The Wrist & Hand Flashcards
Causes of wrist/hand pain that fall into that are considered “serious diagnoses” are divided into what 2 categories?
- Traumatic or insidious
- Post-operative
List 4 traumatic/insidious diagnoses that can cause wrist/hand pain.
- fracture (scaphoid)
- instability
- nerve injury
- inflammatory arthritides
What are the top 5 physical findings which are most useful in screening for wrist fracture? Which 3 are the most sensitive? What is the bottom line with regards to referring the patient for x-rays?
- localized tenderness (Sn 94%)
- pain on active motion (Sn 97%)
- pain on passive motion (Sn 94%)
- pain with grip (Sn 71%)
- pain with supination (Sn 68%)
Bottom Line: any one of these findings + h/o trauma should get radiographs
Fractures of the metacarpals accounts for roughly what percentage of all hand fractures?
over 50% of hand fractures occur in the metacarpals
What is a mallet fracture and what is the most common cause in sports?
base of distal phalanx; most common MOI is a ball hitting the extended finger
What is a distal phalanx fracture called?
Mallet fracture
What are the 2 most common mechanisms of injury of a metatarsal shaft fracture?
direct trauma or repetitive stress
What is a Boxer’s fracture, and what is the most common MOI?
fracture of distal shaft of 5th metatarsal; most common MOI is direct trauma or repetitive stress
What is the most common MOI for Hamate fractures in sports
direct trauma or repetitive stress while holding a racquet
What is the most common MOI for a scaphoid fracture?
FOOSH (fall on outstretched hand)
What is a Smith’s fracture and what is the most common MOI?
distal radius fracture from a FOOSH in wrist flexion
What is a Colles’ fracture, and what is the most common MOI?
distal radius fracture from a FOOSH in wrist extension
Describe the longitudinal compression test for scaphoid fracture. What are the general specificity/sensitivity?
- axial loading of thumb
- passively abduct & extend thumb at the MCP
- apply compressive load through the metacarpal bone
- (+) if painful
- sensitivity and specificity are both excellent (both 98%)
What are 3 ways to test for scaphoid fracture. What are the general specificity/sensitivity?
- snuffbox tenderness
- resisted supination
- longitudinal/axial compression
sensitivity and specificity are both excellent for all three tests (98%-100%)
Dx: vague wrist pain with the sensation of “clicks” or “clunks”
scapholunate instability
What is the most common MOI for scapholunate instability pain?
FOOSH in ulnar deviation
How will a patient with scapholunate instability present during grip testing?
weak grip with minimal pain
Describe the purpose & performance of the Scaphoid Shift test. What is the general sensitivity?
- test to rule out scapholunate instability
- place wrist in ulnar deviation
- palpate scaphoid tubercle with thumb & grasp with index finger on the dorsal side
- maintain firm pressure on scaphoid with thumb while passively moving wrist into radial deviation
- (+) if “clunk” occurs and/or pain is recreated
- (release may cause a click as the scaphoid reduces)
sensitivity is okay, but not great (69%)
Dislocation of which carpal bone can commonly cause volar swelling of the median nerve? What neurologic test might be abnormal in this case?
lunate bone; decreased 2-point discrimination in median nerve distribution
Patients with which wrist condition tend to hold their fingers in partial flexion? Why?
lunate dislocation; they tend to have pain with active/passive wrist/finger extension
Describe the purpose & performance of the Ballottement test for the wrist.
- (+) test is suggestive of a wrist/carpal dislocation
- grasp the lunate between the index finger & thumb
- with other hand, grasp triquetrum (medial/ulnar side of lunate)
- move volarly/dorsally (back & forth)
- (+) test is pain, laxity, and/or crepitus
Which wrist/carpal dislocation can produce considerable swelling? Which dislocation usually presents with minimal swelling?
- perilunate dislocation = lots of swelling (deformity is often present due to fracture fragments on dorsal side)
- scapholunate dislocation = usually minimal swelling
Describe the performance of the Finger Extension test. What are the general specificity/sensitivity?
- put patient’s wrist in flexion
- resist extension of fingers 2-5
- excellent sensitivity (96%) and good specificity (88%) for carpal instability or wrist ganglion cyst
List 4 conditions which might result in a (+) Finger Extension test.
- radiocarpal instability
- midcarpal instability
- scaphoid instability
- occult wrist ganglion cyst
Which soft tissue injury is often present with radial bone fractures?
Triangular Fibrocartilage Complex (TFCC) injury
List the 3 most common mechanisms of Triangular Fibrocartilage Complex (TFCC) injury.
- fall on hyperextended wrist
- distraction
- drill use/gripping
Which soft tissue injury often presents with ulnar variance / radial shortening on radiographs?
Triangular Fibrocartilage Complex (TFCC) injury
List 4 common physical exam findings in a patient with Triangular Fibrocartilage Complex (TFCC) injury.
