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Surgery Block > Orthopaedics - Wrist and Hand > Flashcards

Orthopaedics - Wrist and Hand Flashcards

1
Q

What is the most common carpal bone to be fractured?

A

Scaphoid

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2
Q

What demographic are scaphoid fractures most common in?

A

Men aged 20-30 years

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3
Q

Why is the scaphoid at risk of AVN after a fracture?

A

It recieves blood supply in a retrograde fashion - from the distal end to proximal

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4
Q

What are the clinical features of a scaphoid fracture?

A 
Hx of high energy trauma
Tenderness in the anatomical snuffbox 
Sudden onset wrist pain 
Bruising
Pain on palpation of scaphoid tubercle
Pain on telescoping of ipsilateral thumb
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5
Q

What are the DDx of radial wrist pain following trauma?

A 
Scaphoid fracture
Distal radial fracture
Fracture of other carpal bone
Fracture of base of 1st MC
Ulnar collateral ligament injury
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6
Q

What investigation is used for a scaphoid fracture?

A

X Ray of the hand - scaphoid series (has anteroposterior, lateral and oblique views)

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7
Q

What should be done if there is high clinical suspicion of a scaphoid fracture but negative imaging?

A

Wrist immobilisation in a thumb splint
Repeat plain radiographs in 10-14 days

–> if still negative then MRI wrist

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8
Q

What is the management of an undisplaced scaphoid fracture?

A

Immobilisation with a thumb splint

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9
Q

What is the management for a displaced scaphoid fracture?

A

Percutaneous variable pitched screw

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10
Q

What are the complications arising from scaphoid fractures?

A 
AVN
Non union (due to poor blood supply)
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11
Q

What are the three most common distal radial fracture types?

A

Colle’s (90%)
Smith’s
Barton’s

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12
Q

In what way do distal radial fractures often occur?

A

FOOSH

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13
Q

Describe a Colle’s fracture

A

Extra articular fracture of distal radius with dorsal angulation and displacement - within 2cm of articular surface
By definition also includes avulsion fracture of ulnar styloid

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14
Q

Describe a Smith’s fracture

A

Extra articular fracture of the distal radius with volar angulation +/- displacement

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15
Q

Describe a Barton’s fracture

A

Intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint
(can be volar or dorsal)

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16
Q

What are the risk factors for osteoporosis?

A
  • Increasing age
  • Female
  • Early Menopause
  • Smoking
  • Alcohol excess
  • Prolonged steroid use
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17
Q

Which nerves should be assessed as part of a NV examination in distal radius fractures?

A

Median
Anterior interosseous
Ulnar
Radial

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18
Q

What are the main Ddx for distal radial fractures?

A

Forearm fracture
Carpal bone fracture
Tendonitis or tenosynovitis
Wrist dislocation

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19
Q

What are the measurements used on an X-Ray for a distal radial fracture?

A

Radial height <11cm
Radial inclination <22º
Radial (volar) tilt >11º

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20
Q

What is the management of a displaced distal radial fracture?

A

Closed reduction - needs sufficient traction and MUA

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21
Q

How may a distal radial fracture be restricted for healing?

A

Below-elbow backstab

Surgical intervention using ORIF, K wire or external fixation

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22
Q

Why are X-Rays repeated one week after placement in a backstab?

A

To assess for any displacement

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23
Q

What are the main complications of a distal radial fracture?

A

Malunion
Median nerve compression
Osteoarthritis

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24
Q

What measurement of the radoiocarpal joint gives indication for surgical correction?

A

Intra articular step or radoiocarpal joint >2mm

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25
Q

What is ‘trigger finger’?

A

Stenosing flexor tenosynovitis

Causes the finger or thumb to click or lock in flexion

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26
Q

What conditions is trigger finger associated with?

A

Rheumatoid arthritis
Amyloidosis
Diabetes mellitus

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27
Q

What is the pathophysiology of trigger finger?

A
  • Finger tenosynovitis leading to inflammation of the tendon and sheath
  • Nodal formation at the tendon, distal to the pulley
  • Flexion causes the node to move proximal to the pulley, after which it cannot pass back causing the locking
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28
Q

What are the main risk factors for development of trigger finger?

A 
Occupation/hobby with prolonged gripping and use of hand
RA 
DM
Female
Increasing age
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29
Q

What is the typical description of a presentation of trigger finger?

