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MSK Exam 2 > Upper extremity: Forearm, wrist and hand > Flashcards

Upper extremity: Forearm, wrist and hand Flashcards

1
Q

Metacarpal vs phalangeal fracture

A

○ Metacarpal fx
■ More common in adults
■ Most common fx in the hand Boxer’s Fx-Distal
5 th mcp
○ Phalangeal fx
■ More common in children
■ Distal phalanx fx most common in adults

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2
Q

Metacarpal/Phalange Fractures etiology

A

○ Axial loading & direct trauma
○ Avulsions

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3
Q

Metacarpal/Phalange Fractures clinical presentation

A

○ Local tenderness & swelling
○ Deformity (shortening, rotation)
○ ↓ ROM
○ Possible ↓ sensation

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4
Q

Metacarpal/Phalange Fractures diagnosis

A

● Diagnosis
○ X-ray
■ Phalanges → PA & Lateral
■ Metacarpals → PA, Lateral, & Oblique

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5
Q

Metacarpal/Phalange Fractures Management: boxer fx

A

■ <15° angulation, ulnar gutter splint x 2-3 weeks
■ >15° angulation, if full finger extension maintained, ulnar gutter splint x 2-3 weeks
■ >40° angulation or with extension lag → refer to ortho

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6
Q

Metacarpal/Phalange Fractures Management: nondisplaced fx

A

■ Cast/splint x 3 weeks (phalanges), x 4 weeks (metacarpals)
● More time = ↓ ROM/Stiffness
● Cast/splint joints above & below & adjacent bones

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7
Q

Metacarpal/Phalange Fractures Management: Displaced Fx & Intra-articular Fx

A

Refer to ortho

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8
Q

Metacarpal/Phalange Fractures complications

A

○ Joint stiffness
○ Malunion
○ Malrotation

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9
Q

Fracture of the Base of the Thumb
Metacarpal etiology

A

Traumatic
■ MVA & Bicycle accidents

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10
Q

“Bennett Fracture”

A

oblique fx, base of thumb,
involves carpometacarpal joint CMC
- The Bennet fx involves the base of the
thumb (1 st ) metacarpal & involves the 1 st
CMC join

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11
Q

“Rolando Fracture”

A

Y-shaped intra-articular
fracture, base of thumb CMC
- The Rolando fx is a comminuted intra-articular
Bennet’s fracture with a Y-shaped appearance

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12
Q

Fracture of the Base of the Thumb
Metacarpal: clinical presentation

A

○ Swelling
○ Pain
○ ↓ range of motion
○ Occasionally deformity at the base of the thumb
■ Dorsally & radially displaced metacarpal shaft may be obvious on inspection or palpation
○ Crepitus may be present with intra-articular fractures

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13
Q

Fracture of the Base of the Thumb
Metacarpal Diagnosis

A

○ X-ray
■ Robert view
● Hyperpronated hand, the dorsum of the thumb lies on the X-ray plate (true AP view of
the thumb)
■ Bett view
● Pronated hand ~20-30° & the imaging beam is directed obliquely at 15° (distal to
proximal direction, centered over the trapeziometacarpal joint

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14
Q

Fracture of the Base of the Thumb
Metacarpal management: Rolando fx

A

■ If the fracture is non-displaced,<1 mm of articular step off, then
percutaneous pinning may be attempted.
■ Displacement with large (>3 mm) fragments indicates ORIF

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15
Q

Fracture of the Base of the Thumb
Metacarpal management: Bennett fx

A

■ Closed reduction & thumb spica cast immobilization is effective if the
reduction can be maintained.
■ If closed reduction is unsuccessful or the fracture displaces after
reduction, then percutaneous pinning may be attempted.

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16
Q

Fracture of the Base of the Thumb
Metacarpal complications

A

○ Stiffness
○ ↓ ROM
○ Arthritis

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17
Q

Scaphoid Fracture etiology

A

○ MOI = FOOSH
■ forceful dorsiflexion &
compression of the scaphoid
against the the radius
○ young adult men
○ fall, athletic injury, MVA

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18
Q

Scaphoid Fracture clinical presentation

A

○ Snuffbox tenderness
■ Equated with a scaphoid fracture unless
radiographs prove otherwise.
■ If initial X-ray does not show fracture, f/u
Xray should be obtained in 7-14 days,
because the fracture line may be more
visible after some resorption.
○ ↓ ROM
○ Swelling possible

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19
Q

Scaphoid Fracture diagnosis

A

○ Most sensitive X-ray series includes 4 views: PA, lateral, pronated oblique (60° pronated
oblique), & ulnar deviated oblique (60° supinated oblique)
■ Comparison views of the contralateral wrist may be necessary
○ ~25% of scaphoid fractures are not evident on 1 st X-ray
○ MRI is the most effective imaging modality for suspected scaphoid fx ($$$)
○ Might consider a bone scan. High specificity and sensitivity at 72 hours

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20
Q

Scaphoid Fracture management

A

○ Suspected fx, initial (negative) x-ray → immobilize for 2 weeks & re-evaluate
■ After 2 weeks, and pain persists over the snuffbox, and still no fracture seen → MRI
○ Nondisplaced fx → cast immobilization recommended
○ Displaced or unstable fractures may require percutaneous pin fixation or compression screw
fixation to prevent malunion
○ Surgery is increasingly used for patients who will not tolerate prolonged casting

