MS1: Affectations of the Wrist and Hand Flashcards
describe the distal radioulnar joint
uniaxial - pivot jint
formed by distal radius, articulating disc and ulna
what is the articulating disc of the DRUJ
TFCC - triangular fibrocartilage complex
where is the TFCC located
betw medial and proximal carpal row and distal ulna
what is the composition of TFCC
articular disc - for cushion or shock absorber so ulna will not hit carpals
meniscus homologue
origin of ligaments
which ligaments originate from the TFCC
ulnocarpal - unlolunate and unlotriquetral
ulnar collateral and ECU tendon sheath
radioulnar - dorsal and palmar
what is the function of TFCC
covers nd protects ulnar head
load transmission across ulnocarpal joint and cushion against compression
allows forearm rotation
supports ulnar portion of carpus
how does injury on TFCC typically occur
falling on supinated outstretched wrist
chronic repetitive rotational loading
what are the 2 types of TFCC injury
type 1 - traumatic
type 2 - degenerative
signs and symptoms of TFCC injury
medial wrist pain distal to ulna increased by pronation-supination and gripping
painful click during wrist motions
tenderness on posterior distal to ulnar head
how to test for TFCC injury
mcmurrays test - passive or active ulnar deviation causes pain or snap = +
passive supination w/ ulnar deviation can reproduce pain
sports related to TFCC injury
GOLF, boxing, tennis, waterskiing, gymnastics, pole vaulting, hockey
diagnosis of TFCC injury
imaging
radiograph - usually negative; done to rule out fractures
triple injection arthrography - low specificity; might see tear
MRI - high specificity; identify tear
treatment of TFCC injury
conservative
- modification of lifestyle to remove inciting force
- ice-heat and immobilization for 3-6 weeks then PT
surgical - if may pain after 6 wks
- type 1
- immobilized for 1 wk post op then ROM exercises
- light activity at 3 wks
- normal sports activity at 4-6 wks
management of TFCC injury
conservative
- NSAID
- steroid injections
- physical therapy
- exercises
discuss the differential diagnosis for TFCC injury
TFCC tear - pain on ulnar deviation - negative on xray
ulnar styloid fracture - pain over styloid - fx on xray
ulnar nerve trap at guyons - numbness nd weakness of grip
what makes up the wrsit
distal radius and ulna, 8 carpal bones, 5 base of metacarpals
describe the radiocarpal joint
betw distal raduis and scaphoid, lunate, triquetrum and TFCC
condyloid - main wrist joiny
listers tubercle - dorsal at center of radius
what is the significance of listers tubercle
EPL tendon passes that causes friction
common site of microtears
what are the carpal bones lateral to medial
proximal
- scaphoid, lunate, triquetrum, pisiform
distal
- trapezium, trapezoid, capitate, hamate
what is colle’s fracture
fracture of distal radius with dorsal displacement
due to fall from outstretched hand
what is the epidemiology of colle’s fracture
high in women over 50 - menopausal nd osteoporotic
- bc predictor of other fractures - high chance na osteoporotic
high impact - skiing nd horseback riding
signs and symtoms of colle’s fracture
dinner fork deformity - posterior displacement of distal radial fragment
- dorsal wrist pain
- swelling
- increased angulation of distal radius
- inability to grasp
- numbness
- tenderness
- bruising
management of colle’s fracture
operative - ORIF to normal length of radius
- Fx displaced intra-articular
- volar/dorsal comminution
- severe osteoporosis
- more than 5mm of radial shortening
- dorsal angulation more than 5 degrees
- progression after closed reduction nd casting
- w/ ulnar styloid fracture
non operative - closed reduction and cast immobilization
- less than 5mm of radial shortening
- dorsal angulation less than 5 degrees
what is smith’s fracture
fracture on distal radius with palmar displacement due to falling on the back of flexed hand
reverse colle’s
majority treated with conservatice
surgery same as colle’s
what is barton fracture
intra-articular fracture of distal radius with dislocation of radiocarpal joint
volar - more common
dorsal - less common
causes of barton fracture
joint involved - direct blow to forearm
sudden pronation on fixed wrist
70% common in young men
what is the treatment of barton fracture
conservative
- closed reduction and casting on full supination, mid extension and ulnar deviation
