MSK 3 Flashcards
What is the most frequently injured portion of the hand?
Fingertips
What is nail trephination and what disorder is it useful for?
Putting a hole in the nail plate to allow instant relief to the pts b/c it releases all the pressure and blood; useful for subungual hematomas
Why is a ring block not suggested for laceration repair?
b/c of the possibility of cutting off blood supply
What are the names of the 2 adhesives that can be used instead of stitches in lac repair?
Indermil and Histoacryl
What area are simple lacerations confined to?
Nail bed (do not extend into peripheral soft tissue)
What are 5 steps to repairing a complex stellate lac?
1) Need to remove nail plate
2) Any free tissue should be put back in place
3) Suture nail bed w/small, absorbable sutures
4) Suture nail plate back
5) Trephination of the nail
What image do you always want to order with complex stellate lac and why?
X-ray b/c likely to find a fx underneath (most likely dealing with open fx and will want to put on abx)
What do you do before suturing a displaced fx?
Reduce them (if needed)
What is mallet finger and what finger is most commonly affected?
An injury to the extensor digitorum tendon at the DIP usually caused by trauma to the distal phalanx; middle finger most common
What is the etiology of mallet finger?
Axial loading of finger; causes sudden forced flexion of distal phalanx→ flexion damages the extensor tendon
What are the 4 findings on clinical presentation/PE of mallet finger?
(1) unable to extend distal phalanx after trauma
(2) pain over DIP
(3) swelling
(4) ecchymosis
What is the tx of mallet finger?
Splinting in full extension or hyperextension for 6-8 weeks 24/7 (or tx has to restart)
What ruptures in rugger-jersey finger and which finger is most commonly affected?
The flexor digitorum profundus; ring finger (75%)
Why does rugger-jersey finger need to be fixed promptly?
b/c if not fixed promptly, pt can be left with FDP finger where they won’t be able to flex that finger again
What is the etiology of rugger-jersey finger?
Forced hyperextension
What are the 3 findings on clinical presentation/PE of rugger-jersey finger?
(1) acute pain
(2) swelling volar aspect of DIP (palmar side)
(3) inability to flex the distal phalanx
What is the tx in almost all cases of rugger-jersey finger?
surgery
What are ganglions and what do they contain?
Fluid filled swelling overlying a joint or tendon sheath; contain mucinous or gelatinous fluid
Where are flexor tendon ganglions usually located? Where are joint ganglions usually located?
Flexor tendon: usually on palms and fingers
joint: usually on dorsal wrist
What are 2 etiologies of ganglions?
(1) degeneration of periarticular structures like synovial lining
(2) repetitive movements
What are 4 possible findings on clinical presentation/PE of ganglions?
(1) obvious swelling
(2) without swelling, just joint pain
(3) cyst typically smooth, firm, rounded and rubbery
(4) sometimes tender
What are the 3 tx options of ganglions?
(1) observation
(2) needle aspiration w/18 G needle w/3 cc syringe (3) surgical removal for recurrent cysts
What is the location of a mucous cyst?
Usually at the DIP on the dorsal surface
What disorder are mucous cysts usually associated with?
osteoarthritis
Differentiate mucous cysts from Heberden’s nodes.
Mucous cysts typically only present on 1 finger, Heberden’s nodes present on multiple fingers
What are 4 possible findings on clinical presentation/PE of mucous cysts?
(1) typically visible swelling on dorsal side of finger
(2) translucent nodule
(3) may be painful
(4) groove in fingernail d/t pressure on the matrix
What are 2 tx options for mucous cysts?
(1) intralesional corticosteroid injections-triamcinolone
2) surgical removal (risk of septic osteoarthritis
What is trigger finger and in what 2 populations is there a higher prevalence?
Stenosing flexor tenosynovitis; a painless snapping, catching, or locking of the finger(s) that occurs during flexion→ pts have to manually extend their fingers
-higher in diabetics and RA pts
What are the 5 tx and management options for trigger finger?
