The Wrist & Hand Flashcards
What percent of all fractures do distal radius fractures make up?
1/4 all fractures seen clinically
Distal metaphysis of radius
Correct diagnosis & management crucial - significant implications
FOOSH most commonly
Osteoporosis ⬆️older, also 5-15yrs
What types of Diageo radius fractures are there? Which is the most common?
Colles fractures
90%
Extra-articular fracture distal radius with dorsal angulation/ displacement
Included avulsion fracture of ulnar styloid
Fragility fracture - wrist dorsiflexed
Smith’s fracture
Volar angulation distal fragment of extra-articular fracture
Landing dorsal surface wrist
Barton’s fracture
Intra-articular + dislocation radio-carpal joint
How would you carry out a neurological examination in a suspected distal radius fracture?
- Median N
Abduction thumb
Sensory radial distal 2nd digit - anterior interosseous N
Opposition thumb & index finger 👌 - Ulnar N
Adduction thumb
Sensory ulnar surface distal 5th digit - radial N
Extension iPJ thumb
Sensory dorsal 1st webspace
Plain radiographs are the quickest & definitive investigations of most fractures. What are 3 measurements on a plain radiograph for distal radius fracture diagnosis?
Radial height <11mm
Radial inclination <22 d
Radial (volar) tilt >11 d
May use Ct/ MRI more complex
Management of distal radius fractures
Resus
Stabilise
Closed reduction (conscious sedation - haematoma block/ Bier’s block)
After reduction immobilised:
- stable below elbow backslab case -> radiograph 1wk
- significantly displaced/ unstable surgical intervention either:
Open reduction & internal fixation,
K-wire fixation,
External fixation
PhysioT
What is the the most common carpus to be fractured? Who gets them mostly?
Scaphoid
Men 20-30yrs
10% associated fracture
Describe the blood supply to different poles of scaphoid. What does this mean for fractures of the scaphoid?
3 parts
Proximal pole
Waist
Distal pole
Branches radial A
Dorsal branch - 80% enters in distal pole -> retrograde -> proximal P
Fractures can compromise blood supply -> avascular necrosis (30%, increasing risk more proximal) + degenerative wrist disease
The floor of the anatomical snuffbox is often tender with scaphoid fractures. Boundaries of the anatomical snuffbox?
Lateral APL tendon (abductor) EPB tendon
Medial
EPL tendon
Contents
RA
Superficial RN
Cephalic V
Floor
Scaphoid, trapezium
Plain radiographs are the first investigation for scaphoid fractures. If it can’t be detected but there remains sufficient clinical suspicion what would be the next step? If this still doesn’t help but clinical findings still keep with a scaphoid fracture what would you do?
Wrist immobilised thumb splint -> repeat plain radiograph 10-14days
MRI wrist
Definitive
How are scaphoid fractures managed?
Undisplaced - strict immobilisation plaster with thumb spica splint (proximal pole - high risk AVN surgical treatment May advocated)
All displaced fractures - fixed operatively
Percutaneous variable-pitched screw
Why is the palm often spared in carpal tunnel syndrome? Where does get affected?
Palmar cutaneous branch of median N branches proximal to flexor retinaculum & passing over carpal tunnel
Pain, numbness, paraesthesia lateral 3.5 digits
Worse night
-> later stages - weakness thumb abduction, wasting thenar eminence
What are 2 tests for Carpal tunnel syndrome?
Tinel’s test
Percussions over median N - sensory symptoms
Phalen’s test
Hold wrist full flexion 1 min - sensory symptoms
Treatment for carpal tunnel syndrome
Conservative initially:
Wrist splint (commonly night - worse)
PhysioT
Training exercises
Corticosteroid injections
NSAIDs
Surgical (severely limiting cases)
- carpal tunnel release surgery (cut though flexor retinaculum)
90% improved symptoms
What is Dupuytren’s contracture? Who is most likely to get it?
