MSK Hand/Wrist Flashcards
metacarpal fx’s result of what trauma?
direct trauma
what is a boxer’s fx? how does it occur? what angulation do see on PE?
fx thru the 5th metacarpal neck
occurs when an object is struck with a closed fist
have volar angulation (up to 40 deg) is acceptable
what should be assessed with boxer’s fx? why?
assess to see if there is rotational deformity - rotational deformity is NOT acceptable
tx of boxer’s fx?
If >45 deg volar angulation: reduce
Orthoglass splint first, then ulnar gutter cast 3-4 weeks
Surgical repair if rotated or >45 degrees volar angulation -> cast 3-6 weeks
what is a Bennett fx dislocation?
intra-articular (break crosses into surface of joint) two-part fx of the base of 1st metacarpal d/t forced abduction of 1st metacarpal
what is the most frequent thumb fx?
Bennet fx dislocation
what is seen on imaging for Bennet fx?
2-piece fracture dislocation at the base of 1st metacarpal
Intra-articular extension
Dorsolateral dislocation
-lateral retraction of the first metacarpal shaft by abductor pollicus longus
Small fragment of 1st metacarpal continues to articulate with trapezium
what is a Rolando rx?
comminuted Bennet’s fx (at least 3 parts) -> worse prognosis
CRPP tx of Bennet fx if?
CRPP fixation if:
- < 3mm of displacement
- When break of the fragment <50% of plamar slope of the metacarpal
- When concave dome of the metacarpal maintained
what type of cast for Bennet fx?
thumb spica cast for 4-6 weeks
if CRPP of Bennet fx is not possible, then what’s the tx?
ORIF with AO cortical screw
what common fx’s use thumb spica cast?
Bennet fx-dislocation
Scaphoid fx’s
what is the MOST frequently fx carpal bone?
scaphoid
what part of the scaphoid is most commonly fx?
waist
scaphoid suspected with what fall?
FOOSH
what part of scaphoid is most commonly fx in kids?
distal pole d/t ossification sequence
tenderness with what compression and towards what in scaphoid fx?
Tenderness with axial compression of thumb toward the snuff box
limitation of what wrist movements with scaphoid fx? radial and ulnar deviation results in pain on what side of wrist?
wrist flexion and extension
pain on radial side of wrist
forced ___ elicits significant tenderness in scaphoid fx
Forced dorsiflexion usually elicits significant tenderness in scaphoid fx
what is the blood supply of the scaphoid? 80% of scaphoid via ___ blood flow
dorsal carpal branch of radial artery
-80% of scaphoid via retrograde blood flow
time to union of scaphoid fx’s is greater for what scaphoid fx’s/
proximal scaphoid fx’s
fx of distal third of scaphoid heals when? fx of middle third heals when? fx of proximal third heals when?
Fracture of distal third heal in approx. 6-8 weeks
Middle third fractures heal in 8-12 weeks
Fracture of proximal third heal in 12-23 weeks
at what location is the incidence of avascular necrosis 100% with scaphoid fx? 33%
proximal 5th AVN rate of 100%
proximal 3rd AVN rate of 33%
tx of non-displaced scaphoid fx?
thumb spica splint/cast x6 weeks followed by short thumb spica splint/cast until signs of union are seen on radiograph
tx of displaced scaphoid fx?
ORIF followed by thumb spica cast 6-8 weeks
what is basal joint arthritis?
arthritis of the 1st CMC joint
what is the most common form of OA of the hand?
basal joint arthritis
basal joint arthritis more common in what people?
post-menopausal women
what do ppl with basal joint arthritis complain of?
insidious radial thumb pain that originally worsened with use
when do you change casts for scaphoid fx? why?
cast changes q 10-14 days for 1st 6 weeks to ensure it remains firms around forearm/wrist
what actions increase pain in basal joint arthritis?
opposition (writing, opening jars, carrying heavy objects) increases pain
PE of basal joint arthritis
+TTP at trapeziometacarpal joint as well the scaphotrapezial joint in advanced stage
Grind test of the trapeziometacarpal joint will often produce pain
tx of basal joint arthritis?
- NSAIDs
- Splinting
- Ice
- Intraarticular cortisone injection
- Total joint replacement
how is total joint replacement done for basal joint arthritis?
“anchovy technique” (excision of distal 1/2 trapezium, FCR tendon used as spacer - put in FCR tendon)
what is Boutonniere deformity and what is the tx?
seen in RA
-flexion of PIP and hyperextension of DIP
Tx:
Splinting - tried for 3 months before surgery
Surgery - strengthen, repair of central slip, and hold with K-wire
what is swan neck deformity and what is the tx?
seen in RA
-hyperextension of PIP and flexion of DIP
Tx:
- ***silver ring splints
- joint fusion
- joint arthroplasty
what nerve is compressed in carpal tunnel syndrome? what is the compression d/t?
median nerve in the carpal tunnel d/t decreased canal size of increased volume of soft tissue structures in the canal
what are the 2 signs that are positive for carpal tunnel syndrome?
