Radial dorsal hand

Question 1

Radial dorsal

Answer 1

1. 1st CMC
2. scaphoid fracture
3. radial styloid
4. De Quervains - EPb & APL
5. Dorsal Radial Sensory Nerve

Question 2

radial dorsal most common

Answer 2

1. first cmc oa
2. de quervains
3. scaphoid fracture/non-union
4. DRSN neuritis

Question 3

1st CMC Ax

Answer 3

40 - 60 yrs old (post menopause) - females

Pt History: morning stifneess, insidious onset pain

Tests: +ve grind test (pain +/- crepitus)
palpation: look for:
Box sign, thumb adduction
Early stages frequently tender on volar aspect

Question 4

1st Mx

Answer 4

Conservative
Conservative:
1. Rest in acute phase + NSAIDs
o Contraindicated if CV or kidney disease or GIT problems, No prolonged use
2. Splint
o Hand based thumb MP joint splint without restricting wrist ROM
3. avoid pinch activities
4. exercises - •
Often have a shorted AdPL need length in the web space
o Peg on the peg space or point of the elbow = self-release
• First, AROM, then isometrics, then progression to resisted palmar ABD
• Provides muscular reinforcement to degenerating beak ligament
• Twisting tube: work on pincer technique > progress to pincer (water bottle weights)
• Strengthen 1st dorsal interosseus (distraction of 1st CMC joint)

Question 5

Scaphoid fracture

Answer 5

* young males
Ax: + xray diagnosis
Palpate the anatomical snuff box: EPL, EPB, AbPL
With ulnar and radial deviation.
Tenderness could be:
Fracture, Non-union or SL instability

• Vascular necrosis - distal to proximal supply
  type:
  1. tubercle - not usualy displaced, Tx is immob.
  2. Waist - 70-80% increased displacmenet w/ inc. need for surgery
  3. proximal pole = inc. risk of avascular necorsis and high chance of surgery

MOI:

1. FOOSH in wrist HE & radial deviation
2. longitudinal compression - non-displacement fracture but less common

Question 6

scaphoid fracture

Answer 6

Closed treatment (plaster for 6-8 weeks)
•	Stable, non-displaced fracture of waist or distal pole
•	Contraindications for closed treatment
o	Proximal pole fracture
o	Delayed union
o	Comminution

Surgical intervention
• Indicated if it is a displaced fracture = ORIF +/- bone graft (NB: 90% heal without surgery)
• Intraoperative stability will determine commencement of mobilisation

Differential diagnosis
• Scapholunate instability
• Keinbock’s disease

Question 7

De Quervains tenosynovitis

Answer 7

• woman - 35 - 55 yo (new mums, pregs, RA)
• degenerative thickening of the extensor retinaculum & APL & EPD tendon sheaths = dec. space for tendon gliding = mechanical impingement

MOI: gradual onset at radial styloid, mum holding bubbba’s head,
Pain with: 1st ext. compartment, ulnar dev (lifting cup, clenching wrist, ‘pulling’ along radial side of wrist), stiffness

Ax:

1. Swelling/thickening
2. Palpate radial styloid + proximal boarder of snuff box.
3. Pain with Thumb flexion + ulnar deviation (Finklestein’s test), Resisted EPB& APL contraction

• EPB and APL tendons form first extensor compartment

Question 8

De Quervains tenosynovitis Mx

Answer 8

Conservative
1. Rest: Education of loading techniques & overuse, on aggravating movements (RD and UD), ADL modification
= Avoid activities that cause mechanical friction of the tendons
Look at proximal segments, ergonomics
2. Kinesiotape

3. SPlint: supp. wrist & thumb (relatively solid)
   Splint to support wrist and thumb (relatively solid splint)
   • Immobilising thumb and wrist reduces mechanical friction of the tendons
   o 3-8 weeks, 24 hours per day (EXCLUDING pain-free ROM)
   o Then wean to a neoprene wrist/thumb support

• Acute symptoms
o Thermoplastic rigid forearm splint to at least 1/3 of forearm for 2 weeks
o Immobilise wrist and thumb
• Subacute
o Neoprene with supports to rest AbPL, EPL

4. MT =
   • Gentle active ROM exercises once pain free
   * no evidenc for strengthening, don’t overstretch/strengthen (do small amounts)
   * tendon gliding ex.
   * Address proximal posture/joints

Surg = decompression of 1st dorsal compartment (cut) to inc. area for tendons to move
- post op wound care, gentle ROM and strengthening acter 6 wks

• Generally takes 6 - 12 wks to resolve
• can be slow and easy to aggravate

Question 9

Dorsal Radial Sensory Nerve Compression: Wartenburg’s syndrome / neuralgia

Answer 9

• caused by compression of brachioradialis tendon & ECRL tendon in hand pronation & wrist ulnar deviation
• Diabetes, tight splints or plasters

MOI: 2nd to injury on radial side of arm & complains of numbness, tingling & weakness in the posterior aspect of thumb

Ax: Tinels test = P&Ns or pain, nerve conduction studies

S/S: numbness tingling pain dorsal radial aspect of hand.
to stretch the nerve:
wrist in flexion
to further stretch:
unlar deviation
Tinel’s:
Tap distally to proximally along nerve pathway

Mx = rest