surgical
- ORIF with 16 wks healing time
what is madelung’s deformity
uncommon, congenital
retardation of growth of ulna and volar distal radius = tilting of distal radius
what is epidiemiology of madelung’s disease
common in female
usually bilateral
congenital and slowly progressive
signs and symptoms of madelung’s deformity
wrist is enlarged and unstable radioulnar joint upon palpation
end of radius is displaced anteriorly
dorsal prominence on lower end of ulna and limitation of wrist DF
wrist weakness
supination lessened nd pronation can be decreased
treatment of madelung’s deformity
unnecessary - person can adapt
mild pain - temporary splinting
severe cases - resection of distal ulna to allign bones
describe the scaphoid
palpated distal to radial styloid in anatomic snuffbox
most common fractured carpal bone
avascular necrosis - preiser’s disease
biggest in proximal row
describe the lunate
distal and ulnar to lister’s tubercle
most commonly dislocated carpal and scapholunate most common area for carpal instability
osteonecrosis follows after single severe trauma to wrist
spontanenous osteonecrosis - keinblock’s disease due to repetitive trauma
describe osteonecrosis or avascular necrosis
common in 20-40 yo
pain nd swelling for several days to wks
localize swelling nd tenderness nd DF is limited
radiographic - initially negative but later flattening = abnormally dense
treatment of osteonecrosis or avascular necrosis
conservative - immobilization bc bone is soft
surgery - excision the replace with metal prosthetic implant
what is the extensor retinaculum
from lateral border of distal radius to posterior surface of distal ulna and ulnar styloid, pisiform and triquetrum
prevents bow stringing of tendons nd enhances efficiency
what is the anatomic snuffbox
triangular depression at lateral of the wrist at compartment 1
what are the compartments of extensor retinaculum
1 - APL and EPB
2 - ECRL and ECRB
lister’s tubercle
3 - EPL
4 - extensor digitorum and extensor indicis
5 - EDM
6 - ECU
what are the compartments of extensor retinaculum
1 - APL and EPB
2 - ECRL and ECRB
lister’s tubercle
3 - EPL
4 - extensor digitorum and extensor indicis
5 - EDM
6 - ECU
what is de quervain’s syndrome
stenosing tenosynovial inflammation of the 1st dorsal compartment - APL nd EPB
what is the epidemiology of de quervain’s syndrome
more common in women
30 - 50 yo
more common in dominant hand but can be bilateral
risk factors
overuse
repetitive wringing, grasping clenching or pinching
post-traumatic
postpartum
what are the symptoms of de quervain’s syndrome
pain on lateral wrist when moving wrist and thumb that shoots into thumb and wrist and forearm
localized swelling
thickening of tendon sheath and hard nodule on styloid process of radius
how to test for de quervain’s syndrome
finklestein’s test - pt will grasp thum and ulnar deviate if pain over styloid = +
what is treatment for de quervain’s syndrome
conservative
- wrist brace/cast
- anti-inflammatory medication
- restricted movement of wrist and thumb
- ice-heat
- cortisone injections
- PT nd OT
- avoid movement that cause pain
surgical
- release of constriction or partial resection of sheath
what is the flexor retinaculum
from tubercle of scaphoid and pisiform and hook of hamate and tubercle of trapezium
aka transverse carpal ligament
functions of flexor retinaculum
attachment for thenar and hypothenar muscles
help maintain transverse carpal arch
restrain against bowstringing of extrinsic flexors
protects median nerve
what are the structures that pass deep to the flexor retinaculum
4 FDS tendons
4 FDP tendons
FPL
median nerve
what are the structures that pass superficial to the flexor retinaculum
ulnar nerve and artery
palmaris longus tendon
sensory branch of medial nerve
describe the carpal tunnel
conduit for the medial nerve and 9 flexor tendons
common location for nerve impingement
what are the boundaries of the carpal tunnel
roof - flexor retinaculum
ulnar border - hook of hamate
radial border - trapezium
floor - radiocarpal ligaments and palmar ligament complex
describe the median nerve
sensory - palmar cutaneous passes superficial to flexor retinaculum or outside carpal tunnel
- innervates central palm over thenar eminence
enters carpal tunnel
- motor: APB, OP and FPB and 1st nd 2nd lumbricals
