Session 10 Clinical Conditions Flashcards
What fractures account for 70-80% of carpal bones
Scaphoid
Most common in adolescents and young adults following FOOSH
Patients with a scaphoid fracture usually complain of
Pain in Anatomical snuffbox
Exacerbated by moving the wrist
Passive ROM reduced
Swelling around radial and posterior aspects of wrist
Fractures most commonly affect what part of scaphoid
Waist
Also proximal pole an distal pole
X-rays of scaphoid fracture
May not reveal fracture immediately
10-14 days may show as fracture line become more visible after some bone resorption
CT or MRI may be needed
Complications of scaphoid fracture
Retrograde from distal to proximal pole
Blood supply to proximal pole is tenuous so fractures through waist of scaphoid can result in avascular necrosis
High risk of non-union, malunion or avascular necrosis (secondary OA)
What is colles’ fracture
Extra- articular fracture of the distal radial metaphysis, with dorsal angulation and impaction
Associated ulnar styloid fracture often present
Colles’ fracture features
Most common type of distal radial fracture
Common in patients with osteoporosis such as post-menopausal women
High impact trauma in young kids
Mechanism of fracture for colles’ fracture
FOOSH
Pronated forearm and wrist in dorsiflexion
Presentation of colles’ fracture
Painful, deformed swollen wrist
Fracture line, dorsal angulation and impaction visible on lateral view of X ray
Treatment of colles’ fracture
Reduction and immobilisation in a cast
Complications of colles’ fracture
- Malunion resulting in dinner fork deformity
- Median nerve palsy and post traumatic carpal tunnel syndrome
- Secondary OA
- Tear of extensor pollicis longus tendon
What is smith fracture
Fractures of distal radius with palmar angulation of distal fracture fragments
85% are extra-articular so reverse colles’ fracture
Smith fractures usually occur in
Young males or elderly females
Mechanism of smith fracture
Fall onto dorsum of a flexed wrist or a direct blow to the back of the wrist
What is garden spade deformity
Malunion of smith fracture, residual volar/palmar displacement of the distal radius
Cosmetic deformity
Narrows and distorts carpal tunnel and can result in carpal tunnel syndrome
RA particularly affects
MCPJ, PIPJ, cervical spine
Presentation of RA
- Often symmetrical
- pain and swelling of PIPJs and MCPJs
- erythema
- stiffness worst in morning
- Carpal tunnel syndrome due to synovial swelling
- fatigue and flu-like symptoms
- Rheumatoid nodules
X ray features of RA
Joint space narrowing
Periarticular osteopenia
Juxta-articular bony erosions (marginal)
Subluxation and gross deformity
Most common deformities of people with advanced RA
Swan neck deformity
Boutonnière deformity
What is swan neck deformity
PIPJ hyperextends and MCPJ and DIPJ flex
Tissues on volar aspect of PIPJ become lax as a result of synovitis
Elongation or rupture of insertion of extensor digitorum onto base of distal phalanx
What is boutonnière deformity
MCPJ and DIPJ are hyperextended and PIPJ is flexed
Inflammation in PIPJ leads to lengthening or rupture of extensor digitorum at insertion to base of middle phalanx on dorsal surface
Lateral bands slip down onto palmar surface and act as flexors
What is psoriatic arthropathy
Asymmetrical
Sausage shaped (fusiform) swelling of digits known as dactylitis
Can progress to arthritis mutilans
Psoriatic arthritis most commonly affects DIPJs and causes nail lesions (pitting and onycholysis)
Joint in the hand most commonly affected by OA
1st carpometacarpal joint (between trapezium and first metacarpal)
More common in women
Presentation of OA of 1st CMC joint
Pain at base of thumb- worsened by movement relieved by rest
Stiffness in morning
Swelling
First metacarpal subluxes in ulnar direction
What are Heberden’s nodes
Classic sign of osteoarthritis and affect DIPJ of fingers
Chronic swelling or sudden onset of pain swelling and loss of manual dexterity
Cystic swelling containing hyaluronic acid on dorsal aspect. Initial inflammation and pain subside and left with osteophyte
More women, genetic
What are bouchard’s nodes
OA in PIPJS causing cystic swelling and an osteophyte
What is carpal tunnel syndrome
Compression of median nerve
Risk factors for carpal tunnel syndrome
Obesity Repetitive wrist work Pregnancy RA Hypothyroidism
Consequences of nerve compression
Ischeamia, focal demyelination, decrease in axonal calibre, eventually axonal loss
Complaints in carpal tunnel syndrome
Parasthesia in the distribution of the median nerve
Symptoms worse at night
Daily activities aggravate paraesthesia
Sensation to the palm is spared in carpal tunnel syndrome why
Palmar cutaneous branch of median nerve branches proximal to carpal tunnel and passes superficial into it into the palm
Long standing carpal tunnel syndrome can result in
Muscle weakness and atrophy of thenar muscles (flexor pollicis brevis superficial head, abductor pollicis brevis and opponens pollicis)
