Orthopaedics - wrist & hand

Question 1

Distal radius fractures pathophysiology

Answer 1

Most commonly caused by a fall on an outstretched hand (FOOSH)
Due to osteoporosis, the risk of these fractures increases with age
Distal radius takes 80% of the axial load underneath the scaphoid and lunate fossae -> FOOSH causes a forced supination/pronation of the carpus, this in turn increased the impaction load of the distal radius

Question 2

Colles’ fracture

Answer 2

Extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement within 2cm of the articular surface
Typically occurs as a fragility fracture in osteoporotic bone
Occurs when a person falls forwards & plants their outstretched hand in front of them -> transfer of load as their body falls forces the wrist into supination

Question 3

Smith’s fracture

Answer 3

Volar angulation of the distal fragment of an extra-articular fracture of the distal radius, with/without volar displacement
This type of fracture is caused by falling backwards & planting the outstretched hand behind the body, causing a force pronation type injury

Question 4

Barton’s fracture

Answer 4

Intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint
Can be described as volar or dorsal

Question 5

Distal radius fractures risk factors

Answer 5

Increasing age
Female gender
Early menopause
Smoking/alcohol excess
Prolonged steroid use

Question 6

Distal radius fractures clinical features

Answer 6

Present following an episode of trauma, complaining of immediate pain +/- deformity & sudden swelling around the fracture site
Any neurological involvement can also result in paraesthesia/weakness
Examination – important to assess for any evidence of neurovascular compromise
- Nerve function
- Limb perfusion: CRT & pulses
Examine the joints above and below to identify occult injuries

Question 7

Distal radius fracture neurological examination

Answer 7

Median nerve
- Motor: abduction of the thumb
- Sensory: radial surface of distal 2nd digit
- AIN: opposition of the thumb & index finger
Ulnar nerve
- Motor: adduction of the thumb
- Sensory: ulnar surface of the distal 5th digit
Radial nerve
- Motor: extension of IPJ of thumb
- Sensory: dorsal surface of 1st webspace

Question 8

Distal radius fracture investigations

Answer 8

Plain radiographs – AP and lateral:
1) Radial height <11mm
2) Radial inclination < 22 degrees
3) Radial (volar) tilt > 11 degrees
CT/MRI – operative planning

Question 9

Distal radius fracture conservative management

Answer 9

Suitable resuscitation and stabilisation of the patient
Closed reduction in ED, can be performed with a haematoma block or Bier’s block
Below-elbow backslab cast, then radiographs repeated after 1 week to check for displacement
Once sufficient bone healing has occurred, patients should be rehabilitated via physiotherapy

Question 10

Distal radius fracture surgical management

Answer 10

Significantly displaced/unstable fractures
Open reduction and internal fixation with plating/K-wire fixation
Patients will be placed in a cast to ensure ongoing immobility for a few weeks

Question 11

Distal radius fracture complications

Answer 11

Malunion – poor realignment leads to shorted radius compared to the ulnar
- Treated with corrective osteotomy of the malunion
Median nerve compression
Osteoarthritis

Question 12

Scaphoid fractures pathophysiology

Answer 12

Scaphoid is anatomically divided into three parts – proximal pole, waist and distal pole
Dorsal branch of the radial artery enters in the distal pole & travels in a retrograde fashion towards the proximal pole
Therefore, fractures can compromise the blood supply & lead to avascular necrosis (more proximal the fracture, the higher the risk of AVN)

Question 13

Scaphoid fracture clinical features

Answer 13

Fractured following trauma which is often high energy
Complain of sudden onset wrist pain & bruising may be present
Tenderness in the floor of the anatomical snuffbox, pain on palpating the scaphoid tubercle & pain on telescoping of the thumb

Question 14

Scaphoid fracture investigations

Answer 14

Initial plain radiographs should be taken – scaphoid series should be requested: AP, lateral & oblique views
Not always detected by initial radiographs, if there is sufficient clinical suspicion, patient should have wrist immobilised in a thumb splint & repeat plain radiographs in 10-14 days
If repeat radiographic imaging is negative, but clinical findings are still positive, MRI scan is indicated

