S2_L4 Trauma at the Wrist & Hand Flashcards
Advanced Imaging Techniques
It has value in the identification of inter- and intraosseous ganglia and the synovial cysts of the dorsal wrist.
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
C. Ultrasound
Advanced Imaging Techniques
It can localize the problem but not a pathology. It is highly sensitive to early joint arthrosis, nonunion, and avascularity.
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
B. Bone scans
Advanced Imaging Techniques
Aids in the diagnosis of interosseous ligament tears, intraarticular fractures, vascularity changes, and tears of the TFCC.
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
E. MRI and MR arthrography
Advanced Imaging Techniques
It has value in identifying surface irregularities of joints, identification of exact anatomic location of contrast media leaks, and subtle characteristics of fractures and malunions.
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
D. CT and CT arthrography
Advanced Imaging Techniques
It evaluates the radiocarpal, radioulnar, and midcarpal joints by separate injections (3 phases).
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
A. Arthrography
Advanced Imaging Techniques
Leakage from the distal radiocarpal joint into the distal radioulnar joint indicates a tear of the TFCC.
A. Arthrography
B. Bone scans
C. Ultrasound
D. CT and CT arthrography
E. MRI and MR arthrography
A. Arthrography
Degenerative Joint Disease
Modified TF
A. Heberden nodes are found on the distal interphalangeal joints.
B. Bouchard’s nodes are found on the proximal interphalangeal joints.
TT
The ff are radiologic characteristics of DJD, except
A. Decrease in radiographic joint space
B. Sclerosis of subchondral bone
C. Osteophyte formation at the joint margins
D. Joint deformities
E. None
E. None
TRUE OR FALSE: In order to follow-up known fractures, radiographic intervals are usually 8-12 days after immobilization.
False, to follow-up known fractures, radiographic intervals are usually 7-10 days after immobilization.
Thumb metacarpal fractures
- Comminuted fracture of the base of the first metacarpal
- Fracture dislocation of the base of the first metacarpal resulting from an axial blow to a partially flexed MC
A. Bennet fracture
B. Rolando fracture
- B
- A
TRUE OR FALSE: A Gamekeeper’s fracture is an avulsion fracture at the site of attachment of the MCP joint ulnar collateral ligament.
True
Modified TF
A. Scaphoid fractures occur most commonly in the midportion or waist of the scaphoid, which can lead to necrosis.
B. The proximal pole of the scaphoid is often rendered avascular as a complication of fracture across the waist.
TT
Modified TF
A. The MOI of scaphoid fractures is a fall on an outstretched hand.
B. The blood supply to the scaphoid comes from the distal pole.
TT
Modified TF
A. Pisiform fractures are uncommon and unusually undisplaced, due to a direct blow to the hypothenar eminence.
B. Trapezium fractures occur due to an axial load on an adducted thumb or fall on an extended wrist.
TT
Modified TF
A. Isolated trapezoid fractures are rare.
B. Trapezoid fractures occur due to an axial load on the third metacarpal which often results in a dislocation of the base.
TF
B: Trapezoid fractures occur due to an axial load on the second metacarpal which often results in a dislocation of the base.
TRUE OR FALSE: Rheumatoid arthritis is a degenerative joint disease characteristically seen in the small joints of the wrist, the MCPs, and the IPs.
True
The ff are causes of CTS, except
A. Anatomical compression (fractures dislocations at the wrist)
B. Fluid shifts in pregnancy and menopause
C. Inflammation due to diabetes, thyroid problems, alcoholism
D. Mechanical forces (joint position, vibration, tendon load)
E. None
E. None
Modified TF
A. Conventional radiographs are used to rule out osseous abnormalities or fracture dislocations in the diagnosis of CTS.
B. MRI has a limited role in assessing CTS.
TT
Other diagnostic modalities for CTS:
1. Semmes Weinstein monofilament testing
2. Electrodiagnostic testing
Modified TF
A. Degenerative joint disease or OA usually affects the DIPs, PIPs, and 1st CMC (thumb).
B. Basal joint arthritis affects the 3rd CMC and adjacent joints at the base of the thumb.
TF
B. Basal joint arthritis affects the 1st CMC and adjacent joints at the base of the thumb.
Modified TF
A. The TFCC is a biconcave fibrocartilage band that normally appears dark on all imaging sequences and is surrounded by higher-signal synovial fluid or hyaline cartilage on MRI.