- sensory - thumb, index, middle
what are the causes of carpal tunnel syndrome
- synovitis or inflammation
- trauma: colle’s
- edema: pregnancy
- metabolic: diabetes, thyroid
- repeated stress in hands
signs and symptoms of carpal tunnel syndrome
numbness or tingling in hand: thumb, index and middle
paint in wrist or hand that may extend to shoulder
weakness and clumsiness with grip and pinch
worse at night or at driving or when holding objects, gripping
severe - atrophy of thenar muscles
how is carpal tunnel syndrome tested
tinel test - are over median nerve is tapped an palmar surface of wrist; if produces tingling = +
flick’s manuever - pt sitting and shakes hand vigorously; resolution of paresthesia = +
prayer’s test - full wrist and finger extension; if psi on carpal tunnel inc = +
phalen’s test - reverse prayer’s
- better test
what is the treatment of CTS
conservative
- lifestyle modifications
- splinting
- medication
- NSAID
- steroids
- PT
- cortisone injections
surgical - carpal tunnel release
describe the tunnel of guyon
depression superficial to flexor retinaculum betw hook of hamate and pisiform
passage of ulnar nerve and artery into hands to supply intrinsic muscles
boundaries of tunnel of guyon
roof - flexor retinaculum, palmaris brevis and palmar aponeurosis
floor - pisohamate ligament and pisometacarpal ligament
describe the ulnar nerve
from inferior roots of brachial plexus (C8-T1) and branches out at forearm
- palmar cutaneous: skin over hypothenar eminence
- dorsal cutaneous: dorsal aspect of fingers
motor branch passes cubital tunnel to supply FCU and FDP to 4th and 5th digits
describe the ulnar nerve as it passes the tunnel of guyon
deep motor branch - FDM, ADM, ODM, AP, palmaris brevis, 3rd and 4th lumbricals, deep head of FPB and interossei
superficial sensory branch - 4ht and 5th palmary, tips dorsally
describe canal of guyon syndrome
distal impingement of ulnar nerve at canal of guyon
causes of canal of guyon syndrome
ganglion cyst
hook of hamate fracture/displacement
tumors
repetitive trauma
abberant tunnel or excess fat tissue w/in canal
ulnar artery thrombosis or aneurysm
signs and symptoms of canal of guyon syndrome
purely motor/sensory or mixed depending on the zone of nerve lesion
motor
- weakness or paralysis of intrinsic muscles
- weakening of grip
- clawing of 4th and 5th digit: benedict sign
- advanced: hypothenar atrophy
how to test for tunnel of guyon syndrome
froment’s test - grip sheet of paper using thumb; thump IP joint flexion = +
wartenberg’s sign - 5th digit is over-abducted
- seen in ulnar nerve palsy
- sensory: pain/paresthesia of medial palm and ulnar half of 4th digit and anterior of 5th digit
differential diagnosis for canal of guyon syndrome
- test for strength of muscles
- intrinsic: guyon
- extrinsic: ulnar - sparing of dorsal surface of hand and 4th and th fingers = guyon
- tinel’s - tap the nerve to identify and localiz e
differential diagnosis for canal of guyon syndrome and cubital fossa syndrome
- test for strength of muscles
- intrinsic: guyon
- extrinsic: ulnar - sparing of dorsal surface of hand and 4th and th fingers = guyon
- tinel’s - tap the nerve to identify and localiz e
treatment for canal of guyon syndrome
conservative
- avoidance of stress at guyon’s canal
- ergonomical handle bar
- minimize wrist extension
- splint wrist at neutral position at night for 12 wks
- PT
surgical
- for high intensity trauma
describe the radial nerve
splits into superficial and deep as enters cubital fossa
superficial: lateral border of forearm
- at wrist divides into 4-5 digital branches = sensory to lateral 2/3 of dorsal hand and lateral 2 1/2 of fingers
deep: motor to muscles of posterior compartment of forearm
what is the palmar aponeurosis
deep to subcutaneous tissue from palmaris longus tendon to fascia of thenar and hypothenar up to transverse carpal ligament
continues to fingers and splits and wraps the 4 tendons around MCP
protects ulnar artery and nerve and digital nerves and vessels
describe dupuytren’s contracture
fibrotic condition of palmar aponeurosis; nodule or scarring
finger flexion contracture
often in men 55-75
common in ring or 5th finger or both
common bilateral; if uni affects R
clinical appearance of dupuytren’s contracture
small nodular in palmar fascia at MCP joint
flexion of MCP and PIP; DIP sparred
