Lecture 9: The Wrist and Hand

Question 1

List the 4 stages of healing for bone fractures.

Answer 1

1. Inflammatory
2. Soft Callus Formation
3. Hard Callus Formation
4. Remodeling

Question 2

Which 3 bones are most likely to get injured when falling on an outstretched hand?

Answer 2

• Hook of Hamate
• Tubercle of scaphoid
• Pisiform

Question 3

Why is the scaphoid susceptible to avascular necrosis?

Answer 3

The scaphoid has distal to proximal arterial supply which can become easily compromised during a bone fracture, thus cutting off nutrients to the scaphoid.

Question 4

What are the 4 classes of triangular fibrocartilage complex tears?

Answer 4

• Class 1A: Central tear of the fibrocartilage disk tissue (I)
• Class 1B: Ulnar-sided peripheral detachment (II)
• Class 1C: Tear of the volar ulnar extrinsic ligaments(III)
• Class 1D: Radial-sided peripheral detachment (IV)

Question 5

What usually causes triangular fibrocartilage complex tears?

Answer 5

Axial loading with ulnar deviation and forearm rotation

Ex: Push-ups

Question 6

A patient comes into the clinic with ulnar-sided wrist pain upon palpation, that is replicated with forearm rotation. They note that their wrist feels very “unstable”. What condition do they have?

Answer 6

Triangular fibrocartilage complex tear

Question 7

Break down how you would treat a triangular fibrocartilage complex tear.

Answer 7

• Modify activity: Don’t do push-ups
• Strengthening: Forearm strengthening exercises that focus on endurance (high reps, low load)
• NSAIDs and PRICE: to manage acute pain

Question 8

An elderly man trips and falls, landing on his outstretched hand in an attempt to catch his fall. Thankfully he manages to catch himself, however he notices that his wrist hurts which his doctor identifies as posterior radial-sided. There is pain with palpation to his anatomical snuff box, and he cannot radially deviate his wrist. The doctor sends him in for an x-ray which comes back negative. What condition does the man likely have?

Answer 8

Scaphoid facture

Note: x-rays are not very good at detecting scaphoid facture

Question 9

Which direction does the fragment of distal radius shift in a Colles fracture, and what is the mechanism of injury?

Answer 9

1. Posterior displacement of a distal fragment
2. Fall on outstretched hand (FOOSH)

Question 10

Which direction does the fragment of distal radius shift in a Smith’s fracture, and what is the mechanism of injury?

Answer 10

1. Anterior displacement of a distal fragment
2. Fall on the back of a flexed hand

Question 11

What is a Barton fracture and how does it happen?

Answer 11

1. Articular fracture of the distal radius
2. Direct and violent injury to the wrist, or from sudden pronation of the distal forearm on a fixed wrist

Question 12

Why are females at higher risk of a distal radius fracture?

Answer 12

Lower bone mineral density

Question 12

A woman fell on her outstretched hand and now has a gross deformity at her wrist as well as swelling and tenderness with palpation. What injury does she have?

Answer 12

Distal radius fracture (Colles)

Question 13

How would you rehabilitate a Barton’s fracture?

Answer 13

• Don’t put too much load on it right away
• Continuously put motion through the joint to prevent OA
• Use traction

Question 14

What are the symptoms of a wrist sprain?

Answer 14

• Possible swelling around the wrist joint
• Pain with ulnar or radial deviation
• Bruising, and difficulty with wrist movements

Question 15

What is the most common mechanism of injury for wrist sprain?

Answer 15

FOOSH

Question 16

What other types of conditions is complex regional pain syndrome associated with?

Answer 16

Mental health conditions

Question 17

Explain the difference between complex regional pain syndrome type 1 and 2.

Answer 17

Type 1 is triggered by a noxious event, whereas type 2 is not always caused by noxious event.

Type 1 is not limited to a single peripheral nerve, whereas type 2 involves direct partial or complete injury to a nerve or one of its major branches.

Question 18

What is the etiology of complex regional pain syndrome?

Answer 18

Exaggerated inflammatory response

Question 19

What is a practitioner’s goal for a patient with complex regional pain syndrome?

Answer 19

Make sure condition doesn’t worsen, find out what triggers flare-ups.

Question 20

What is the bone mineral density for osteopenia?

Answer 20

1 to 2.5 standard deviations below the young adult reference mean

Question 21

What is the bone mineral density for osteoporosis?

Answer 21

> 2.5 SD below the reference mean

Question 22

List 3 non-modifiable risk factors for osteopenia.

Answer 22

• Genetics
• Female
• Family history

Question 23

List 7 modifiable risk factors for osteopenia.

Answer 23

• Pregnancy at an early age
• Smoking
• Sedentary lifestyle
• Alcoholism
• Low calcium intake
• Prolonged bed rest
• Anorexia

Question 24

What is wrong with the press test?

Answer 24

- Puts too much load on a wrist injury (would hurt way too much) - Rules in a lot of wrist injuries (if they have pain, they are probably injured)

Question 25

Name a self-report measure that can be used assess wrist pain and function. What is the MCID for this for this scale?

Answer 25

1. Patient-rated wrist evaluation 2. 11.5

Question 26

Explain the x-ray protocol for a possible scaphoid fracture.

Answer 26

1st x-ray: If negative, immobilize for 7-10 days 2nd x-ray: If positive, cast for 6 weeks A second x-ray is done because due to swelling the x-ray image can be unclear, making it difficult to be certain that the first x-ray is negative.

Question 27

What do you do if you still think a patient has a scaphoid fracture after a negative x-ray result?

Answer 27

Send for ultrasound