Med Screen & differential Diagnosis of Forearm, Wrist & Hand Flashcards
1
Q
what are special questions for forearm, wrist & hand?
A
Trauma
Osteoporosis
Steroid
Weakness, clumsiness, dropping items
Smoking
RA
Circulatory problems in digits
Systems review
Vascular/arterial insufficiency
Cervical screen & relationships of UE sx
2
Q
what are the 3 main vascular pathologies?
A
Cardiac Refferal
Raynaud’s disease
Compartment Syndrome
3
Q
what are some symptoms of cardiac referral?
A
Majority men & women experience an acute coronary syndrome have chest pain
Chest pain & sweating most frequent sx in men & women
4
Q
what are the sex difference of sx for cardiac referral?
A
2x as likely to have pain b/w shoulder blades
64% more likely to have nausea or vomiting
34% more likely to experience SOB
5
Q
what is Raynaud’s disease?
A
small artery/arteriole contraction in hands & feet
6
Q
what are the demographics for raynauds disease?
A
females > males
15-40
typically bilateral
more common w/ RA, occlusive vascular disease, smokers, B-blockers use
7
Q
what are the symptoms of Raynaud’s disease?
A
- Hands blanch, become cyanotic, turn red
- Rubor Stage: pain/paresthesia as blood returns
- Usually lasts 15-20 min, alleviate w/ warm water
8
Q
differentiate b/w primary & secondary Raynaud’s disease?
A
Primary –> vasospastic disorder
Secondary –> due to underlying causes
9
Q
what is Buerger’s Disease?
A
Vasculitis (inflammation & thrombosis) of arteries/veins in hands/feet
10
Q
what are the demographics of Buerger’s disease?
A
- High correlation w/ smoking or use of tabacco
- 20-40 yr old males > females
11
Q
what is the clinical picture of Buerger’s Disease?
A
- Pain from claudication/reduced flow (reduced O2)
- In Hands: digital, palmar, ulnar arteries most affected
- May also have edema, cold sensitivity, rubor, cyanosis, trophic skin changes, paresthesias
- May result in progressive disability from pain, functional loss, amputation
12
Q
what does acute compartment syndrome most commonly affect?
A
volar forearm & hand
13
Q
what is acute compartment syndrome caused by?
A
- Fracture
- Penetrating trauma/ Combat injuries
- High pressure injection injury
- Surgery
14
Q
what are the 5 P’s in regards to Acute Compartment Syndrome?
A
-Pain
- Paresthesia
- Paresis
- Pallor
- Pulselessness
15
Q
what is acute compartment syndrome & what number indicates it?
A
- Inadequate perfusion & relative ischemia of the involved extremity
- Intra-compartmental pressure >30 mmHg
16
Q
what are all the inflammation/ infection pathologies?
A
Bursitis
Synovitis
Arthritis
Peripheral Neuritis
Epiphysis
Myositis
Osteomyelitis
Septic Arthritis
Cellultitis
Herpes Zoster
17
Q
what inflammation/infection pathologies that require immediate referral?
A
Osteomyelitis
Septic Arthritis
Cellultitis
Herpes Zoster
18
Q
what is the clinical picture of osteoarthritis ?
A
Pain
Swelling
Morning Stiffness
Muscle Weakness (Difficulty gripping & twisting objects)
Osteophyte formation at dorsal aspect of IP Joint
19
Q
what is the meds/ surgery management of OA?
A
NSAIDS
Steroid Injections
arthroplasty
20
Q
what is heberden’s node?
A
osteoarthritic enlargement of DIP
21
Q
what is Bouchard’s nodes?
A
osteoarthritic enlargement of PIP
22
Q
what is RA?
A
- Systemic Disease involving inflammation of synovial joints & tendon sheaths
- Autoimmune
- Wrist & hand biomechanics often adversely affected
23
Q
what deformities will be seen in RA?
A
- Ulnar Drift at MCP’s & RD of wrist
- Bouchard’s Nodes–> swelling & thickening of MCP & PIP synovium
24
Q
what is the clinical picture of hand infections?
A
-Swelling
-Pain
-Tender
-Redness
-Warmth
-Loss of motion
-Swelling can cause bone splaying
25
where is the prime area for hand infection?
- Multiple Spaces (prime area for infection development)
-Hand: mid-palmar space, web space, thenar space
-Fingers: volar surface spaces (pulp spaces)
26
why can hand infections be medical emergency?
- Risk of osteomyelitis/septic arthritis, sepsis & amputation
- Immunosuppressed pts are at greatest risk
27
what are Kanavel's 4 Cardinal Signs of Flexor Sheath Infection?
-Finger/hand held in slight flexion
-Swelling
-Tenderness over tendon sheath
-Pain on passive extension
28
what is ascending lymphangitis?