Question 15

Scaphoid fracture management

Answer 15

Undisplaced fractures – strict immobilisation in a plaster with a thumb spica splint
- Undisplaced fractures of the proximal pole have a high risk of AVN -> surgical treatment may be advocated
All displaced fractures – fixed operatively
- Most common operative technique is using a percutaneous variable-pitched screw

Question 16

Scaphoid fractures complications

Answer 16

Avascular necrosis
Non-union – the bone is failing to heal properly, most commonly due to poor blood supply
- Managed with internal fixation and bone grafts

Question 17

Carpal tunnel syndrome

Answer 17

Compression of the median nerve within the carpal tunnel of the wrist due to a raised pressure within this compartment

Question 18

Carpal tunnel syndrome risk factors

Answer 18

Female gender
Increasing age
Pregnancy
Obesity
Previous injury to the wrist
Associated with other conditions – diabetes mellitus, rheumatoid arthritis & hypothyroidism
Repetitive hand or wrist movements

Question 19

Carpal tunnel syndrome clinical features

Answer 19

Pain, numbness and/or paraesthesia throughout the median nerve sensory distribution
Palm is spared -> palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum
Typically worse during the night & symptoms can be temporarily relieved by hanging the affected arm over the side of the bed/by shaking it back & forth
Examination – sensory symptoms can be reproduced by either percussing over the median nerve (Tinel’s test) or holding the wrist in full flexion for one minute (Phalen’s test)
Later stages – may be weakness of thumb abduction and/or wasting of the thenar eminence

Question 20

Carpal tunnel syndrome investigation

Answer 20

Clinical diagnosis & evident pathology in most cases on history and examination
Nerve conduction studies may be useful to confirm median nerve damage

Question 21

Carpal tunnel syndrome conservative management

Answer 21

Can be treated conservatively initially with a wrist splint -> can relieve some of the symptoms by preventing wrist flexion
Corticosteroid injections can be trialled

Question 22

Carpal tunnel syndrome surgical management

Answer 22

Undertaken in a symptomatic patient, where previous treatments have not been successful
Carpal tunnel release surgery – decompresses the carpal tunnel (can be done under local)
Complications of surgical management – recurrence, persistent CTS symptoms, infection, scar formation, nerve damage, trigger thumb

Question 23

Carpal tunnel syndrome complications

Answer 23

Long-term untreated CTS can lead to permanent neurological impairment that will not improve with surgery

Question 24

Ganglionic cysts

Answer 24

Non-cancerous soft tissue lumps that occur along any joint/tendon
Arise from degeneration within the joint capsule/tendon sheath of the joint, subsequently becoming filled with synovial fluid
Most commonly found around the hands and feet

Question 25

Ganglionic cysts risk factors

Answer 25

Female
Osteoarthritis
Previous joint/tendon injury

Question 26

Ganglionic cysts clinical features

Answer 26

Smooth spherical painless lump adjacent to the joint affected
Examination – lump will be soft & transilluminate, may have neurological symptoms if cyst exerts any pressure upon an adjacent nerve

Question 27

Ganglionic cysts investigations

Answer 27

Most are diagnosed clinically
Plain film radiograph may assist in ruling out differentials
Uncertain cases, imaging via ultrasound or MRI can be done in order to assess the shape, size & depth of the cyst

Question 28

Ganglionic cysts management

Answer 28

Simply monitor as cysts often disappear spontaneously without further intervention
1) Aspiration +/- steroid injection, this is associated with infection & high rate of recurrence
2) Cysts excision – removing the cyst capsule along with a portion of the associated tendon sheath (often reserved for symptomatic cases with recurrence following aspiration)

Question 29

Trigger finger

Answer 29

A condition in which the finger or thumb click or lock when in flexion, preventing a return to extension
Can affect one or more tendons of the hand, with most cases occurring spontaneously in otherwise healthy individuals

Question 30

Trigger finger pathophysiology

Answer 30

Most cases are preceded by flexor tenosynovitis leading to inflammation of the tendon and sheath
Superficial and deep flexor tendons with local tenosynovitis at the metacarpal head subsequently develop localised nodal formation on the tendon
When the fingers are flexed, the node moves proximal to the pulley, however when the patient attempts to extend the digit this node fails to pass back under the pulley
Consequently, digit becomes locked in a flexed position