- pain/clicking with wrist ROM
- wrist weakness
- increased mobility with distal radioulnar joint mob
- lunotriquetral ligament tenderness
What are the 3 connective tissue structures that make up the Triangular Fibrocartilage Complex (TFCC) of the wrist?
- radioulnar ligament
- ulnar collateral ligament
- tendon sheath of extensor carpi ulnaris
Describe the purpose & performance of the Ulna Fovea sign. What are the general specificity/sensitivity?
- test for TFCC instability
- press thumb into anterior interval between ulnar styloid process and flexor carpi ulnaris tendon (just distal to ulnar styloid)
- excellent sensitivity (95%), moderately good specificity (86%)
When trying to distinguish between osteoarthritis of the wrist/hand & rheumatoid arthritis, what can the location of symptoms tell you?
RA: MCP, PIP, and carpal/wrist pain
OA: DIP, PIP, 1st MCP joint pain
What are the 2 most common serious conditions of the hand/wrist that can present post-operatively? What less common condition should also be considered if symptoms are persistent?
- infection
- iatrogenic injury
Chronic Regional Pain Syndrome
Describe 4 nerve injuries of the wrist/hand & their respective nerves.
- Benediction hand (4th/5th finger flexion); median nerve
- Claw hand (MCP extension with PIP flexion); median or ulnar nerve
- Ape hand (inability to abduct the thumb); median nerve
- Wrist drop; radial nerve
Generally, how reliable is radiography in detecting scaphoid fractures?
Always first line, but sometimes it can miss small fractures. Refer for MRI if a fracture is still suspected (snuffbox palpation & axial compression are +)
How can reflex testing help to differentiate between Cervical Radiculopathy, Carpal Tunnel Syndrome, and Cervical Myelopathy?
- C5-6 Radiculopathy: hyporeflexia
- CTS: no reflex changes
- Cervical Myelopathy: hyperreflexia; pathological reflexes (Babinski, Hoffman, clonus) may be present
How can you use ROM and manual assessment to help differentiate between Cervical Radiculopathy, Carpal Tunnel Syndrome, and Cervical Myelopathy?
- C5-6 Radiculopathy: cervical ROM or PAs should reproduce sx
- CTS: ROM of wrist may aggravate sx & compression test might be (+); cervical spine is clear
- Cervical Myelopathy: cervical ROM or PAs may reproduce sx & wrist ROM is painless
How can manual muscle testing help to differentiate between Cervical Radiculopathy, Carpal Tunnel Syndrome, and Cervical Myelopathy?
- C5-6 Radiculopathy: biceps or deltoid weakness
- CTS: thenar muscle weakness
- Cervical Myelopathy: general limb weakness
Describe the purpose & performance of the Compression test of the wrist/hand.
- carpal tunnel test
- place wrist is flexion
- use flat thumb to compress the carpal tunnel & hold 30 seconds
- (+) test is reproduction of symptoms
(+3.5 LR)
According to Seddon, what are the 3 types of nerve injury?
- neurapraxia
- axonotmesis
- neurotmesis
What is neurapraxia?
- mildest form of traumatic peripheral nerve injury
- local segmental demyelination without disruption of axon continuity or surrounding connective tissue
- results in blockage of nerve conduction & transient weakness or paresthesia
(greek “neur” [nerve] + “a” [not] + “praxis” [action])
Which type of nerve injury is characterized by local segmental demyelination without disruption of axon continuity or surrounding connective tissue?
neurapraxia
What is axonotmesis?
- injury to the axon with no or only partial injury to the connective tissue framework
- endoneurial sheath is intact, so regeneration can take place
- (+) Tinel’s sign
- axon & myelin degeneration distal to injury, causing complete denervation
What type of nerve injury is characterized by damage to the axon and myelin with no or only partial injury to the connective tissue framework?
axonotmesis
What is neurotmesis?
- most severe type of peripheral nerve injury
- complete disruption of the nerve
- complete functional loss and no potential for recovery without surgery
Describe the purpose & performance of the Thumb Ulnar Collateral Ligament Laxity Test. What are the general specificity and sensitivity?
- to test for laxity of the UCL / 1st MCP joint (Skier’s Thumb)
- passively bring thumb into extension and apply a valgus stress to the 1st MCP joint
- (+) test is 30°-35° of valgus motion
- test both with palm up & palm down
specificity is poor (12%) and sensitivity is moderate (87%)
List the 3 items that are most closely associated with 1st CMC osteoarthritis.
- radial wrist pain
- older age
- 1st CMC grind test
List the 3 items that are most closely associated with a thumb UCL injury.
- history of trauma (hyperabduction or traction)
- pain at MCP without pain at CMC or IPs)
- (+) UCL Laxity test
