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Session 10 Clinical Conditions Flashcards

1
Q

What fractures account for 70-80% of carpal bones

A

Scaphoid

Most common in adolescents and young adults following FOOSH

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2
Q

Patients with a scaphoid fracture usually complain of

A

Pain in Anatomical snuffbox
Exacerbated by moving the wrist
Passive ROM reduced
Swelling around radial and posterior aspects of wrist

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3
Q

Fractures most commonly affect what part of scaphoid

A

Waist

Also proximal pole an distal pole

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4
Q

X-rays of scaphoid fracture

A

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

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5
Q

Complications of scaphoid fracture

A

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)

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6
Q

What is colles’ fracture

A

Extra- articular fracture of the distal radial metaphysis, with dorsal angulation and impaction

Associated ulnar styloid fracture often present

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7
Q

Colles’ fracture features

A

Most common type of distal radial fracture

Common in patients with osteoporosis such as post-menopausal women

High impact trauma in young kids

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8
Q

Mechanism of fracture for colles’ fracture

A

FOOSH

Pronated forearm and wrist in dorsiflexion

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9
Q

Presentation of colles’ fracture

A

Painful, deformed swollen wrist

Fracture line, dorsal angulation and impaction visible on lateral view of X ray

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10
Q

Treatment of colles’ fracture

A

Reduction and immobilisation in a cast

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11
Q

Complications of colles’ fracture

A
  • Malunion resulting in dinner fork deformity
  • Median nerve palsy and post traumatic carpal tunnel syndrome
  • Secondary OA
  • Tear of extensor pollicis longus tendon
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12
Q

What is smith fracture

A

Fractures of distal radius with palmar angulation of distal fracture fragments

85% are extra-articular so reverse colles’ fracture

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13
Q

Smith fractures usually occur in

A

Young males or elderly females

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14
Q

Mechanism of smith fracture

A

Fall onto dorsum of a flexed wrist or a direct blow to the back of the wrist

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15
Q

What is garden spade deformity

A

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

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16
Q

RA particularly affects

A

MCPJ, PIPJ, cervical spine

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17
Q

Presentation of RA

A
  • 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
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18
Q

X ray features of RA

A

Joint space narrowing
Periarticular osteopenia
Juxta-articular bony erosions (marginal)
Subluxation and gross deformity

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19
Q

Most common deformities of people with advanced RA

A

Swan neck deformity

Boutonnière deformity

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20
Q

What is swan neck deformity

A

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

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21
Q

What is boutonnière deformity

A

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

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22
Q

What is psoriatic arthropathy

A

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)

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23
Q

Joint in the hand most commonly affected by OA

A

1st carpometacarpal joint (between trapezium and first metacarpal)

More common in women

24
Q

Presentation of OA of 1st CMC joint

A

Pain at base of thumb- worsened by movement relieved by rest

Stiffness in morning

Swelling

First metacarpal subluxes in ulnar direction

25
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
26
What are bouchard’s nodes
OA in PIPJS causing cystic swelling and an osteophyte
27
What is carpal tunnel syndrome
Compression of median nerve
28
Risk factors for carpal tunnel syndrome
``` Obesity Repetitive wrist work Pregnancy RA Hypothyroidism ```
29
Consequences of nerve compression
Ischeamia, focal demyelination, decrease in axonal calibre, eventually axonal loss
30
Complaints in carpal tunnel syndrome
Parasthesia in the distribution of the median nerve Symptoms worse at night Daily activities aggravate paraesthesia
31
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
32
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)
33
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
34
What is ulnar tunnel syndrome
Ulnar nerve compressed in Guyon’s canal Passes lateral to pisiform bone over volar surface of the flexor retinaculum
35
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
36
What is Dupuytren’s contracture
Localised thickening and contracture of palmar aponeurosis leading to flexion deformity of adjacent fingers
37
Dupuytren’s contracture presentation
Thickening or nodule on palm Painful or painless Myofibroblasts contract leading to formation of tight bands called cords Fixed flexion
38
Most common affected parts of hand in Dupuytren’s contracture
Ring and little finger First we space and thumb May also be involved
39
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
40
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
41
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
42
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
43
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
44
Common mechanism of injury to median nerve
Injury to median nerve above level of elbow following supracondylar fracture of the humerus
45
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
46
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
47
What is LOAF
Lumbricals to index and middle fingers Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis
48
What is ape hand deformity
Thenar eminence flattened, thumb adducted and laterally rotated
49
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
50
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)
51
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,
52
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
53
Ulnar nerve may be damaged at the elbow by a
Medial epicondylar fracture or compression of cubital tunnel
54
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
55
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

Msk (38 decks)

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