoid fractures?
1. Snuff box tenderness 2. Plain X-ray +ve 2 weeks after fracture * If in doubt, do CT 3. Occult fractures: Splint if fracture suspected
65
What are the 3 classification of scaphoid fractures?
1. Tubercle 2. Waist 3. Proximal pole
66
What is a feature of tubercle scaphoid fractures?
Not usually displaced
67
What is the management of tubercle scaphoid fractures?
Immobilisation
68
What is the feature of waist scaphoid fractures?
* 70-80% * Increased displacement
69
What is the management of waist scaphoid fractures?
Increased need for surgery
70
What is the feature of proximal pole scaphoid fractures?
Increased risk of arterial compromise
71
What is the management of proximal pole scaphoid fractures?
High chance of surgery
72
What are 2 conservative management of scaphoir fractures?
1. Stable, non-displaced fracture of waist or distal pole 2. Scaphoid cast immobilises wrist & thumb * Don't actually need to immobilise thumb because you get the same recovery, and it is more comfortable to wear
73
What are 3 contraindications for conservative management of scaphoid fractures?
1. Proximal pole fracture 2. Delayed union 3. Comminution
74
What surgeries as management of scaphoid fractures?
1. ORIF +/- bone graft 2. Intraoperative stability will determine commencement of mobilisation
75
What are 3 features that carpal instability depends on?
1. Bony geometry 2. Ligamentous constraints: Intercarpal, radiocarpal, ulnocarpal ligaments 3. Musculotendinous support: Passive compression of tendons across carpals
76
77
What are 3 characteristics of Carpal Instability Dissociative Scapholunate Instability?
1. Disruption of scapholunate ligament 2. Uncommon 3. Scaphoid naturally wants to flex, triquetrum wants to extend. Lunate goes along with triquetrum
78
What is dorsal intercalated segmental instability?
Angle between scaphoid and lunate \>60°on lateral view
79
What is the MOI of Carpal Instability Dissociative Scapholunate Instability?
FOOSH
80
What are symptoms of Carpal Instability Dissociative Scapholunate Instability?
Dorsal central pain/swelling
81
What are provocative wrists test of Carpal Instability Dissociative Scapholunate Instability?
* Watson's test becomes more positive as time goes on and swelling reduces. * Early stage only shows instability with load, no collapse - do X-ray with grip
82
What are X-ray findings of Carpal Instability Dissociative Scapholunate Instability?
1. Terry Thomas sign: Gap between scaphoid & lunate (dissociation) 2. Ring sign: Scaphoids bends over, distal pole looks like a ring 3. Grip stress 4. RD & UD view may show gap
83
What is the best imaging for the diagnosis of Carpal Instability Dissociative Scapholunate Instability?
MRI is best
84
What are the 5 considerations on the management of Scapholunate Instability?
1. Grade of ligament injury 2. Repairability: Healing potential - when did injury happen? 3. Reducibility: How well can you push it back to original position? 4. Status of cartilage 5. Early identify, early referral, early treatment
85
What are the 3 grades of ligament injuries for Scapholunate Instability?
1. Grade 1 2. Grade 2 3. Grade 3
86
What are 4 managements in grade 1 of ligament injury?
1. Initial rest/immobilisation in splint 1. Type of splint: Customised splint fits better. Shelf ones can move around a little. 2. Length of time 3. Start AROM depending on pain & inflammation 2. Exercises * Dart throwing motion: Highly functional - radial E to ulnar F * Most stable/safe motion for proximal carpal row * Wrist isometrics * FCR exercises as it supports scapholunate ligament 3. Activity modification * Avoid excessive early grip strengthening * Avoid WB as it separates scaphoid & lunate 4. Proprioception retraining * OKC is better in early stage * Power ball * Slosh pipes
87
What is the management in grade 2 of ligament injury?
Surgery: Pinning? Thermal shrinking? Repair? Capsulodesis?
88
What is the management in grade 3 of ligament injury?
Surgery: Open repair, fusion
89
What are 3 features of initial rest/immbolisation in splint as management in grade 1 of ligament injury?
1. Type of splint: Customised splint fits better. Shelf ones can move around a little. 2. Length of time 3. Start AROM depending on pain & inflammation
90
What are 3 exercises in splint as management in grade 1 of ligament injury?
1. Dart throwing motion: Highly functional - radial E to ulnar F * Most stable/safe motion for proximal carpal row 2. Wrist isometrics 3. FCR exercises as it supports scapholunate ligament
91
What are 2 activity modifications in splint as management in grade 1 of ligament injury?
1. Avoid excessive early grip strengthening 2. Avoid WB as it separates scaphoid & lunate
92
What are 3 features of proprioception retraining in splint as management in grade 1 of ligament injury?
1. OKC is better in early stage 2. Power ball 3. Slosh pipes

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