MSK Re-Up #3 (Finger and Hand) Flashcards
Explain the sensory parts of the median, radial, and ulnar nerves.
-Palmar Side: Median (thumb, index, middle, half of ring). Ulnar (half of ring, pinky)
-Dorsal Side: Ulnar (Pinky, ring, lower half of middle), Radial (lower half of middle, lower half of index, lower half of thumb), Median (Tips of middle, index, and thumb)
What is the motor function of the following nerves:
-Radial Nerve:
-Median Nerve:
-Ulnar Nerve:
Radial: Thumb extension (extensors)
Median: Thumb Opposition (flexors)
Ulnar: Criss cross fingers (intrinsics)
Name the bones of the wrist in order (Palmar side)
-Scaphoid
-Lunate
-Triquetrum
-Pisiform
-Trapezium
-Trapezoid
-Capitate
-Hamate
What is the MC fractured carpal bone? What is it from?
What is one common symptom of this condition?
Scaphoid (Navicular) Fracture
FOOSH
Pain along radial surface of wrist with anatomical snuffbox tenderness
With a scaphoid (navicular) fracture, it may not show up on radiographs for 2 weeks. Therefore, if the patient has snuffbox tenderness, you should treat as a fracture because there is a high risk of _____ and ________.
What is the treatment for a scaphoid fracture if:
-Nondisplaced:
-Displaced > 1 mm:
-High risk of avascular necrosis and nonunion
-Nondisplaced: thumb spica split
-Displaced: ORIF or percutaneous pin placement
Scapholunate dissociation is a widened space between the scaphoid and lunate bones. This occurs due to a FOOSH. What is seen on radiographs?
What is a symptom of this condition?
-Radiographs: Widened scapholunate spaces > 3 mm (Terry Thomas Sign)
-Pain on dorsal radial side of wrist with minimal swelling. Pain with dorsiflexion. May have a click with wrist movement.
What is done initially for scapholunate dissociation and what should be done definitively?
Initially: Radial gutter splint
Definitively: surgical repair of scapholunate ligament
What occurs in a lunate dislocation (explain it)?
Lunate doesn’t articulate with the radius and the capitate.
Explain what can be seen on radiographs with a lunate dislocation.
-Lunate appears triangular (piece of pie sign)
-Displacement and tilt of lunate (spilled teacup sign)
What is the treatment for lunate dislocation?
-Emergent closed reduction and splint followed by ORIF
–This is an orthopedic emergency!
The most serious carpal fracture is _________ because _______.
A common complication of this condition, like a scaphoid fracture is ________.
-Lunate fracture
-Because it occupies 2/3 of the radial articular surface
-Avascular necrosis of the lunate bone (Kienbock’s Disease)
What should you do with a lunate fracture?
-Immobilize and ortho follow up
What is a Mallet (Baseball) Finger and how does it occur?
What is a physical exam finding of this condition?
-Avulsion of extensor tendon after blow to tip of finger causing forced flexion of an extended finger (hyperextension of DIP joint)
-Unable to actively extend the DIP joint
What are the three joints of the metacarpals?
-DIP (Distal)
-PIP (Middle)
-MCP (Knuckle)
What is the management for a mallet (baseball) finger?
-Uninterrupted extension splint (mallet finger splint) of DIP joint x 6-8 weeks
On the other hand, what is a boutonniere deformity of the finger?
Finger flexed at PIP joint and hyperextended at DIP joint
How about a swan neck deformity?
-Finger flexed at DIP joint and hyperextended at PIP joint
What is a gamekeeper’s (skier’s) thumb and how does it occur?
-Sprain or tear of ulnar collateral ligament –> MCP joint instability
-Forced abduction of the thumb (from a fall)
What exam finding would suggest a gamekeeper’s thumb?
What is the treatment?
-Thumb far away from other digits, weakness in pinch strength
-Thumb spica splint and referral to hand surgeon
What is a Boxer’s Fracture?
How does it occur?
-Fracture through the fifth metacarpal neck (maybe the fourth as well)
-Direct trauma to a closed fist against a hard surface (wall)
What is the treatment for a Boxer’s Fracture?
Initial: Ulnar gutter splint with joints at 60’ of flexion
ORIF if > 40 degrees angulation of 5th metacarpal
With a Boxer’s Fracture, what should you always remember to check for? What is the treatment?
-Check for bite wounds
–If present, treat with Amox-Clavulanate (Augmentin)
Explain what a Bennett Fracture and a Rolando Fracture is (what is the difference)?
-Bennett: non-comminuted partial intra-articular fracture of the base of the thumb
-Rolando: comminuted complete intra-articular fracture of the base of the thumb
What is one symptom to remember for a Bennett/Rolando Fracture?
What is one unique finding on radiograph for a Rolando fracture?
-Tenderness to CMC joint (base of thumb)
-Y sign: splitting of first metacarpal base into dorsal and solar fragments (shaped like a Y)
Management for Bennett/Rolando Fractures if:
-Immediate:
-Bennett:
-Rolando:
-Immediate: thumb spica splint
-Bennett: immobilization, closed reduction with pin, ORIF if displaced
-Rolando: ORIF, external fixation, or closed reduction with percutaneous pinning
What is pronator teres syndrome?
What are some symptoms of this condition (think about where the affected nerve sits).
-Median nerve compression where the nerve transverses the pronator teres muscle
-Paresthesia or pain of lateral palmar aspect of the first 3 (and radial half of the fourth) digits.
