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Junior surgery > T&O - wrist and hand > Flashcards

T&O - wrist and hand Flashcards

1
Q

Describe this X-Ray

A
  • AP and Lateral X-Ray views (of unknown person taken at unknown time)
  • Of the Right wrist and hand
  • The most obvious deformity is a extra-articular fracture to the distal radius with dorsal angulation and dorsal displacement consistent with a Colle’s fracture
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2
Q

How does a Smith’s fracture appear on X-ray?

A
  • Extra-articular Distal radius fracture with volar angulation +/- volar displacement
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3
Q

What is a Barton’s fracture?

A

An intra-capsular fracture of the distal radius with associated dislocation of the radio-carpal joint

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4
Q

What are risk factors for distal radius fractures?

A
  • Mainly related to osteoperosis
  • Increasing age
  • Female gender
  • Early menopause
  • Smoking
  • Alcohol excess
  • Prolonged alcohol missuse
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5
Q

How do you assess the neurovascular supply of the hand following a distal radius fracture?

A

Median nerve:

  • Sensory radial surface of 2nd digit
  • Motor abduction of the thumb (anterior iterosseus nerve)

Radial nerve:

  • Sensory dorsum of 1st web space
  • Motor extension of IPJ of the thumb

Ulnar nerve:

  • Sensory ulnar surface of 5th digit
  • Motor adduction of the thumb (Frommet’s sign)
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6
Q

What measurements are taken on an X-ray of a distal radius fracture?

A
  1. Radial height (<11mm)
  2. Radial inclination (<22º)
  3. Radial volar tile (>11 º)
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7
Q

How are distal radius fractues managed?

A

Mostly conervatively: traction and manipulation under anaesthetic + below elbow backslab cast

Surgery: only required if severely displaced or unstable

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8
Q

What complications can occur after a distal radius fracture?

A
  • Malunion
  • Dinner fork deformity in Colle’s fracture if not properly manipulated
  • Median nerve compression
  • Osteoarthritis
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9
Q

Describe the blood supply to the scaphoid

A

Branches of the radial artery

a) volar branch
b) dorsal branch - supplies 80% of blood

  • enters the distal pole in a retrograde fashion
  • The more proximal the scaphoid fracture the high the risk of AVN
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10
Q

What is felt on examination in a scaphoid fracture?

A
  • Sudden onset wrist pain and bruising following trauma
  • Tenderness over the anatomic snuffbox
  • Pain on palpating the scaphoid tubercle
  • Pain on telescoping of the thumb (pulling)
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11
Q

What x-ray views are needed in scaphoid fractures?

A
  • Lateral
  • AP
  • Oblique
  • Knwon as the ‘scaphoid series’
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12
Q

What is the issue with detecting a scaphoid fracture on initial presentation? How do you procede?

A
  • Fractures are not always detected on initial x-ray
  • If there is clinical suspicion despite negative imaging then immobilise wrist in a thumb splint and repeat 10-14 days later
  • If radiographing is still negative 10-14 days later then do an MRI of the wrist
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13
Q

How are scaphoid fractures managed?

A

Undisplaced: struct immobilisation under plast with a thumb splint

However, due to high risk of AVN surgery may be advocated especially if it is the patients dominant hand

Displaced: will need surgery - percutaneous variable pitched screw

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14
Q

What are some of the complications of a scaphoid fracture?

A
  • AVN (risk increases the more proximal the fracture)
  • Non-union due to poor blood supply
    • can be managed with internal fixation and bone grafts
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15
Q

Give the border and contents of the carpal tunnel

A
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16
Q

What are some risk factors for developing carpal tunnel syndrome?

A
  • Female
  • Increasing age
  • Pregnancy
  • Obesity
  • Previous wrist injury
  • Diabetes Mellitus
  • RA
  • Hypothyroidism
  • Repetive hand or wrist movements
17
Q

Descibe the clinical presentation of carpal tunnel syndrome?

A
  • Pain numbness and paraesthesia in median nerves sensory distribution
    • palm is often spared as plamar cutaneous branch of median nerve branches before carpal tunnel
  • Symptoms typically worse at night
    • can be relieved by hanging affected arm out the bed or shaking
  • No visible findings on examination
  • Tinel’s test (percussing over nerve) and Phalen’s test (wrist in full flexion for 1 minute causes the sesnsory symptoms
  • Later stages: may see weakness of thumb abduction or wasting of the thenar eminence
18
Q

What differential diagnosis should be considered if suspecting carpal tunnel syndrome?