B. The TFCC is best demonstrated on sagittal images.
TF
B: The TFCC is best demonstrated on coronal images.
Modified TF
A. On MRI, traumatic tears of the TFCC tend to be parallel to the long axis of the TFCC.
B. High signal intensity in the region on T2 weighted sequences is the most reliable finding.
FT
A: On MRI, traumatic tears of the TFCC tend to be perpendicular to the long axis of the TFCC.
Radiographic staging of avascular necrosis of the lunate
Radiographs show advanced bone density changes with fragmentation, cystic resorption, collapse of lunate, and subluxation of adjacent carpals.
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
C. Stage III
Radiographic staging of avascular necrosis of the lunate
Routine radiographs are normal. Tomography is positive for linear fracture. MRI confirms vascular changes.
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A. Stage I
Radiographic staging of avascular necrosis of the lunate
Radiographs show perilunate arthritic changes, complete collapse and fragmentation of lunate.
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
D. Stage IV
Radiographic staging of avascular necrosis of the lunate
Radiographs show sclerosis, fracture line, and cystic changes. No collapse deformity.
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
TRUE OR FALSE: Radiographs for trauma at the wrist and hand serve to confirm radiologic evidence union, justify removal of internal fixation, and permit rehabilitation to proceed.
True
Modified TF
A. Complete healing usually take about 4 weeks longer than the period of recommended immobilization.
B. Mobilization of the injured area should be done as soon as clearance is given to minimize stiffness or LOM.
FT
A: Complete healing usually take about 2 weeks longer than the period of recommended immobilization.
Modified TF
A. A general treatment principle is the reduction should be as close to anatomic alignment as possible.
B. Elevation of the extremity can also be done to limit edema.
TT
Immobilization duration for:
1. stable fractures range from [] to [] weeks
2. unstable fractures range from [] to [] weeks
3. avulsion fractures range from [] to [] weeks
- 3 to 4
- 4 to 6
- 6 to 8
TRUE OR FALSE: Immobilization should be done in an intrinsic plus or protected position with the MCPs at an angle greater than 50 degrees.
False, immobilization should be done in an intrinsic plus or protected position with the MCPs at an angle greater than 70 degrees.
Most common neuropathy of the upper extremity, it is a compressive neuropathy of the median nerve at the wrist
Carpal tunnel syndrome
The ff are reasons why the scaphoid is susceptible to fractures, except
A. Acts as a principal block to excessive wrist dorsiflexion
B. Accepts compressive force from the lunate and thumb axis
C. Serves as a link between the carpal rows
D. None
B. Accepts compressive force from the lunate and thumb axis
Correct answer: Accepts compressive force from the capitate and thumb axis
Distal radius fractures
- Dorsal apex and volar angulation of the distal fragment
- MOI: FOOSH, extended wrist
- MOI: Direct blow to the back of the wrist, flexed wrist
A. Colle’s
B. Smith’s
C. Barton
- B
- A
- B
Distal radius fractures
Extraarticular fracture located about 1½ inches proximal to the end of the radius, with a volar apex and dorsal angulation of the distal fragment without an associated ulnar styloid fracture.
A. Colle’s
B. Smith’s
C. Barton
A. Colle’s
Distal radius fractures
Fracture dislocation injury in which the volar or dorsal radial arm is fractured and displaces with the hand and carpus
A. Colle’s
B. Smith’s
C. Barton
C. Barton
Modified TF
A. Dorsal instability of the DRUJ presents with pain and dislocation in supination.
B. Volar instability of the DRUJ presents with pain and dislocation in pronation.
FF
A: Dorsal instability of the DRUJ presents with pain and dislocation in pronation.
B: Volar instability of the DRUJ presents with pain and dislocation in supination.