-Symptoms NOT worse at night (compared to carpal tunnel syndrome)
-Tenderness over proximal median nerve aggravated by pronation of forearm
Management for pronator teres syndrome
-Reduce symptom inducing activities
-NSAIDs for pain
-Steroid injections
-Surgical decompression
Similarly, carpal tunnel syndrome is _____________. There is increased incidence in this condition in what populations?
-Median nerve entrapment and compression at the carpal tunnel
-Women, Diabetics, Pregnancy, Hypothyroidism, RA, Occupations with repetitive extension and flexion of wrists (typing)
Symptoms of carpal tunnel syndrome?
What two diagnostic exam tests can be done to diagnose carpal tunnel syndrome?
-Paresthesias or pain on palmar aspect of first 3 and radial half of fourth digits ESPECIALLY at night
-Thenar muscle wasting in advanced cases
-Tinel Test: percussion of median nerve
-Phalen Test: flexion of both wrists for 30-60 seconds produces symptoms
Management for carpal tunnel syndrome
-Volar splint initial management, NSAIDs, avoid movements
-Corticosteroid injections
-Surgery if refractory
What is a dupuytren contracture?
What are some risk factors associated with this condition?
Progressive fibrosis of the palmar fascia leading to contractures as a result of nodules or longitudinal bands in the palm
-Men, > 40 years old, Northern Europeans, ETOH abuse, cirrhosis, DM, Smoking
Symptoms of a Dupuytren Contracture
-Visible or palpable nodules over distal palmar crease or proximal phalanx (especially ring or little finger) along course of flexor tendons
-Fixed flexion deformity at MCP joint
Treatment for a Dupuytren Contracture
-Intralesional collagenase or steroid injections
-Fasciotomy if refractory or advanced
A trigger finger is entrapment of a finger flexor tendon most times at ________.
Which finger is MC?
Symptoms?
Treatment?
-Most times at the A1 pulley
-Ring finger MC
-Finger clicks or gets locked in flexed position, +/- pain, pain over metacarpal head
-Splint, NSAIDs, Steroid injections
A subungal hematoma is ________
What is the treatment for this? There is a specific procedure
-Blood under the nail plate secondary to trauma
-Trephination (paperclip, 18G needle, #11 blade)
-Dry sterile dressing, wound care
When should you refer a patient to ortho for a subungal hematoma?
-If open wound
-or if 50% diameter of hematoma
A paronychia is _____ and is usually due to what bacteria?
What are some etiologies?
-Infection of lateral nail fold usually due to Staph A
Due to hang nail, local trauma, biting nails, etc.
Treatment for a paronychia
-I&D with digital block
-Wound care (warm soaks, dressing)
-ABX (Cephalexin, Dicloxacillin)
—MRSA: Bactrim, Clinda
On the other hand, a felon is _________
This is MC due to what bacteria?
Treatment is the same as a paronychia.
-Subcutaneous abscess of volar finger pad due to puncture wound (nail, puncture, etc.)
-Staph A
De Quervain Tenosynovitis is entrapment tendinitis of the first dorsal compartment. What two muscles are entrapped?
Who is this seen in (what is the MOA)?
-APL and EPB
–Abdutor pollicus longus
–Extensor pollicus brevis
-Excessive thumb use and repetitive action. Golfers, clerical workers, women postpartum (from lifting newborn), diabetics
Symptoms of De Quervain’s Tenosynovitis
What test can be done to diagnose this condition?
-Pain along radial aspect of wrist and base of thumb radiating to forearm especially with thumb extension or gripping
-Finkelstein Test: pain with ulnar deviation while thumb is flexed in the palm
Management for De Quervain’s Tenosynovitis?
-Thumb spica splint initially
-NSAIDs, PT
-Steroid injections
-Surgical release if refractory
A ganglion cyst is a ______ filled synovial cyst. Explain symptoms of this.
What can you do for it?
-Mucin-filled cyst
Firm, well circumscribed painless mass, fixed to deep tissue. Translucent with illumination.
Observe, Aspirate, Surgery if decreased ROM
What is a Colles Fracture?
MOA?
Explain what is seen on physical examination (how does this fracture look)
-Distal radius fracture with dorsal angulation
-FOOSH with wrist extension
-Dinner fork deformity appearance to the wrist
Management for a Colles Fracture?
-Closed reduction followed by sugar tong splint or cast
-ORIF if unstable (>20 degrees angulation, intraarticular, etc.)
What is the MC complication of a Colles Fracture?
Extensor pollicus longus tendon rupture MC complication
On the other hand, what is a Smith Fracture?
MOA?
Explain what is seen on physical examination (what does this fracture look like)
-Distal radius fracture with ventral angulation of distal fragment
-FOOSH with wrist flexed
-Garden spade deformity appearance to the wrist
Management for Smith Fracture
-Closed reduction followed by sugar tong splint
-ORIF if comminuted or unstable
Suppurative Flexor Tenosynovitis is infection of a flexor tendon sheath of a finger. What is the MCC and what is the MC etiology?
-Staph A from a penetrating injury
Symptoms of Suppurative Flexor Tenosynovitis (FLEX)
-Kanavel’s Signs (FLEX)
–Finger held in flexion
–Length of tendon sheath tender
–Enlarged Finger
–Xtension of finger causes pain
How do you diagnose Suppurative Flexor Tenosynovitis?
Treatment?
-Aspirate and biopsy
-Treatment: I&D, ABX