1) Start conservatively
2) NSAIDs
3) Splinting
4) Glucocorticoid injection
5) Surgery to release the A1 pulley
What is Bennett’s fracture?
A fracture dislocation of the base of the metacarpal
What are 3 etiologies of Bennett’s fractures?
(1) axial load on the thumb
(2) hyper abduction +/or hyperextension after fall
(3) torsional injuries
What are 3 possible findings on clinical presentation/PE of Bennett’s fractures?
(1) pain
(2) swelling over dorsal base of thumb
(3) difficulty w/thumb ROM
What is crucial in tx of Bennett’s fractures?
Integrity of the CMC joint of the thumb
What type of splint is applied in a Bennett’s fracture?
thumb spic splint
What is basal joint arthritis?
Arthritis of the CMC joint of the thumb
What are 6 possible findings on clinical presentation/PE of basal joint arthritis?
1) Pain
2) Tenderness
3) Stiffness
4) Swelling
5) Dec strength
6) Pain w/twisting motions (unlocking doors)
What are 5 tx options for basal joint arthritis?
1) NSAIDs
2) Splinting
3) Ice
4) Intra-articular cortisone injections
5) Total joint replacement
What is gamekeeper’s thumb and what is it also known as?
Ulnar collateral ligament injury; skier’s thumb
What are 3 etiologies of gamekeeper’s thumb?
(1) forced abduction of the MCP joint
(2) falling
(3) ski pole injury
What are 2 possible findings on clinical presentation/PE of gamekeeper’s thumb?
1) Pain, tenderness, swelling over the UCL and MCP joint of the thumb ulnar side
2) Stener lesion: usually a sign of complete rupture
How do you tx gamekeeper’s thumb? How do you tx if there is complete rupture?
Splinting-thumb spica cast 4 weeks; complete ruptures require surgical repair
What is herpetic whitlow?
Fingertip infection involving 1 or more fingers that is intensely painful
What is a dead giveaway finding of herpetic whitlow?
Vesicular lesions on fingertips
What is the #1 cause and #2 cause of herpetic whitlow?
HSV-1 and HSV-2
What are the 2 most common digits affected?
Thumb and index fingers
T/F: herpetic whitlow may have a prodrome of fever and malaise.
True
If dx unable to made clinically, what 3 tests can be ordered to confirm herpetic whitlow dx?
(1) Tzank smear
(2) viral culture
(3) serum antibody titers
What are 3 drug options for tx of herpetic whitlow?
(1) acyclovir
(2) famciclovir
(3) valacyclovir
What is felon?
An infection of fingertip pulp
What 2 conditions can felon lead to?
Ischemic necrosis and osteomyelitis
What are 4 possible findings on clinical presentation/PE of felon?
(1) throbbing pain
(2) tension
(3) edema
(4) erythema
What are 3 bacterial etiologies of felon?
(1) Staphlococcus
(2) MRSA
(3) Eikenella corrodens (diabetics who bite their nails)
What are the 2 tx of felon?
(1) I&D
(2) abx directed at MRSA and Staph
What are 6 abx options to tx felon?
1) Dicloxacillan
2) Cephalexin
3) Bactrim
4) Clindamycin
5) Nafcillin
6) Doxycycline
What is a partial amputation?
When bone and tissue keep the part attached still
What should you place an amputated finger in and what should you avoid contact with?
Place finger in saline soaked gauze, in a watertight container (Ziploc bag); avoid direct contact w/ice
What should you always do to an amputated part before reattaching it?
X-ray it to make sure it is still viable and able to be reattached
What is a boutonniere deformity?
Pathologic flexion of the PIP and hyperextension of the DIP; disruption of central slip
What are 3 common causes of boutonniere deformities?
Trauma, RA, and burns
What are 4 possible findings on clinical presentation/PE of boutonniere deformities?