Functionally, the distal forearm is composed of the ff, except:
A. DRUJ
B. TFCC
C. Radiocarpal ligaments
D. Interosseous membrane
C. Radiocarpal ligaments
Correct answer: Ulnocarpal ligaments
Modified TF: Instability of the DRUJ
A. Pain with ulnar deviation suggests TFCC pathology or ulnar impaction.
B. Snapping or popping sensations may present subluxing or dislocating tendons, carpal instabilities, or TFCC tears.
TT
TRUE OR FALSE: DJD or osteoarthritis is commonly seen in the large joints of the adult hand.
False, DJD or osteoarthritis is commonly seen in the small joints of the adult hand.
Basal Joint Arthritis Grading
Ligamentous laxity of the 1st CMC demonstrated on stress views, whereby the MC base subluxes dorsally and laterally as the tips of the thumbs pressed together
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
A. Stage 1
Basal Joint Arthritis Grading
osteoarthritis is radiographcally evident in adjacent joints
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
C. Stage 3
Basal Joint Arthritis Grading
- osteoarthritis of the thumb MCP is present
- chronic subluxation and osteoarthritis is present
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
- D
- B
Carpal Fractures
- May fracture from a force transmitted from the 5th metacarpal
- 2nd most commonly fractured carpal
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- F
- B
Carpal Fractures
- MOI is direct trauma to the ulnar side of the wrist or an avulsion d/t ligamental damage
- Fractures here can cause thumb weakness, LOM, and chronic joint pain
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- C
- D
Carpal Fractures
- Isolated fractures are rare due to its protected position (located at the center)
- May fracture its body from a direct crush injury
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- E
- F
Carpal Fractures
- Fractures may injure the ulnar nerve and may present with paresthesia and weakness of the intrinsic muscles
- Fractures are associated with scaphoid fractures and lunate dislocations
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- F
- E
Carpal Fractures
- Comprises 60% of all carpal injuries
- MOI is fall on hyperextended wrist or punching with the wrist in hyperextension
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- A
- B
Carpal Fractures
- Fractures are often unrecognized until avascular necrosis forms
- Account for < 5% of carpal fractures
- 1-2% of all carpal fractures
A. Scaphoid fx
B. Lunate fx
C. Triquetrum fx
D. Trapezium fx
E. Capitate fx
F. Hamate fx
- B
- D
- E
TRUE OR FALSE: Hook of hamate fractures can occur due to athletic injuries from bats, hockey sticks, golf clubs, and rackets.
True
Modified TF
A. Instability of the wrist includes instability of the DRUJ and instability between the intercarpal joints.
B. Instability of the DRUJ presents as instability or degenerative arthritis with the primary feature of painful forearm rotation.
TT
Fracture at the junction of the middle and distal thirds of the radius with an associated DRUJ dislocation.
A. Galeazzi fracture
B. Ulnar styloid fracture
C. Radial head fracture
A. Galeazzi fracture
Also known as Essex-Lopresti fracture dislocation. Fracture occurs with dislocation of the DRUJ and disruption of the interosseous membrane.
A. Galeazzi fracture
B. Ulnar styloid fracture
C. Radial head fracture
C. Radial head fracture
Instability of the DRUJ results from this fracture and associated tears of the TFCC.
A. Galeazzi fracture
B. Ulnar styloid fracture
C. Radial head fracture
B. Ulnar styloid fracture
NOTE: Ulnar styloid fractures comprise 50% of the fractures of the distal radius
TRUE OR FALSE: Carpal instability is instability of the wrist with altered joint kinematics in which one or more carpal bones are permitted abnormal movement as a result of joint laxity, ligamentous lesions, or bony abnormalities.