Flexion and adduction of thumb in carpal tunnel syndrome
Can still flex thumb as flexor pollicis longus innervated by anterior interosseous branch of median nerve
Can still adduct as adductor pollicis is supplied by ulner nerve
What is ulnar tunnel syndrome
Ulnar nerve compressed in Guyon’s canal
Passes lateral to pisiform bone over volar surface of the flexor retinaculum
Presentation of ulnar nerve compression in Guyon’s canal
Paraesthesia in ring and little fingers
Weakness of intrinsic muscles of hand supplied by ulnar nerve
What is Dupuytren’s contracture
Localised thickening and contracture of palmar aponeurosis leading to flexion deformity of adjacent fingers
Dupuytren’s contracture presentation
Thickening or nodule on palm
Painful or painless
Myofibroblasts contract leading to formation of tight bands called cords
Fixed flexion
Most common affected parts of hand in Dupuytren’s contracture
Ring and little finger
First we space and thumb May also be involved
Conditions that increase risk of developing Dupuytren’s contracture
- Type 1 diabetes
- Frozen shoulder
- Epilepsy
- Liver disease/XS alcohol
- Smoking
- Hypercholesterolaemia
- Heart disease
- HIV
- Hypo or hyperthyroidism
- Trauma to the hand or fingers
- Vibration-related hand injury
Where does the radial nerve run
Radial (spiral) groove in posterior surface of shaft of humerus
Closely associated with the bone and may therefore be injured in a mid-shaft humeral fracture
Will a patient still be able to actively extend their elbow during injury to the radial nerve
Yes
Normal or mildly compromised
Nerve supply to long and lateral heads of triceps are given off prior to the radial nerve entering spiral groove
Medial head supply given off in the spiral groove
Anconeus is paralysed but only has minor role in elbow extension
In what position Will a patient’s wrist and fingers be when the wrist is pronated in radial nerve injury
Wrist and fingers flexed
Paralysis of brachioradialis and all extensor muscles of wrist and fingers
Wrist drop
Likely distribution of sensory impairment in injury to radial nerve
Posterior cutaneous nerve branches from radial nerve above spiral groove so is unaffected
Lower lateral cutaneous nerve of the arm and posterior cutaneous nerve of forearm branch high in spiral groove so are also usually unaffected
Paraesthesia is therefore usually in the distribution of the superficial branch of the radial nerve
Common mechanism of injury to median nerve
Injury to median nerve above level of elbow following supracondylar fracture of the humerus
Injury to median nerve consequences
Paralyse muscles in anterior forearm so will be supinated, flexion weak and accompanied by adduction
Flexion of thumb weak or absent, opposition and palmar abduction absent
When making a fist the index and middle fingers wont flex- hand of benediction
IPJ and MCPJ will be extended and thumb adducted
Ape hand deformity
High lesion if absent flexion of IPJ of thumb 0
Rotation of thumb due to loss of opponens pollicis
Thenar wasting
Injury to median nerve at wrist
Penetrating injury or compression at carpal tunnel
Differs to high as muscles at common flexor origin are intact
LOAF muscles paralysed
What is LOAF
Lumbricals to index and middle fingers
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What is ape hand deformity
Thenar eminence flattened, thumb adducted and laterally rotated
Ulnar nerve injury at wrist damage
Supplies muscles of Hypothenar eminence, adductor pollicis, deep head of flexor pollicis brevis, interossei, lumbricals to ring and little finger, Palmaris brevis, ulnar 1.5 digits
What is claw hand
Long standing damage to ulnar nerve
Affects little and ring fingers (hyperextended at MCP and flexed at proximal and distal IP)
Why are MCPJs of ring and little fingers hyperextended and IPJs flexed in ulnar nerve injury at wrist
MCPJs: 3rd and 4th lumbricals are paralysed (usually flex)
Unopposed extension
IPJs: unopposed flexion from FDS and FDP,
What can be seen in ulnar nerve at wrist injury as consequences
Wasting or interossei
Atrophy of adductor pollicis and first dorsal interosseous - loss of bulk of first web space of hand
Atrophy of Hypothenar muscles - loss of Hypothenar Eminence
Sensation lost in palmar aspect of ulnar 1.5 digits and the dosrum over the distal phalanges
Ulnar nerve may be damaged at the elbow by a
Medial epicondylar fracture or compression of cubital tunnel
Damage to ulnar nerve at elbow leads to
Paralysis of flexor carpi ulnaris, ulnar half of FDP and loss of sensation in dorsal and palmar cutaneous branches
Presentation of ulnar nerve at elbow
Clawing seen is less pronounced - FDP paralysed so not any flexion in DIPJ of ring and little fingers
Only hyperextension at MCPJs and flexion at PIPJs
Intact FDS due to median nerve supply
Ulnar paradox- more proximal inquiry does not cause a more pronounced deformity
