L30b: Hand & Wrist Case Studies

Question 1

Case 1: De Quervains. What are 5 features?

Answer 1

1. Often new moms overloading wrist holding baby
2. 4-6 weeks splint usually
3. New mom may need splint for months because they cannot stop lifting the baby
4. A&E on feeding position, holding position, offload the tendons as much as possible
5. Offload to reduce pain & symptoms > regain ROM > gradually load again

Question 2

Case 2: UCL sprain grade 2. What are 5 features?

Answer 2

1. DDx: UCL sprain, volar plate injury, fracture.
2. Hand based thumb fica: Immobilise thumb MCP F for 4-6 weeks.
   
   • At 4 week: Palpate for tenderness. A little stress test.
   • At 6 weeks: Full stress test.
   • Take out splint when no pain, no laxity.
3. A&E: Avoid ball sports, pinching, loading through thumb
4. ROM exercise at 4 weeks
5. Strengthening at 6-8 weeks: Ensure full opposition pain-free > gentle load > more resistance.

Question 3

Case 3: TFCC partial tear. What are 5 features?

Answer 3

1. DDx: TFCC tear, DRUJ injury, ECU/FCU tendonitis, lunate fracture, triquetrum avulsion fracture (with wrist hyperE), lunotriquetral ligament injury.
   
   • TFCC tears often occur together with ECU tendonitis
2. Wrist based splint for 6-8 weeks
   
   • To restrict pronation/supination, need sugar tong splint (shorter time)
3. Isometrics when pain-free
4. Wrist proprioception exercise
5. Steroid injection for ECU synovitis if unresponsive to splinting

Question 4

Case 4: Distral radius undisplaced fracture. What are 4 features?

Answer 4

1. DDx: Distal radius fracture, scaphoid fracture, metacarpal base fracture, lunotriquetral ligament injury ○ If suspect fracture, do not do too much tests as it may displace the fracture.
2. Wrist immobilisation splint for 5-6 weeks
3. Ask for GP/hand specialist opinion on X-ray, whether it is ok to manage conservatively
4. Exercises of uninvolved joints: ROM fingers & thumb

Question 5

Case 5: 5th metacarpal neck fracture. What are 4 features?

Answer 5

1. DDx: 5th metacarpal base, shaft, head, neck fracture, TFCC tear, triquetrum avulsion fracture, lunotriquetral ligament injury
2. Hand splint of metacarpal at 30-45°F for 3-6 weeks
3. Check clinical healing by palpation
4. Exercises MCP joint, wrist, fingers
   
   • At 3 weeks, should have full fist ROM

Question 6

Case 6: Volar plate avulsion fracture. What are 3 features?

Answer 6

1. DDx: Volar plate injury, radial/ulnar collateral ligament injury, central slip injury
2. Finger based dorsal splint for easy exercise. 3-5 weeks.
   
   1. Volar plate avulsion: Start 20-30°F, progress to full E
   2. Volar plate sprain: Full E ASAP
3. Start moving ASAP to prevent FFD.