A

Painless clicking or snapping when extending the finger (can develop pain over time - especially volar aspect)

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30
Q

What are the DDx for trigger finger?

A

Dupuytren’s contracture
Acromegaly
Infection of the tendon sheath
Ganglion of a tendon sheath

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31
Q

What investigations are indicated for trigger finger?

A

Clinical diagnosis - investigations may only be needed to rule out DDx

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32
Q

What is the management of a mild trigger finger?

A

Conservative - advice on activities causing pain and small splint
Steroid injections may be trialled

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33
Q

What surgical management can be used for trigger finger?

A

Percutaneous trigger finger release

Surgical decompression of a tendon tunnel can be tried in severe cases

34
Q

What is the risk to patients if they do not begin immediate motion following surgical management of trigger finger?

A

Adhesion formation

35
Q

What is Dupuytren’s contracture?

A

Contraction of the longitudinal palmar fascia - starts as painless nodules, fibrous cords and then flexion contractures at the MCP and IP joints

36
Q

Which demographic does Dupuytren’s contracture tend to most commonly occur in?

A

Men (6x more) with peak onset 40-60yrs

37
Q

Describe the pathophysiology of Dupuytren’s contracture

A

Fibroplastic hyperplasia and altered collagen matrix of the palmar fascia –> thickening and contraction of the palmar fascia

38
Q

What is the pattern of disease progression in Dupuytren’s contracture?

A
  1. Pitting + thickening of palmar skin and underlying sub cut tissue with loss of mobility in overlying skin
  2. Firm, painless nodule forms. Becomes fixed to skin and deeper fascia
  3. Cord develops, resembling a tendon
  4. Contraction of the cord pulls on MCP and PIP joints
39
Q

What risk factors are there for Dupuytren’s contracture?

A
  • Smoking (x3)
  • Alcoholic liver cirrhosis
  • Diabetes mellitus
  • Occupational exposure (eg. use of vibrational tools or heavy manual work)
40
Q

What clinical features are there in Dupuytren’s contracture?

A
  • Reduced range of motion
  • Nodular deformity
  • Thickened band on palm
  • Skin blanching on active extension
41
Q

What specific test can be done for patients with Dupuytren’s contracture?

A

Hueston’s test - positive if patient is unable to lay palm flat on tabletop

42
Q

Where does Dupuytren’s contracture most commonly affect

A 
Ulnar digits (4th+5th)
Right hand if unilateral
43
Q

What can be injected to help relieve pain in Dupuytren’s contracture?

A

Injectable collagenase clostridium histolyticum (CCM)

44
Q

What initial management is given for Dupuytren’s contracture?

A

Hand therapy - daily stretching exercises to keep the hand active

45
Q

What surgical procedures can be used for Dupuytren’s contracture?

A

Fasciectomy

  • Regional (entire cord removed)
  • Segmental (only short segments)
  • Dermofasciectomy (cord and overlying skin removed)
46
Q

What indications are there for surgery in Dupuytren’s contracture?

A
  • Functional impairment
  • MCP joint contracture >30 degrees
  • PIP contracture
  • Rapidly progressive disease
47
Q

What is De Quervain’s Tenosynovitis?

A

Inflammation of the tendons within the first extensor compartment of the wrist

48
Q

What demographic does De Quervain’s tenosynovitis tend to affect?

A

Women between the ages 30-50

49
Q

What risk factors are there for De Quervain’s tenosynovitis?

A
  • Age (30-50yrs)
  • Female
  • Pregnancy
  • Occupations/hobbies involving repetitive movements
50
Q

What are the clinical features of De Quervain’s tenosynovitis?

A
  • Pain near base of thumb
  • Associated swelling
  • Thickening over tendon group fibrous sheath
  • Pain on grasping/pinching
51
Q

What is Finkelstein’s test?

A

Longitudinal traction and ulnar deviation applied to affected thumb - pain at radial styloid process + along length of EPB and APL tendons is positive for De Quervain’s tenosynovitis

52
Q

What are the main DDx for De Quervain’s tenosynovitis?

A
  • Arthritis of CMC joint
  • Intersection syndrome
  • Wartenberg’s syndrome
53
Q

What is the Grind test?

A

Forcefully pushing thumb against CMC joint whilst rotating slightly - positive when pain is felt on volar side of wrist

54
Q

What is intersection syndrome?