Question 31

Trigger finger risk factors

Answer 31

Occupation or hobby that involved prolonged gripping and use of the hand
Other risk factors: rheumatoid arthritis, diabetes mellitus, female gender & increasing age

Question 32

Trigger finger clinical features

Answer 32

Initially report a painless clicking/snapping/catching when trying to extend their finger
Over time this may become painful, especially over the volar aspect of the MCPJ
Examination – proximal aspect of the phalanx should be palpated to assess for any clicking, pain associated with movement & any lumps/masses

Question 33

Trigger finger management

Answer 33

Can be managed conservatively, small splint can be used to hold the finger in the extension position at night
Steroid injections can be trialled
Surgical management – percutaneous trigger finger release via a needle, surgical decompression of tendon tunnel can be trialled

Question 34

Trigger finger complications

Answer 34

Recurrence of triggering following surgery is uncommon
Adhesions can form is the patient does not begin immediate motion following surgery

Question 35

De Quervain’s tenosynovitis

Answer 35

Inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling
Most common in women between the ages of 30-50, especially in those with occupations or hobbies involving repetitive movements of the wrist

Question 36

De Quervain’s tenosynovitis risk factors

Answer 36

Age – most common between 30 and 50 years
Female gender
Pregnancy

Question 37

De Quervain’s tenosynovitis clinical features

Answer 37

Complain of pain near the base of the thumb with an associated swelling
Movements – grasping/pinching are particularly painful and difficult
Examination – swelling and palpable thickening over the tendon group fibrous sheath & Finkelstein’s test positive (longitudinal traction & ulnar deviation to the affected thumb)

Question 38

De Quervain’s tenosynovitis investigations

Answer 38

Clinical diagnosis
Plain hand radiograph may be used to exclude other diagnoses

Question 39

De Quervain’s tenosynovitis management

Answer 39

Conservative management – lifestyle advice and a wrist splint, steroid injections will reduce swelling and relieve pain in most cases
Surgical management – surgical decompression of the extensor compartment can be performed under local/general anaesthetic
- Complications: failure to resolve, reduce range of movements in wrist/hand, neuroma formation & nerve impingement

Question 40

Dupuytren’s contracture

Answer 40

Common condition involving contraction of the longitudinal palmar fascia

Question 41

Dupuytren’s contracture pathophysiology

Answer 41

Fibroplastic hyperplasia and altered collagen matrix of the palmar fascia, compositional change leads to a thickening and contraction of the palmar fascia
1) Initial pitting and thickening of the palmar skin & underlying subcutaneous tissue, with loss of mobility of overlying skin
2) A firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing inside
3) A cord then develops, resembling a tendon, which begins to contract over months to years
4) Contraction of the cord pulls on the MCP and PIPJs, leading to progressive flexion deformity in the fingers

Question 42

Dupuytren’s contracture risk factors

Answer 42

Smoking
Alcoholic liver cirrhosis
Diabetes mellitus
Certain occupational exposures

Question 43

Dupuytren’s contracture clinical features

Answer 43

Present at varied stages of progression – may therefore range from reduced ROM & nodular deformity to complete loss of movement
Ring and litter finger are most commonly involved
Examination – thickened band or firm nodule adherent to the skin may be palpable, skin blanching may occur on active extension of the affected digits, advanced disease = affected digit may be in contracture
Hueston’s test – specific test, if patient is unable to lay their palm flat on a table top, this is a positive test

Question 44

Dupuytren’s contracture investigations

Answer 44

Diagnosis is clinical
Patient should have routine bloods (including LFTs and HbA1C) to assess for potential associated risk factors
Ultrasound imaging can be used for increased accuracy in applying intralesional injections

Question 45

Dupuytren’s contracture conservative management

Answer 45

Undergo hand therapy
Injectable collagenase clostridum histolyticum is used by some clinicians in early disease

Question 46

Dupuytren’s contracture surgical management

Answer 46

Surgical procedures – involve the excision of diseased fascia
Indicated in:
- Functional impairment
- MCP joint contracture > 30 degrees
- PIP contracture
- Rapidly progressive disease
Fasciectomy is performed under local/general anaesthetic
Closed fasciotomy – can be performed in the outpatient setting
Finger amputation – only ever considered in very severe cases