Orthopaedics & Rheumatology/ Elbow, Hand And Wrist Injuries

Question 1

Soft tissue injury associated with elbow pain reproduced by resisted wrist or middle finger extension

Answer 1

Lateral epicondylitis (tennis elbow)

Question 2

Soft tissue injury associated with - elbow pain from overuse of flexor pronator, made worse by wrist flexion

Answer 2

Medial epicondylitis (golfer’s elbow or little league elbow)

Question 3

Soft tissue injury associated with - acute onset of medial elbow pain after throwing, worst at acceleration phase

Answer 3

Ulnar collateral ligament sprain

Question 4

Soft tissue injury associated with - posterior elbow pain at terminal extension while throwing

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Answer 4

Posterior impingement

Question 5

What is the most common carpal fracture in the hand?

Answer 5

Scaphoid fracture

Question 6

How is the diagnosis of a scaphoid fracture made?

Answer 6

• Fracture on radiographs
  
  • Radiographs may take 10-14 days to reveal the fracture
• clinical suspicion
  
  • tenderness in the anatomical snuff box.

Question 7

What is the treatment of an uncomplicated scaphoid fracture?

Answer 7

Thumb spica cast for 12 weeks

Question 8

With a distal interphalangeal (DIP) joint fracture, when do you need to use open reduction/internal fixation (ORIF) to avoid degenerative change?

Answer 8

If >30% of the articular surface is involved

Question 9

Injuries most commonly associated with - A teenage softball player hurt her finger while catching a ball yesterday. On examination, she is tender over the distal interphalangeal (DIP), and unable to extend the joint fully, without evidence of fracture.

Answer 9

Ruptured distal extensor tendon at distal phalanx (mallet finger)

Question 10

What is the treatment of Ruptured distal extensor tendon at distal phalanx (mallet finger)?

Answer 10

Splint DIP joint continuously for 6 weeks

Question 11

Injury commonly associated with - a football player hyperextends his fourth right finger while tackling an opposing player during practice today, and now has bruising and tenderness over the entire volar aspect of his finger and cannot flex the DIP.

Answer 11

Avulsion of flexor digitorum profundus (jersey finger)

Question 12

What is the treatment of a jersey finger(avulsion of flexor digitorium profoundus) ?

Answer 12

Splint finger and immediate orthopedic referral

Question 13

In commonly associated with - patient presents 2 weeks after a forced flexion injury of the proximal interphalangeal (PIP) joint. He did not see a doctor initially, but now presents with a flexion deformity of the PIP joint.

Answer 13

• Central slip tear of the extensor mechanism proximal to PIP (Boutonniere deformity)

Question 14

What is the treatment of a Boutonniere deformity?

Answer 14

Splint PIP in full extension for 6 weeks

Question 15

What is the treatment of a mild collateral ligament sprain of the PIP joint, with no fracture on x-ray, and slight laxity?

Answer 15

Buddy taping to adjacent finger for 6 weeks, NSAIDs for symptomatic relief

Question 16

A patient presents to your office with swelling at the base of her thumb, and pain that is worse when she tries to make a fist or move her thumb. She has lost strength in her grip and ROM in her thumb. What is the most likely diagnosis?

Answer 16

De Quervain tenosynovitis

Question 17

What tendons are involved in De Quervain tenosynovitis?

Answer 17

• Abductor pollicis longus
• extensor brevis

Question 18

What physical examination test is diagnostic of De Quervain Tenosynovitis?

Answer 18

Finkelstein test: full flexion of thumb in the palm, then ulnar deviation of the wrist

Question 19

What group of patients is most commonly affected by De Quervain Tenosynovitis?

Answer 19

Middle-aged women

Question 20

What is the treatment of De Quervain Tenosynovitis?

Answer 20

• Thumb spica splint and 2-week course of NSAIDs
• With corticosteroid injection if no improvement

Question 21

What nerve is entrapped at the wrist in carpal tunnel syndrome (CTS)?

Answer 21

Median nerve

Question 22

What conditions can precipitate CTS?

Answer 22

• Overuse trauma
• diabetes mellitus
• thyroid dysfunction
• pregnancy
• rheumatoid arthritis

Question 23

What is the differential diagnosis of pain and paresthesias in the wrist?

Answer 23

• Arthritis
• cervical radiculopathy at C6
• ulnar neuropathy
• ganglion cyst
• hypothyroidism
• diabetic neuropathy
• flexor carpi radialis tenosynovitis

Question 24

What group of people does carpal tunnel most often affect?

Answer 24

Middle-aged or pregnant women

Question 25

Where do patients typically report paresthesias or numbness in CTS?

Answer 25

• Median nerve distribution: palmar aspect of thumb, index finger, long finger, and half of the ring finger

Question 26

What daily tasks will patients with carpal tunnel often complain of trouble with?

Answer 26

• Opening jars
• grasping objects
• twisting lids
• driving
• reading

Question 27

Aside from the wrist, where do patients often report aching in CTS?

Answer 27

Proximal forearm and in some cases the shoulder

Question 28

What physical examination findings can suggest a diagnosis of CTS?

Answer 28

• Thenar atrophy
• weakness of thenar muscles
• positive provocative test

Question 29

The name of the clinical test- Have the patients place the wrists in flexion and look for aching or numbness in the median nerve distribution within 60 seconds

Answer 29

Phalen maneuver

Question 30

The name of the clinical test- The examiner uses his thumb to put pressure over the median nerve at the wrist for up to 30 seconds, looking for either pain or numbness in the median nerve distribution

Answer 30

Durken carpal compression test

Question 31

Name the clinical test- The examiner taps over the median nerve at the wrist and looks for tingling in some or all digits in the median nerve distribution

Answer 31

Tinel sign

Question 32

How is the diagnosis of CTS made?

Answer 32

• Clinical history and physical examination
• electrophysiologic testing only to confirm, if needed

Question 33

What is the treatment of mild cases of CTS?

Answer 33

• Splinting in neutral position at night and as tolerated during the day
• NSAIDs
• ergonomic modifications to keyboards if work-related

Question 34

If conservative treatment fails, what other therapies can be considered?

Answer 34

Corticosteroid injection to carpal canal

Question 35

What are the indications for referral in CTS?

Answer 35

• Failed nonsurgical treatment for 3 months or persistent sensory loss

Question 36

What is the treatment of CTS in pregnancy?

Answer 36

• Splinting or corticosteroid injection (since most cases resolve after delivery)