(1) obvious deformity
(2) muscle atrophy
(3) traumatic injury will present w/tenderness
(4) pain and swelling
What are 2 tx options for boutonniere deformities?
(1) splinting (2) surgery to repair central slip with w K-wire
What is a swan neck deformity?
The DIP is flexed and the PIP is hyperextended; volar plate stretches
What are the 3 etiologies of swan neck deformities?
(1) injury
(2) inflammatory conditions like RA
(3) congenital condition- Ehlers-Danlos syndrome
What are 3 tx and management options of swan neck deformities?
(1) silver ring splints
(2) joint fusion
(3) joint arthroplasty
What are 3 common conditions of the hand?
(1) Dupuytren’s contracture (2) boxer’s fracture
(3) hand infections
What are dupuytren’s contractures?
Progressive fibrosis of the palmar fascia that is benign; a loss of full extension of the hand and fingers
Which 2 digits are affected earliest with dupuytren’s contractures?
4th and 5th fingers
What are 4 tx and management options for dupuytren’s contractures?
1) Cortisone injections into sheath
2) Surgery w/open fasciotomy
3) Collagenase injections to reduce contractures and improve ROM
4) Prophylactic external beam radiation therapy to slow progression
A boxer’s fracture is a fx of which metacarpal?
5th
What 5 things do you use to classify a boxer’s fracture?
1) Fracture location
2) Degree of displacement
3) Angulation
4) Shortening
5) Rotation
What must you always pay attention to with boxer’s fractures and why?
Skin integrity (ex: teeth marks) b/c almost always turn into an infection
What are the 5 tx options for boxer’s fractures?
1) Splint non-displaced, well aligned fractures
2) Analgesics
3) Reduction w/local anesthesia
4) Surgical intervention
5) Bite injuries w/fractures: get IV abx, possible washout, and surgery
What are Kanavel’s 4 cardinal signs of flexor tenosynovitis?
(1) tenderness along flexor tendon
(2) edema
(3) pain with passive extension
(4) flexed resting posture
What are the 4 usual bacteria that cause hand infections, and which one is found in cat bites?
(1) Staph
(2) Strep
(3) Pasterella- cat bites
(4) oral anaerobes
What is the sign of a spreading infection on clinical presentation of hand infections?
Lymphangitis
What are 5 abx options for tx of hand infections?
(1) Cephalexin
(2) Clindamycin
(3) Cefazolin
(4) Unasyn
(5) Vancomycin
What are 4 common conditions of the wrist?
(1) Carpal Tunnel Syndrome (2) De Quervain’s tendonitis (3) Scaphoid fx
(4) Colles fx/silver fork deformity
What is carpal tunnel syndrome indicative of?
Median nerve compression
What are 6 possible etiologies of carpal tunnel?
1) Repetitive movements
2) Prolonged force through the wrist
3) Pregnancy and postpartum
4) Use of wheelchairs and walking devices
5) Low aerobic fitness
6) Increased BMI
What are 2 things found on clinical presentation of carpal tunnel?
(1) numbness tingling in thumb, index, and middle fingers
(2) thenar atrophy: wasting and weakness
What are the LOAF muscles?
Lumbricals
Opponens pollicis Abductor pollicis
Flexor pollicis brevis
What are 2 signs/tests on PE indicative of carpal tunnel?
(1) Phalen sign
(2) Carpal compression test
What are 4 diagnostic tests ordered for carpal tunnel?
(1) EMG-electromyography (2) NCS- nerve conduction studies
(3) US
(4) MRI preop-when they open up the wrist so they know what they’re cutting into
What are 4 tx options for carpal tunnel?
1) Mild disease: night splints
2) NSAIDs
3) Work-site eval (to get special keyboard, etc.)
4) Surgical intervention: release the transverse ligament
Which 2 tendons does de quervain’s tendonitis affect and where?