less or no pain - splints and stretching
non-functional or non-correctable - surgery then splint
what is the differential diagnosis for dupuytren’s contracture
rule out flexion from:
- congenital malformation
- spasticity
- trauma and infection
describe the extensor hood and extensor expansion
distal part of the hood receives tendons from lumbricals and distal phalanx
central band - band inserts in proximal dorsal edge of middle phalanx and insert at extensor hood on lateral slide and splits going to distal
lateral bands - rejoins over middle phalanx into terminal tendon and inserts at distal phalanx
what are the flexor tendon zones
1 - tip of finger to middle phalanx; FDP
2 - middle of middle phalanx to distal palmar crease; flexor tendon superficialis and flexor tendon profundus
- no man’s land bc repair is difficult
3 - distal palmar crease to distal edge of flexor carpal ligament; lumbrical zone
4 - under carpal tunnel ligament and carpal tunnel
5 - proximal to wrist joint from origin of flexor tendons to muscle bellies to proximal carpal tunnel
- vv small in thum
what are the extensor tendon zones
1 - DIPJ
2 - middle phalanx
3 - PIPJ
4 - proximal phalanx
5 - MCPj
6 - metacarpals
7 - wrist joint
8 - distal 1/3 of forearm
9 - proximal 2/3 of forearm
what are the extensor tendon injuries
1 - mallet finger
2 - disruption of EPL
3 - central slip; boutonniere’s deformity
5 - fight bite
describe mallet finger
rupture or avulsion of terminal extensor tendon
DIP flex while PIP extended; baseball
what is swan neck deformity
hyperextended PIP and flexed DIP
related to arthritis
injury to extensor tendon insetion
describe boutonierre’s deformity
affectation of central slip tendon; nothing holds PIP
PIP flexed but DIP extended
central slip rupture
what are the flexor pulleys from proximal to distal
A1
A2
C1
A3
C2
A4
C3
A5
what is trigger finger
pain, stiffness or locking when you bend or straighten finger
ring and thumb are most affected
swelling of flexor tendon
- A1 pulley becomes inflamed = hard for tendon to glide
- FDP nodule = same effect
what are the classifications of trigger finger
1 - pain on A1 pulley
2 - triggering on PE can extend PIP active
3A - PIP extended passively
3B - patient cannot flex
4 - rigid or stuck in flexion or extension
etiology of trigger finger
2-3% of gen pop
10% of diabetic popu - common in diabetic
more common in females over 50
treatment of trigger finger
non-operative:
- splinting
- modify activity
- NSAID
- corticosteroid injections
- PT
operative:
- percutaneous release of A1 pulley
- open surgical debridement and release of A1
describe swan neck deformity
most frequent deformity in fingers
- if thumb = zigzag deformity
hyperextention of PIP and flexion of DIP
inability to grasp
causes of swan neck deformity
lax volar plate
imbalance of extension > flexion force on PIP = passive flexion of DIP
rupture of FDS
describe ulnar drift
ulnar shift and deviation at MCP w rheumatoid arthritis
more common than radial bc of opening bottles, doors
MCP capsule and ligaments are stretched = loosens collateral ligaments and dec joint stability
describe intrinsic minus deformity
claw hand - strong extrinsic; no intrinsic
MCP hyperextension and PIP and DIP flexion
causes of intrinsic minus deformity
ulnar nerve palsy - cubital or ulnar tunnel
median nerve palsy
- volkmann’s ischemic fracture
- leprosy: hansen’s
- failure to splint in intrinsic plus
charcot-marie-tooth disease - hereditry
compartment syndrome of hand
describe intrinsic plus hand
spastic intrinsics and weak extrinsics
MCP flexion and PIP and DIP extension
describe gamekeeper’s thumb
rupture of collateral ligament on ulnar side of thumb at MCPJ
overextended and abducted
skier’s thumb; deals w cards
what are the causes of gamekeeper’s thumb
blow or fall on extended thumb
repeated abduction of thumb
signs and symptoms of gamekeeper’s thumbs
pain at base of thumb
swelling at base
difficulty grabbing and throwing
unstable or wobbly thumb
brusing
weak thumb-index pinch
what is the treatment of gamekeeper’s thumb
incomplete acute tears - immobilize for 4-6 wks
acute complete and chronic fracture - surgery
decribe the piano key sign
floating ulnar styloid due to damage to radioulnar ligament
ulnar styloid moves when applying pressure to finger
causes:
arthtritic conditions
ligament laxity
trauma
overuse