-inflammation of lymphatic channels that occur as a result of infection at a distal site
-Bacterial lymphangitis in severe cases can lead to tacteramei, sepsis & death
29
what are some neoplasm pathologies?
-Ganglion cyst (Benign)
-Neuromas
-Skin Cancer (Malignant melanoma & basal cell carcinoma)
-Pancoast Tumors
-Axillary Masses (Lymphatic, Metastatic tumors, Abscess, Hodgkin's, Leukemia)
30
what is a Pancoast tumor?
-Tumor of pulmonary apex
-Lung Cancer defined primarily by location
-Spreads to nearby tissues such as ribs & vertebrae
31
what are the demographics of Pancoast Tumor?
-Cigarette smoking
-Average age is in 60's
-Men > women
32
what are the symptoms of Pancoast Tumor?
-Severs & unrelenting shoulder & arm pain along distribution of 8th cervical & 1st + 2nd thoracic nerve trunks
-Horner's Syndrome
-Atrophy of intrinsic hand muscle
33
what is a ganglion cyst?
-Benign thin walled, cystic, synovial lined lesion containing thick, clear mucinous fluid
-Cyst on dorsal of hand
-Soft swelling that tends to enlarge gradually
-May become painful
34
what is the treatment for ganglion cyst?
-Nothing
-Aspiration
-Surgical excision
35
what is the classification of nerve injuries (Seddon)?
-Neurapraxia
-Axonotmasis
-Neurotmesis
36
What is neurapraxia?
compressed myelin so single can not get across
37
what is axonotmesis?
prolonged compression of the axon for a long period of time
38
what is neurotmesis?
-Grade III (start to lose endometrium)
-Grade IV (start to lose perineum)
-Grade V (complete transaction)
39
what are the neurologic pathologies?
-Carpal Tunnel Syndrome (Median N)
-Guyon's Canal (Ulnar N)
-Superficial Radial Neuritis (Radial N)
-Wartenberg Syndrome (Radial N)
40
what is carpal tunnel syndrome?
-Median Neuropathy at wrist
-Most prevalent entrapment neuropathy
41
what are the most important intrinsic risk factor for carpal tunnel syndrome?
-Obesity, Age & female sex
42
what are extrinsic risk factors for carpal tunnel syndrome?
-Forceful hand exertions
43
what are the symptoms of carpal tunnel syndrome/
-Paraethsia and/or pain in palmar surface of thumb, index, middle finger & lateral border of 4th digit
-Nocturnal Paresthesia
-Pain at wrist (may extend up to elbow & shoulder)
-Weakness in thenar muscles (APB, Opposes Pollicis, FPB)
-May have wasting or atrophy in thenar eminence
-Hypoesthesia D1-D4 (lateral border)
44
what is the clinical examination presentation of carpal tunnel syndrome?
-Sensory (decreased or absent sensation in thumb, index finger, middle finger & lateral border of 4th digit)
-Motor (weakness or atrophy in ABP, OP, FPB)
-Reflex (normal)
45
what is the management of carpal tunnel syndrome?
-PT/OT
-Splinting/bracing
-Edema inflammatory in nature-cortisone injections
-Surgical decompression (longitudinal division of transverse carpal ligament)
46
what are the symptoms for ulnar nerve entrapment at guyon's canal?
-Complaints of weakness & atrophy of ulnar intrinsic hand muscles
-Complaints of numbness on palmar aspect of hand as well as digits 5 & medial border of digit 4
47
what is the clinical examination presentation of ulnar nerve entrapment at guyon's canal?
-Sensory (decreased or absent sensation in ulnar half of palm, digit 5, medial border of digit 4)
-Motor (significant weakness of ADM, FDI & intrinsic including interossei & ulnar innervated lumbricals & atrophy of ADM/FDI/Intrinsic)
-Ulnar Clas Hand, Wattenberg's Sign
-Reflex (normal)
48
what is wartenberg syndrome?
-Entrapment of superficial radial nerve
-Wrist watch or handcuff neuropathy
49
what is the moi for wartenberg syndrome?
-Trauma
-Prolonged compression
-Operative complication during fracture reduction
50
what are the symptoms of wartenberg syndrome?
-Paraethsia and/or pain along anatomic snuff box, thumb, & dorm of digits 2-3 & lateral border of 4
-May be worse w/ gripping or use of hand
-No weakness as this is only sensory
51
what is the clinical examination presentation for the wartenberg syndrome?
-Sensory (decreased of absent sensation in snuff box & dorsal surfaces of thumb, index finger, middle finger, & lateral border of 4th digit)
-Motor (no weakness)
-Reflex (normal)
52
what is wrist drop-radial nerve at elbow & proximal?
-Paralysis of the wrist & finger extensor muscles from temporary compression of radial nerve
53
Differentiate between ischemic & demyelinating for wrist drop-radial nerve at elbow & proximal?