A

Pain felt over the second compartment due to tendons in the first compartment crossing over those in the second

55
Q

What is Wartenberg’s syndrome?

A

Neuritis of the superficial radial nerve

56
Q

What conservative management is there for De Quervain’s tenosynovitis?

A
  • Lifestyle - avoidance of repetitive actions
  • Wrist splint
  • Steroid injections to reduce swelling and pain
57
Q

What surgical management can be used in De Quervain’s tenosynovitis?

A

Surgical decompression of the extensor compartment - transverse or longitudinal incision made and tendon sheath split in central aspect

58
Q

What are the complications of surgical decompression for De Quervain’s tenosynovitis?

A
  • Failure to resolve
  • Reduced range of motion in wrist or hand
  • Neuroma formation
  • Nerve impingement
59
Q

What is a ganglionic cyst?

A

Non-cancerous soft tissue lump that occurs along any joint or tendon

60
Q

What causes formation of a ganglionic cyst?

A

Degeneration within the joint capsule/tendon sheath of the joint, which then becomes filled with synovial fluid

61
Q

What demographic do ganglionic cysts tend to most commonly affect?

A

Females - peak age of onset at 20-40yrs

62
Q

What are the main risk factors for developing ganglionic cysts?

A
  • Female
  • Osteoarthritis
  • Previous joint/tendon injury
63
Q

How does a ganglionic cyst present clinically?

A

Smooth spherical painless lump found adjacent to affected joint
Will transilluminate

64
Q

What are the main DDx for ganglionic cysts?

A
  • Tenosynovitis
  • Giant cell tumour of the tendon sheath
  • Lipoma
  • Osteoarthritis
  • Sarcoma
65
Q

What is the treatment for an asymptomatic ganglionic cyst?

A

Monitor as they often disappear spontaneously

66
Q

What symptoms may patients with ganglionic cysts present with?

A
  • Pain or paraesthesia if compression of adjacent nerves

- Mechanical restriction of range of motion

67
Q

What management is there for a symptomatic ganglionic cyst?

A
  • Aspiration +/- steroid injection

- Cyst excision

68
Q

What is carpal tunnel syndrome?

A

Condition in which there is increased pressure within the carpal tunnel causing median nerve compression

69
Q

What is the main demographic affected by carpal tunnel syndrome?

A

Females aged 45-60

70
Q

What are the main risk factors for carpal tunnel syndrome?

A
  • Female
  • Increasing age
  • Pregnancy
  • Obesity
  • Previous wrist injury
  • Repetitive hand/wrist movements
  • Diabetes
  • Rheumatoid arthritis
  • Hypothyroidism
71
Q

What symptoms do patients with carpal tunnel syndrome tend to complain of?

A

Pain, numbness and/or paraesthesia in the median nerve distribution

72
Q

Why is the palm often spared in carpal tunnel syndrome?

A

Palmar cutaneous branch of the median nerve branches proximal to the flexor retinaculum (ie. doesn’t pass through carpal tunnel)

73
Q

What is characteristic about the pain in carpal tunnel syndrome?

A

Worse at night - relieved by hanging affected arm over the side of the bed or by shaking it back and forth

74
Q

What two tests can specifically be done for carpal tunnel syndrome?

A 
Tinnels test (percuss over carpal tunnel)
Phalens test (hold wrists in full flexion for 1min)
75
Q

What may be seen in later stages of carpal tunnel syndrome?

A

Weakness of thumb abduction and/or wasting of thenar eminence

76
Q

What are the main DDx for carpal tunnel syndrome?

A
  • Cervical radiculopathy
  • Pronator teres syndrome
  • Flexor carpi radialis tenosynovitis
77
Q

What is pronator teres syndrome?

A

Median nerve compression by pronator teres

78
Q

What conservative treatment is indicated for carpal tunnel syndrome?

A
  • Wrist splint
  • Physiotherapy
  • Corticosteroid injections
  • NSAIDs
79
Q

What surgical treatment is there for carpal tunnel syndrome?

A

Carpal tunnel release surgery - decompresses the carpal tunnel by cutting into the flexor retinaculum

80
Q

What are the complications of carpal tunnel release surgery?

A
  • Persistent CTS symptoms
  • Infection
  • Scar formation
  • Nerve damage
  • Trigger thumb

Surgery Block (12 decks)

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