Common
Contraction longitudinal palmar fascia
Painless nodules, fibrous cords, flexion contractures MCP & IPJs - limit digital movement
Men, 40-60yrs, smoking, alcoholic liver cirrhosis, ulnar digits more commonly DM, occupation exposure, genetic (test for random glucose, LFTs)
Pathophysiology of dupuytren’s contracture
Fibroplastic hyperplasia
Altered collagen matrix of palmar fascia
- > thickening & contraction of palmar fascia
1. Initial pitting, thickening PaLamar skin & subcutaneous tissue, loss mobility skin overlying
2. Film painless nodule -> fixed
3. Cord develops (looks like tendon) contracts months-yrs
4. Pulls MCP PIP -> flexion deformity
What is Hueston’s test?
Advanced dupuytren’s contracture MCP &/or PIP joints contracture
If unable to lie palm flat tabletop ➕
Differentials for dupuytren’s contracture
Stenosing tenosynovitis (painful, associated overuse/ trauma)
Ulnar N palsy (reduced movement/ strength, loss sensation)
Trigger finger - module associated finger motion
Management of dupuytren’s contracture
Depends stage of presentation
Conservative:
Hand therapy (active, stretching)
Injectable collagenase clostridium histolyticum
Surgical:
Regional fasciectomy (entire cord removed)
Segmental fasciectomy
Dermofasciectomy (cord & overlying skin removed, followed by skin graft)
Closed fasciectomy
Finger amputation (v severe)
What is De Quevervain’s tensoynovitis? Who is most likely to get it?
Inflammation of tendons within 1st extensor compartment of wrist (EPB, Ab PL) -> pain & swelling, pinching/ grasping difficult, thickening tendon group
Woman, 30-50yrs, repetitive movements, pregnant
What are the extensor compartments of the wrist?
6 on dorsal aspect, lateral to medial:
- EPB & Ab PL
- ECR L&B
- EPL
- EI & ED
- EDM
- ECU
What is Finkelstein’s test?
Longitudinal traction & ulnar deviation to affected thumb
Pain radial styloid process & along length EPB & ABPL ➕
For De Quervain’s tenosynovitis
Differentials for de Quervain’s tenosynovitis
Arthritis carpometacarpal joint
+ grind test
Intersection syndrome
Wartenberg’s syndrome
Neuritis superficial RN
Management of de Quervain’s tenosynovitis
Conservative - lifestyle, wrist splint, steroid injections
Surgical decompression extensor compartment
How do ganglionic cystic arise? Who is most likely to get them?
Non cancerous soft tissue slumps along joint/ tendon
Arise from degeneration within joint capsule or tendon sheath of joint -> filled synovial fluid
Most common hands & feet, females, 20-40yrs, oesteoarthritis, previous injury
How will a ganglionic cyst present?
Smooth spherical painless jump Adjacent joint Could subside & reapear Transilluminate Could exert pressure nerves (paraesthesia, pain, weakness)
Differentials for ganglionic cysts & investigations
Tenosynovitis- no discrete mass, swelling along tendon
Giant cell tumour of tendon sheath - solid, not transilluminate, fixed
Lipoma
OA
Sarcoma
Clinical, Plain radiograph rule out
Uncertain - USS/ MRI
Aspirated - cytology
What’s the technical name for trigger finger & what does it mean? Who is more likely to get it?
Stenosing flexor tenosynovitis
Finger/ thumb click/ lock when in flexion preventing return to extension
1+ tendon
2/100 ppl, RA, amyloidlsos, DM , prolonged gripping, female, older
Pathophysiology of trigger finger
Priced flexor tenosynovitis mostly - repetitive movements -> inflammation tendon & sheath
When flexed node moves proximal, extend. Ode fails pass back
Differentials for trigger finger
Dupuytren’s contracture
Acromegaly
Infection
Ganglion
Management of trigger finger
Conservative if mild
Activities
Small splint hold extension night
Steroid injections
Surgical:
Percutaneous trigger finger release needle
Surgical decompression tendon tunnel - severe
