L27: Clinical Reasoning in Examination of the Hand Flashcards
What are the 6 major pathologies of the hand?
- Hook of hamate
- TFCC Tears
- PIP dislocations
- Phalangeal fractures
- Metacarpal fractures
- Stenosing Tenosynovitis (Trigger Finger)
What is the MOI of the Hook of Hamate Fracture?
Abutment of hook against an object, or a shearing force of the 4-5th FTS
- Common in golfers, baseball, racquet sports
What is the symptom of the hook of hamate fracture?
Tenderness over hook in palm
What are 4 features of ulnar wrist pain?
- Acute traumatic
- Chronic overuse
- Common in athletes (tennis)
- Need stability to sustain grip
What are 4 structures that contribute to DRUJ stability?
- TFCC
- ECU
- Interosseous membrane
- Pronator quadratus
What are 2 management of hook of hamate fractures?
- Conservative: Wrist splint 6 weeks
- Surgery: ORIF, excision
What is the conservative management of hook of hamate fractures?
Wrist splint 6 weeks
What is the surgical management of hook of hamate fractures?
ORIF, excision
Where is pain in TFCC?
Ulnar sided pain
What is MOI for TFCC?
FOOSH with wrist E + extreme rotation + UD
- Gymnastics, hockey, racquet/batting sports, boxing, and pole vaulting
What are 5 TFCC classifications?
What are the 3 injuries in Class 1 (traumatic) for TFCC?
- 1A Central disk
- 1B Avulsion from insertion on ulna
- 1C Detachment from lunate
What are the 2 injuries in Class 2 (degenerative) for TFCC?
- 2A Thinning & wearing without perforation
- 2B Chondromalacia of lunate and/or ulnar
What are 8 conservative managements for class 1 TFCC tears?
- Rest/immobilisation 2-3 weeks in wrist splint depending on severity & longevity of symptoms
- Progressive pain-free ROM
- Avoid aggravating activities
- Isometric loading of pronator quadratus (stabiliser)
- Restricted sports 4-6 weeks
- Strapping as needed
- Wrist splint
- Acute pain: Circumferential wrist splint to restrict rotation
- Mild pain: Oapl, wrist widget to stabilise DRUJ
- HCLA
____ is the most common dislocated joint in body
PIP
What is poor management of PIP dislocations?
Poor management: Often underestimated or immobilized for too long > long term stiffness, pain, instability
What happens when there is a large fragment of PIP dislocation?
If large fragment, then refer to hand surgeon
What are 2 types of PIP dislocations?
- PIP Dorsal Dislocation
- PIP Lateral Dislocations
What are 4 characteristics of PIP Dorsal Dislocation?
- Volar plate ruptures from distal attachment +/- avulsion fracture
- Dorsal dislocation MOI: Axial loading with PIP hyperextension
- Ball handling sports
- PIP dislocation is often associated with fracture - difficult to manage
- May have associated collateral ligament tear.
What is the MOI for PIP Dorsal Dislocation?
Dorsal dislocation MOI: Axial loading with PIP hyperextension
- Ball handling sports
What are 4 managements of PIP Dorsal Dislocations?
- Control oedema +++: Compression for a few weeks
- Tendency for PIP to develop fixed flexion deformity (FFD) or extensor lag, but also want to avoid ongoing instability
- FFD develops due to excessive oedema bending the fingers
- Early F AROM is important
- Monitor closely to ensure progressive increase in ROM F/E
What are the 3 stability splints for PIP dorsal dislocation?
What are 4 characteristics of PIP Lateral Dislocations?
- Rupture of the collateral ligament on one side and partial avulsion of the volar plate
- Can have a subluxation or dislocation injury
- Often stable once reduced
- X-ray to check no large bony fragment
What are 4 Management of PIP Lateral Dislocations?
- Oedema control
- Resting PIP extension splint (night) to stop FFD
- Early AROM - buddy
- RTP - buddy strap
What is the management of PIP Fixed Flexion Deformity?
Unlikely to respond to manual therapy/exercise, will require splintage to provide prolonged gentle stretch
What does the static progressive splint look like?
What are 2 characteristics of Phalangeal Fractures?
- X-ray to assess alignment, position
- Refer to surgeon if failed reduction, displacement, or any rotation present
What are 4 types of Phalangeal Fractures?
- Small unicondylar fracture are usually stable
- Bicondylar fractures are usually unstable
- Shaft fractures (transverse/spiral) need surgery
- Stable/nondisplaced fractures
- Resting extension splint 4 weeks
- Active motion as stability allows
- Buddy strap
- Oedema control
What are 3 characteristics of Distal Phalanx Fractures?
- Usually a crush injury
- Pain and swelling +++
- If intra-articular joint space 30% , then refer to hand surgeon
What are 3 management of Distal Phalanx Fractures?
- Splint for ~3 weeks
- Oedema control
- AROM depending on stability
What are 7 characteristics of Metacarpal Fractures?
- Divided into fractures of metacarpal head, neck, shaft, base
- Metacarpal neck is most common site of fracture
- Fifth metacarpal is most commonly injured
- Incidence: Metacarpal fractures account for 40-50% of all hand fractures
- Demographics: Men 10-29 yos have highest incidence of metacarpal injuries (punch injury)
- Relatively quick healing (3-5 weeks)
- Treatment based on which metacarpal is involved and location of fracture
- Acceptable angulation varies by location
- No malrotation is acceptable. (e.g. 5°rotation results in 1.5 cm digital overlap)
What are 3 managements of Boxer’s Fracture (5th Metacarpal)?
- Oedema control
- Splint to inmmobilise MP in F and IP in E because hand tends to stiffen into a claw
- Malunion can lead to extensor tendon lag
What are 5 Managements of Metacarpal Neck Fractures?
- Hand based fracture brace (Sarmiento) to stabilise metacarpal, joint above and below
- MCP 40-60°
- CMC stabilised
- Can move fingers in splint
- Ensure metacarpal head well supported volarly.
- Gentle AROM MP joint
- Buddy strap usually required.
- Wean from splint 4-6 weeks.
- May continue with buddy strap for longer
What is Stenosing Tenosynovitis (Trigger Finger)?
Inflammation of flexor synovial sheath +/- annular 1 (Al) pulley
What are symptoms of Stenosing Tenosynovitis (Trigger Finger)?
Symptoms vary from intermittent catching to locking
What are associated with overuse of flexor tendons of Stenosing Tenosynovitis (Trigger Finger)?
Associated with overuse of flexor tendons
- Tendon thickens, pulley catches - pain, lodged finger
- e.g. Knitting
Whta are the different stages of the Stenosing Tenosynovitis (Trigger Finger)?
Different stages from mild triggering to finger locking down
What are 5 features of mild to moderate cases in the management of trigger finger?
- Splint to restrict MCP F, IP joints free for 2-3 weeks
- Full PROM daily with splint off
- Oedema control
- Education to avoid aggravating activities oedema till settle down
- US guided HCLA if unresponsive to treatment
What is a feature of severe cases in the management of trigger finger?
Surgery: Cut the pulley - more space for tendon to glide