True
Mayo Clinic System
- Unstable scaphoid fracture
- Triquetrum-Hamate-Capitate Ligament Rupture
- Perilunate dislocation
- Scapholunate dissociation
- Lunotriquetral dissociation
A. Carpal instability dissociative
B. Carpal instability nondissociative
C. Carpal instability combined
- A
- B
- C
- A
- A
Mayo Clinic System
Pathology of both extrinsic and intrinsic ligaments of the wrist
A. Carpal instability dissociative
B. Carpal instability nondissociative
C. Carpal instability combined
C. Carpal instability combined
Mayo Clinic System
Involves the pathology of the extrinsic ligaments that leads to abnormal motions of the entire proximal row of carpals
A. Carpal instability dissociative
B. Carpal instability nondissociative
C. Carpal instability combined
B. Carpal instability nondissociative
Mayo Clinic System
Involves pathology in the intrinsic carpal ligaments and occurs between the bones in the same carpal row
A. Carpal instability dissociative
B. Carpal instability nondissociative
C. Carpal instability combined
A. Carpal instability dissociative
TRUE OR FALSE: Basal joint arthritis occurs most commonly in adults with no prior history of trauma but is also seen as a sequelae to fractures or in patients with RA.
True
A lesion of the TFCC is seen as the ff, except
A. An associated injury with distal ulnar fractures
B. A sequela of malunion of distal radial fractures
C. A sequela to excessive loading through the ulnar side of the wrist
D. A result of degenerative changes that produce central defects
E. None
A. An associated injury with distal ulnar fractures
Correct answer: An associated injury with distal radial fractures
NOTE: Central 80-85% of the articular disk is avascular
Modified TF
A. The TFCC serves as an important stabilizer of the DRUJ, controlling the rotational and sliding movements between the radius and the ulna.
B. The TFCC is located in the ulnar area, in close proximity with the extensor carpi radialis brevis.
TF
B: The TFCC is located in the ulnar area, in close proximity with the extensor carpi ulnaris.
Carpal instability
- Malalignment between the scaphoid and lunate
- Classic clinical sign is pain and clicking/clunking sign or when moving from ulnar to radial deviation (a dynamic subluxation)
A. Triquetrum-Hamate-Capitate Ligament Rupture
B. Perilunate dislocation
C. Unstable scaphoid fracture
D. Lunotriquetral dissociation
E. Scapholunate dissociation
F. D and E only
- F
- A
Carpal instability
MOI is a fall on an extended, ulnar deviated wrist
A. Triquetrum-Hamate-Capitate Ligament Rupture
B. Perilunate dislocation
C. Unstable scaphoid fracture
D. Lunotriquetral dissociation
E. Scapholunate dissociation
E
Carpal instability
Complete dislocation of the head of the capitate from the distal surface of the lunate. It is due to high energy trauma involving mechanisms of wrist extension or hyperflexion compression and intercarpals.
A. Triquetrum-Hamate-Capitate Ligament Rupture
B. Perilunate dislocation
C. Unstable scaphoid fracture
D. Lunotriquetral dissociation
E. Scapholunate dissociation
B. Perilunate dislocation
Not a common injury
Stages of Perilunate dislocation
- Capitate displaces volarly; lunate remains aligned with radius
- Capitate displaces dorsally; lunate remains aligned with radius
A. Dorsal, Stage I
B. Dorsal, Stage II
C. Volar, Stage I
D. Volar, Stage II
- C
- A
Stages of Perilunate dislocation
- Capitate displaces dorsally; lunate displaces volarly
- Capitate displaces volarly; lunate displaces dorsally
A. Dorsal, Stage I
B. Dorsal, Stage II
C. Volar, Stage I
D. Volar, Stage II
- B
- D
TRUE OR FALSE: On MRI of the TFCC, an increased internal signal may sometimes be seen on T1 weighted images and this represents degeneration, not a tear.
True
Modified TF
A. 10-15% of distal radius fractures occur in younger adults due to violent injuries.
B. This fracture is also common in children, and the physeal growth plate is involved 14% of the time.
TT
Modified TF:
A. 60-70% of distal radius fractures occur in post-menopausal women.
B. The MOI of this fracture is a fall on an outstretched hand.
TT
Fractures of the hand
- Crush injury is MOI
- Mostly at the base, divided into intra and extra articular
- Can be classified as stable, unstable, or intraarticular
A. phalangeal fx
B. metacarpal fx
C. thumb metacarpal fx
- A
- C
- A
Modified TF
A. Fractures of the metacarpal necks are common metacarpal fractures.
B. Fracture of the 4th metacarpal is known as Boxer’s fracture.
TF
B: Fracture of the 5th metacarpal is known as Boxer’s fracture.
