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Orthopaedics > The Wrist & Hand > Flashcards

The Wrist & Hand Flashcards

1
Q

What percent of all fractures do distal radius fractures make up?

A

1/4 all fractures seen clinically

Distal metaphysis of radius
Correct diagnosis & management crucial - significant implications

FOOSH most commonly
Osteoporosis ⬆️older, also 5-15yrs

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2
Q

What types of Diageo radius fractures are there? Which is the most common?

A

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

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3
Q

How would you carry out a neurological examination in a suspected distal radius fracture?

A
  • 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
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4
Q

Plain radiographs are the quickest & definitive investigations of most fractures. What are 3 measurements on a plain radiograph for distal radius fracture diagnosis?

A

Radial height <11mm
Radial inclination <22 d
Radial (volar) tilt >11 d

May use Ct/ MRI more complex

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5
Q

Management of distal radius fractures

A

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

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6
Q

What is the the most common carpus to be fractured? Who gets them mostly?

A

Scaphoid
Men 20-30yrs
10% associated fracture

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7
Q

Describe the blood supply to different poles of scaphoid. What does this mean for fractures of the scaphoid?

A

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

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8
Q

The floor of the anatomical snuffbox is often tender with scaphoid fractures. Boundaries of the anatomical snuffbox?

A 
Lateral
APL tendon (abductor)
EPB tendon

Medial
EPL tendon

Contents
RA
Superficial RN
Cephalic V

Floor
Scaphoid, trapezium

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9
Q

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?

A

Wrist immobilised thumb splint -> repeat plain radiograph 10-14days

MRI wrist
Definitive

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10
Q

How are scaphoid fractures managed?

A

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

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11
Q

Why is the palm often spared in carpal tunnel syndrome? Where does get affected?

A

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

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12
Q

What are 2 tests for Carpal tunnel syndrome?

A

Tinel’s test
Percussions over median N - sensory symptoms

Phalen’s test
Hold wrist full flexion 1 min - sensory symptoms

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13
Q

Treatment for carpal tunnel syndrome

A

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

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14
Q

What is Dupuytren’s contracture? Who is most likely to get it?

A

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)

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15
Q

Pathophysiology of dupuytren’s contracture

A

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
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16
Q

What is Hueston’s test?

A

Advanced dupuytren’s contracture MCP &/or PIP joints contracture

If unable to lie palm flat tabletop ➕

17
Q

Differentials for dupuytren’s contracture

A

Stenosing tenosynovitis (painful, associated overuse/ trauma)

Ulnar N palsy (reduced movement/ strength, loss sensation)

Trigger finger - module associated finger motion

18
Q

Management of dupuytren’s contracture

A

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)

19
Q

What is De Quevervain’s tensoynovitis? Who is most likely to get it?

A

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

20
Q

What are the extensor compartments of the wrist?

A

6 on dorsal aspect, lateral to medial:

  1. EPB & Ab PL
  2. ECR L&B
  3. EPL
  4. EI & ED
  5. EDM
  6. ECU
21
Q

What is Finkelstein’s test?

A

Longitudinal traction & ulnar deviation to affected thumb
Pain radial styloid process & along length EPB & ABPL ➕

For De Quervain’s tenosynovitis

22
Q

Differentials for de Quervain’s tenosynovitis

A

Arthritis carpometacarpal joint
+ grind test

Intersection syndrome

Wartenberg’s syndrome
Neuritis superficial RN

23
Q

Management of de Quervain’s tenosynovitis

A

Conservative - lifestyle, wrist splint, steroid injections

Surgical decompression extensor compartment

24
Q

How do ganglionic cystic arise? Who is most likely to get them?

A

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

25
Q

How will a ganglionic cyst present?

A 
Smooth spherical painless jump 
Adjacent joint 
Could subside &amp; reapear
Transilluminate 
 Could exert pressure nerves (paraesthesia, pain, weakness)
26
Q

Differentials for ganglionic cysts & investigations

A

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

27
Q

What’s the technical name for trigger finger & what does it mean? Who is more likely to get it?

A

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

28
Q

Pathophysiology of trigger finger

A

Priced flexor tenosynovitis mostly - repetitive movements -> inflammation tendon & sheath

When flexed node moves proximal, extend. Ode fails pass back

29
Q

Differentials for trigger finger

A

Dupuytren’s contracture

Acromegaly

Infection

Ganglion

30
Q

Management of trigger finger

A

Conservative if mild
Activities
Small splint hold extension night

Steroid injections

Surgical:
Percutaneous trigger finger release needle
Surgical decompression tendon tunnel - severe

Orthopaedics (14 decks)

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