+ Tinel sign (tap over transverse carpal ligament to produce paresthesias)
+ Phalen’s sign
tx of carpal tunnel syndrome
Conservative
- Wrist splint
- PT
- Ergonomics
- Steroid injection
- Surgery
what is deQuervain’s Tenosynovitis? what tendons are affected?
Stenosing tenosynovitis of 1st dorsal compartment of wrist
- Abductor pollicus longus (APL)
- Extensor pollicus brevis (EPB)
sx of deQuervain’s Tenosynovitis?
pain, swelling, point tenderness along dorsal aspect of wrist
what test is used to dx deQuervain’s Tenosynovitis?
Finklestein test
- fist made with thumb inside fingers
- ulnar deviation of wrist reproduces pain
tx of deQuervain’s Tenosynovitis?
- Rest/activity modification
- Thumb spica cast/splint immobilization
- NSAIDs
- PT
- Steroid injections
- Surgical decompression of first dorsal compartment
what is a gamekeeper’s thumb?
Injury to ulnar collateral ligament of thumb at MCP joint
what does gamekeeper’s thumb result in?
instability of MCP joint and decreased thumb grip strength
gamekeeper’s thumb aka?
Skier’s thumb
-injury resulting from FOOSH while gripping ski pole
what will plain films show for gamekeeper’s thumb? what other views MUST you do?
Plain films may not show deviation
Will need to perform stress view
tx of gamekeeper’s thumb? (conservative and surgical)
Conservative (partial tear):
-Thumb spica cast/splint immobilization for 4-6 weeks
Surgical (full tear)
- Open repair of avulsed ligament
- Necessary for Stener lesion
what are the Kanavel’s 4 cardinal signs of hand infection (tenosynovitis)
- Tenderness along flexor tendon
- Edema
- Pain with passive extension
- Flexed resting posture
hand infections often from what traumas?
cat bite, human bite, puncture wounds (always x-ray heroin users)
usual bacterial of hand infections?
***staph, oral anaerobes
strep, pasteurella
sx’s of hand infections
- Erythematous, swollen, warm area
- ***Painful to PROM
- Decreased AROM
- Pustule
- Lymphangitis
x-ray hand infections for what?
foreign bodies and osteomyelitis
tx of hand infections
IV Abx
-Cephalexin, Clindamycin, Cefazolin, Unasyn, Vanco
Pain management
Surgical wash out
tx for finger dislocation?
- Recheck NV status
- Volar alumafoam splint
- Buddy-tape
- APAP, NSAIDs, and ice
- Follow-up with hand surgeon
what is mallet finger?
Disruption of extensor mechanism of finger at DIP joint
mallet finger classically occurs playing ___ and when what happens to DIP?
sports when DIP undergoes sudden flexion (extended finger is struck at the tip of an object I.e. baseball or basketball)
mallet finger includes what 2 injuries?
both bony avulsion injury and tendinous injury without avulsion
sx’s of mallet finger?
Inability to extend the DIP joint
Slight flexion at rest, which is where the term “mallet” comes from
tx of mallet finger?
Stax splint for 6-8 weeks with DIP in slight hyperextension
DIP joint splint (puts DIP in 10 degrees of hyperextension for tissue contact)
what must you explain to pt about DIP joint splint for mallet finger?
that the DIP joint splint CAN’T BE REMOVED for 8 weeks
what’s a jersey finger?
Avulsion injury of flexor digitorum profundus tendon from insertion at base of distal phalanx
jersey finger classically occurs during what activities and what motion?
during certain sports resulting from sudden hyperextension of actively flexed finger (i.e. grabbing opponent’s jersey during rugby)
what finger is involved with jersey finger? why?
Ring finger
-FDP insertion into ring finger anatomically weaker than middle finger
sx’s of jersey finger?
Inability to flex the finger at DIP joint
Slight extension at joint
+TTP over volar aspect distal finger
what does MRI show for jersey finger?
disruption of flexor digitorum profundus (FDP) at volar base of distal phalanx +/- avulsion fragment
tx for jersey finger? (conservative and surgical)
Conservative for partial tear (i.e. splinting, NSAIDs, PT)
Surgical intervention: all complete flexor tendon injuries should be surgically repaired
what is trigger finger?
Stenosing flexor tenosynovitis
what is trigger finger d/t? what does it result in?
repetitive microinjury from frequent flexion-extension movements of the fingers
results in thickening of the flexor tendon sheath and tendon
trigger finger more prevalent among pts with what diseases?