Affects the abductor pollicis longus and extensor pollicis brevis at the radial styloid process
What are 5 findings on clinical presentation of de quervain’s?
(1) radial side pain
(2) swelling
(3) difficulty holding or gripping
(4) radiation to thumb and forearm
(5) x-rays normal
Which test would be positive if de quervain’s is present?
Finkelsteins
What are 4 tx options of de quervain’s?
1) Thumb spica splint
2) NSAIDs
3) Local glucocorticoid injections
4) Surgery: cutting the first extensor dorsal compartment
What most commonly causes a scaphoid fracture?
FOOSH- fall on outstretched hand
What are 4 findings on clinical presentation of a scaphoid fx?
(1) snuffbox tenderness
(2) swelling
(3) pain
(4) grip strength decreased
What are 4 tx options of scaphoid fractures?
(1) splinting
(2) casting
(3) bone stimulation
(4) surgical intervention
A colles fracture is a fracture of what?
Fracture of the distal radius
What are the 2 common causes of a colles fracture?
FOOSH and direct blow
What are 3 tx options for a colles fracture?
(1) reduction
(2) casting
(3) surgery
What are 3 common conditions of the forearm?
(1) Galeazzi fracture
(2) Monteggia
(3) Compartment syndrome
What is a galeazzi fracture and what is it associated with?
A midshaft forearm fracture of the radius associated w/instability or dislocation of distal radioulnar joint-DRUJ
What are the 2 types of traumas that cause galeazzi fractures?
1) High energy trauma (direct blow):
- Falls from height
- Motor vehicle accident
- Sport injuries
2) Low energy trauma (osteoporosis)
- Falls from standing
What is anterior interosseous nerve palsy?
Damage to flexor pollicis longus and flexor digitorum profundus; loss of pinch
What type of splint do you use to fix galeazzi fractures?
Sugar tong splint
What is monteggia?
A fracture of the proximal third of the ulnar shaft + dislocation of the radial head
What is monteggia commonly associated with?
Outstretched hand with forced pronation
What are 6 possible findings on clinical presentation?
1) Significant deformity
2) Elbow pain
3) Pain with elbow flexion and forearm rotation
4) Tenderness
5) Swelling
6) Paresthesia and numbness from radial nerve impingement
What are 4 tx options for monteggia and which ones are specific to adults and children?
1) Splint w/sugar tong
2) Closed reduction and long arm casting for children-ketamine for sedation
3) Adult: associated with significant instability so need surgery
4) Open reduction internal fixation (ORIF)
What is compartment syndrome?
Increased pressure in a compartment that compromises the circulation; occurs following trauma and is a surgical emergency
Compartment syndrome is usually caused by what?
Fractures of the radius and ulna (any fx involving long bones)
What 2 things happen in compartment syndrome that cause it to worsen?
Fascia prevents expansion of tissue and venous outflow decreases
What are 5 nontraumatic causes of compartment syndrome?
(1) animal envenomation (snake and spider bites) (2) injection of rec drugs-Heroin
(3) prolonged compression
(4) thrombosis
(5) vascular disease
What are 9 findings on clinical presentation/PE of compartment syndrome?
1) Rapid progression of symptoms
2) Tense, painful muscles red flag
3) Compartment pressures 10-30 mmHg compromise perfusion
4) Neurologic or vascular compromise
5) Pain out of proportion to injury
6) Deep burning ache
7) Paresthesia
8) Muscle weakness
9) Paralysis
How do you dx compartment syndrome?
Measuring compartment pressures via handheld manometers, insertion of catheter into compartment, or an 18G needle attached to an arterial pressure monitor
How do you tx compartment syndrome?
Surgical emergency and fasciotomy (to relieve pressure- pack and dress wound after procedure)
How long after onset of acute compartment syndrome is neuromuscular damage irreversible
4-6 hours→ limb can become useless w/in 24-48 hrs