A
  • Cervical Radiculopathy - C6 nerve root compression causes similar paraesthesia distribution but there will be neck pain and involvement of entire arm
  • Pronator Teres syndrome - median nerve compression by prontaor teres. Symptoms extend to proximal forearm and palm sesnation is reduced
  • Flexor carpi radialis tenosynovitis- causes tenderness at the base of the thumb
19
Q

How can carpal tunnel syndrome be managed?

A
  • Conservative: wrist splint, preventing wrist flexion, physiotherapy and training exercises
  • Corticosteroid injections direct to carpal tunnel
  • Trial NSAIDs but little evidence
  • Surgery for severely limiting cases
20
Q

Briefly explain carpal tunnel surgery

A
  • Decompression of the carpal tunnel by cutting through the flexor retinaculum which reduces the pressure on the median nerve
  • Can be done under local anaesthetic as a day case
21
Q

What are some complications of carpal tunnel decompression surgery?

A
  • perisitant CTS symptoms if ligament release is incomplete
  • infeciton
  • scar
  • nerve damage
  • trigger thumb
22
Q

What complication can arise if carapal tunnel is untreated?

A

Long term CTS can cause permanent neurological impairment

23
Q

What is Dupuytren’s contracture?

A

Contraction of the longitudinal palmar fascia, starts as painless nodules then develops fibrous cards and flexion contractures which can severely limit digital movement

24
Q

Describe the pathophysiology of Dupuytren’s Contracture

A

Fibroplastic hyperplasia and altered collagen matrix of the palmar fascua leads to thickening and contraction

  1. Inital pitting and thickening of palmar skin and underlying subcut tissue - there is loss of mobility of overlying skin
  2. Firm painless nodules begin to form, gradually increasing in size
  3. Cord develops resmbling a tendon - contracts over months to years
  4. Contraction of the cord pull on MCP and PIP joints causing progressive flexion deformity in the fingers
25
Q

What are some of the risk factors for developing Dupuytren’s Contracture?

A
  • Smoking (x3 more than non-smokers)
  • Alcoholic liver cirrhosis
  • Diabetes mellitus
  • Occupational exposure e.g. vibration toold and heavy manual work
26
Q

Which fingers are most commonly affected by Dupuytren’s contracture?

A

Ring and little finger

(bilateral in 45% of cases)

27
Q

Which test can be performed to test of Dupuytren’s contracture?

A

Hueston’s test

As the patient to lay their palm flat on a table top

If unable to do so this is a positive test

28
Q

How is Duypuytren’s contracture diagnosed?

A

Diagnosis is clinical however should have routine bloods including LFTs, random glucose/ HbA1C to assess for risk factors

NO imaging required

29
Q

What conservative management is done for Duypuytren’s contracture?

A
  • Hand therapy - keeping hand active with multiple stretch exercises throughout the day
  • Injectible collagenase clostridium histolyticum (CCM) - can used in early disease
  • Radiotherapy and steroid injections are not routinely recommeneded
30
Q

What surgical mangement can be done for Duypuytren’s contracture?

A

Basically excision of disease fascia

Indicated in those with functional impairment, MCP joint contracture of >30 degrees, any PIP contracture or rapidly progressive disease

Fasciectomy done under local/general aneasthesic

31
Q

What is De Quervain’s tenosynovitis?

A

Inflammation of the tendons within the first extensor compartment of the wrist causing pain and swelling

Affect the tendons of extensor pollicis brevis and abductor pollicis longus

32
Q

Give some of the main risk factors for developing De Quervain’s tenosynovitis

A
  • Age - age 30-50 most common
  • Female
  • Pregnancy
  • Occupations/ hobbies involving repepetitive movement of hand and wrist
33
Q

How do patients with De Quervain’s tenosynovitis present?

A
  • Pain near the base of thumb with associated swelling (secondary to thickening of tendon sheath)
  • Movements involving pinching or grasping are painful and difficult
  • O/E: swelling and palpable thickening over the tendon group fibrous sheath
  • Finkelstein’s test +
34
Q

What is Finkelstein’s test?

A

Used to assess for De Quervain’s tenosynovitis

Examiner applies longitudinal traction and ulnar deviation to the affected thumb

Pain is felt at the radial styloid process and along the legnth of extensor pollicis brevis and abductor pollicis longus

35
Q

How is De Quervain’s tenosynovitis managed?

A

Conservative:

  • lifestyle advice - avoid repetitive actions
  • wrist splint
  • steroid injections to reduce swelling and relieve pain

Surgical decompression:

  • if do not respond to conservative management
  • Involves incision to tendon sheath, tunnel roof forms again but heals wider and with more space for tendons to move

Junior surgery (8 decks)

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