Ischemic (temporary - min to hours)
Demyelinating/Axonal (weeks to months)
54
what is the clinical examination presentation for wrist drop - radial nerve at elbow & proximal?
-Sensory (decreased or absent sensation in snuff box & dorsal surfaces of thumb, index & middle fingers and lateral border of 4th digit)
-Motor (significant weakness of wrist & finger extension)
-Reflex (diminished or absent brachioradialis reflex)
55
what are degenerative pathologies?
OA
Osteochondroses
Osteochondritis dessicans
Loose Bodies
Cervical spondylosis
Osteroporosis
Stenosing tenosynovitis
DeQuervain's Tenosynovitis
Dupuytren's Disease
56
what is trigger finger?
-Stenosing flexor tenosynovitis, digital tenovaginitis stenosans
-Thickening of flexor tendon sheath (as pt flexes finger tendon sticks)
57
what are the symptoms of trigger fingers?
-Palpable nodular enlargement
-Unable to extend finger activity, can flex actively & extend passively
-Usually worse in morning
-Idiopathic, RA/DM
58
what is De Quervain's Tenosynovitis?
-Tenosynovitis of 1st dorsal compartment (EPB, APL)
59
what are the symptoms of De Quervain's Tenosynovitis?
-Pain & edema
-Wrist pain radiating from radial side of wrist up proximal forearm & distally into thumb
-Firm local tenderness in areas of common fibrous sheath over radial styloid
60
what is the care for De Quervain's Tenosynovitis?
Conservative (rest, NSAIDs, spine, modality, eduction, jt mobs)
Surgical (last resort)
61
what are the demographics of De Quervain's Tenosynovitis?
-Pos Finkelstein test
-Women > Men
- Peak age 40-60 yrs old
62
what is Duputren's Contracture?
-Fibroproliferative disorder resulting in contracture of palmar fascia
-Hyperproliferation of type 3 collagen scar tissue in palms & digits
-Nodules or cords that can progress to contraction at the MCP & PIP joints with hyperextension of DIP joints
-Early nodular thickening in palmar fascia which becomes adherent to overlying skin
63
what is the demographics of Duputren's Contracture?
-Older men of Northern European descent
-55yrs
-Associations include: alcohol, smoking, manual labor, diabetes, & epilepsy
64
what is the medical/surgical management of Duputren's Contracture?
-Surgical excision of all abnormal palmar fascia
-Indication >30 degrees MCP flexion deformity & 10 degree of DIP flexion deformity
-CPM hand device may help to maintain finger joint range gained in surgery
65
what is Kienbock's disease (AVN of Lunate)?
-Isolated collapse of lunate due to vascular insufficiency or AVN
66
what is the demographics of Kienbock's disease?
-Low incidence
-Young adults 15-40 yrs
67
what is the moi of Kienbock's disease?
-Single injury or multiple compression forces disrupting blood supply
-Cause dorsal wrist pain (generally indistinguishable from other wrist pain)
68
what is Presier's Disease (AVN of Scaphoid) clinical presentation?
-Wrist pain at rest & motion
-Tenderness over scaphoid (snuffbox)
-Decreased strength common
-Collapse common as bone becomes more necrotic
69
what is the management of Presier's disease?
-Immobilization
-Surgical debridement, pinning, closed wedge osteotomy
70
what is Presier's disease demographics?
-Occurs in 15-30% of scaphoid fx
-Proximal pole fx
-MRI or puncture bleeding during surgery will help differential
71
what is gout?
-Metabolic disorder of uric acid leading to hyperuricemia
-Damage to hand raised in chronic phase of disease
-Usually remain asymptomatic for several year
72
what are some things that causes gout?
-Uric Acid is product of purine breakdown
-Diet causes: red meat, seafood, dark chocolate
73
what is the acute phase of gout?
-Acute monarthritis mainly in 1st metatarsophalangeal jt
-Damage in hand is rarely the 1st manifestation
74
what is the recurrent phase of gout?
-Onset of new acute phases
75
what is chronic phase of gout?
-Untreated disease may evolve towards chronic tophaceous gout stage
-Most often hand is affected at a later stage when levels of uric acid in blood become very high
76
what is syndactyly?
-Webbing of fingers (variable, 3rd & 4th fingers most common)
-Simple to complex
-Most common congenital anomaly
77
what is the management of syndactyly?
-Surgical repair (skin grafts/z-plasty)
-Surgery before 1 yr due to development of grasp
78
what is clinical presentation of radial club hand (radial deficiency)?
-Radial deviation of hand; shortening and/or curvature of ulnar
-Absent thumb
79
what is the surgery for radial club hand (radial deficiency)?
-Hand Centralization (resection of carpal bones, shortening of ECU & angular osteotomy of ulna)