DM, RA
sx’s of trigger finger
- Difficult to straighten or bend affected finger
- Finger transiently gets locked in the flexed position and then with a painful snapping sensation goes into extension
- Patients often say they have to manually extend their fingers
what do pts with trigger finger say they have to do to their fingers?
have to manually extend their fingers
tx of trigger finger?
surgery - release the A1 pulley
what is dupuytren’s contracture?
slowly progressive fibrosis of the palmar fascia
loss of what in dupuytren’s contracture?
loss of full extension of the hand and finger
sx’s of dupuytren’s contracture? what side of palms affected? which fingers affected earliest?
Initially complain of thickening or nodules in palm
May be painless at first
Ulnar side of both palms
4th and 5th fingers affected earliest
tx of dupuytren’s contracture?
***Cortisone injections into sheath
Surgery with open fasciotomy
Collagenase injections- reduces contractures improves ROM
Ppx external beam radiation therapy- slowed progression
what is a ganglion cyst?
soft tissue tumor of hand (M/C)
flexor tendon and joint (dorsal wrist)
fluid filled swelling overlying a joint or tendon sheath (contains mutinous or gelatinous fluid)
sx’s of ganglion cyst?
Obvious swelling
Can have NO swelling but HAVE joint pain
Cyst is smooth, firm, rounded, rubbery
tx of ganglion cyst?
splinting
needle aspiration with 18G needle and 3cc syringe
surgical removal for recurrent cysts
what is a mucous cyst? associated with?
benign cysts usually at the DIP (dorsal surface)
associated with OA
sx’s of mucous cyst?
swelling on dorsal side of finger
translucent nodule
groove in fingernail d/t pressure on the matrix
tx of mucous cyst?
Intralesional corticosteroid injections (triamcinolone)
Surgical excision
what is Herpetic Whitlow? involves what part of finger?
intensely painful fingertip infection
involves distal phalanx
what is herpetic whitlow d/t?
HSV-1 (60%)
HSV-2 (40%)
why are toddlers more susceptible to herpetic whitlow?
d/t thumb-sucking
sx’s of herpetic whitlow?
Painful, edematous fingertip with vesicular lesions
Most common digits are thumb and index finger
assessment for herpetic whitlow?
- Clinical
- Tzank smear
- Viral culture
- Serum antibody titers
tx for herpetic whitlow?
it’s self-limited
Acyclovir PO or Topical
what is felon? what fingers most affected? what can it lead it?
infection of fingertip pulp
thumb and index fingers most affected
can lead to ischemic necrosis and osteomyelitis
what can lead to felon?
untreated paronychia
sx’s of felon?
- Throbbing pain
- Tension
- Edema
- Erythema
assessment of felon?
Culture any fluid
-Staph, MRSA, Eikenella corrodens found in diabetics who bite their nails, GI pathogens
tx of felon?
-I&D
- **Abx directed at Staph and MRSA
- Dicloxacillin
- Cephalexin
- Bactrim
- Clindamycin
- Nafcillin
- Doxycycline
most nail bed injuries involve what else?
the finger tips
nail bed injuries from what injury?
crush injury
tx for nail bed injuries?
Anesthesia- finger block or sedation
- No ring block
- NO EPI
Adhesives can be used instead of stitches
Simple laceration
-Not extending into peripheral soft tissue
Subungal hematoma
-Trephination
complex stellate repair for nail bed injuries?
need to remove nail plate
if crush injury causing nail bed injury, what part of finger is fx?
distal phalanx fx
what is compartment syndrome? occurs when?
Increased pressure in a compartment compromises the circulation
occurs following trauma
common sites of compartment syndrome?
leg and forearm
compartment syndrome is a complication associated with what injuries?
closed injuries to extremities
what is the tip off of compartment syndrome? suspect in what pts?
pain level higher than expected
suspect in pts with casts and in pain
early sx’s of compartment syndrome?
pain out of proportion to injury
paresthesia - pins and needles sensation
late sx’s of compartment syndrome?
5 P’s
- pain
- pallor
- pulselessness
- paresthesia
- paralysis
compartment syndrome often caused by fx’s in what bones?
radius and ulna
what prevents expansion of tissue in compartment syndrome?
muscle fascia
tx for compartment syndrome
Fasciotomy
- surgical intervention required to relieve pressure in compartment
- return to OR for closure at later date
limit of how many intra-articular corticosteroid injections per joint?
limit of 3 injections per joint in a 12-month period
adrs of intra-articular corticosteroid injections
- Blanching of skin
- Localized fat atrophy
- Infection
- Transient rise in blood glucose levels
dose of intra-articular corticosteroid injections in shoulder/knee
1ml of 80 mg of Depo-Medrol, 2ml of 1% lidocaine without epi, and 2ml of .5% Marcaine
dose of intra-articular corticosteroid injections in greater trochanteric bursitis
1ml of 80 mg of Depo-Medrol, 1ml of 1% lidocaine without epi, and 1ml of .5% Marcaine
dose of intra-articular corticosteroid injections in elbow epiconylitis
.5ml of 80 mg of Depo-Medrol, .5ml of 1% lidocaine without epi, and .5ml of .5% Marcaine