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21
Q

Scaphoid Fracture complications

A

○ delay in diagnosis
○ delayed union
○ ↓ grip strength
○ ↓ range of motion
○ osteoarthritis in radiocarpal joint

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22
Q

Distal Radius Fracture epidemiology and etiology

A

● Epidemiology
○ Colles Fx (Most common) → distal radius
fragment angled dorsally
○ Smith Fx → distal radius fragment angled
volarly
○ Chauffeurs Fx → oblique fx through the base
of the radial styloid
○ Die-punch Fx → depressed fx, articular radial
surface opposite lunate/scaphoid
● Etiology- FOOSH

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23
Q

Distal Radius Fracture Clinical Presentation

A

○ Localized pain & swelling of the wrist
○ Painful ROM
○ A “dinner fork” deformity (Colles)
○ Distal neurovascular exam

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24
Q

Distal Radius Fracture diagnosis

A

○ X-rays (PA, lateral, oblique)
○ May consider CT or MRI of wrist; in
consultation with the orthopedic or
hand surgeon

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25
Q

Distal Radius Fracture management

A

○ Most patients → outpatient reduction & immobilization
○ Operative repair is multifactorial: Age of patient, baseline functional mobility, hand dominance, instability of fracture, disruption of the radiocarpal & radioulnar ligaments, & patient comorbidities
○ Fractures associated with neurovascular injuries need emergent reductions
■ Assess for acute Carpal Tunnel Syndrome
○ Pain medication as needed

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26
Q

Distal Radius Fracture Complications

A

○ Redisplacement of fracture
○ Mal/non-union
○ Median nerve palsy (chronic carpal tunnel
syndrome)
○ Arthritis
○ Compartment syndrome

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27
Q

Distal Radius Fracture referral considerations

A

○ Open fx
○ Associated neurovascular injury
○ Concurrent dislocation
○ Concurrent carpal bone fx
○ Presence of an ulnar styloid fx at its base
■ disrupted radioulnar joint
○ Comminuted fracture pattern
○ Displaced intra-articular fx
○ Unstable fx

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28
Q

Finger Dislocations etiology

A

Trauma

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29
Q

______ → most common finger dislocations

A

PIP joints

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30
Q

Finger Dislocations presentation

A

○ “I jammed my finger”
○ Localized pain & swelling
○ Deformed finger

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31
Q

Finger Dislocations diagnosis

A

○ Check for skin defects (open dislocations)
○ Ulnar & radial stress testing → tests integrity of collateral ligaments
○ Hyperextension stress testing
○ Joint laxity in a particular direction signifies ligament disruption & instability
○ X-ray: P, lateral, & oblique views prior to reduction

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32
Q

Finger Dislocations management

A

○ Usually acutely managed by closed
reduction & immobilization
○ Pain medication prn

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33
Q

Finger Dislocations complications

A

○ Inadequate or delayed reduction (instability, stiffness, deformity)
○ Overaggressive attempts at reduction → fx
○ Redislocation (inadequate stabilization)
○ Muscle contracture (prolonged immobilization)
○ Infection (open fx)

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34
Q

Finger Dislocations referral considerations

A

Orthopedic consultation may be needed for:
■ Open dislocation (high risk of infection)
■ Irreducible dislocation
■ Proximal and/or middle phalangeal fx associated w/ IP joint dislocation

35
Q

Flexor/Extensor Tendon
Lacerations etiology

A

○ sharp object direct laceration
○ crush injury
○ avulsions
○ burns
○ animal or human bites- Infectious tenosynovitis (Fight bite)
○ deep abrasions
○ accompanied by skin injury

36
Q

Flexor/Extensor Tendon Lacerations clinical presentation

A

○ Localized swelling & pain
○ Loss of normal ROM & the tenodesis effect
observed with wrist motion.
○ In lacerations of the FDP alone, the DIP joint
may be held in flexion by the intact short
vinculum.
○ ↓ Sensation

37
Q

Flexor/Extensor Tendon Lacerations diagnosis

A

○ Active ROM
○ Resisted ROM
■ Test both DIP & PIP joints against your finger’s
resistance
● FDP → Pt flexes at the DIP while the PIP is
held straight
● FDS → Pt flexes at the PIP
○ X-ray
■ PA & Lateral (avulsion/fx)

38
Q

Flexor/Extensor Tendon Lacerations management

A

○ Wash out superficial wounds & splint appropriately (more info to come)
○ Tendon injuries typically will need surgical repair

39
Q

Most common closed tendon injury seen in athletes

A

Mallet Finger

40
Q

Mallet Finger etiology

A

○ Forced flexion of the finger while it is held in an extended position.
○ Classic MOI is a finger held rigidly in extension when the finger is
struck on the tip by a softball, volleyball, or basketball

41
Q

Mallet finger

A

Disruption of the terminal extensor mechanism at the distal interphalangeal (DIP)

42
Q

Mallet Finger diagnosis

A

PA & lateral radiographs centered at the distal
interphalangeal (DIP) joint

43
Q

Mallet Finger management

A

○ Splint DIP joint continuously for 6-8 weeks
○ No DIP flexion, even for a moment, until treatment complete
■ Compliance = 61.5% excellent outcomes
■ Noncompliance = 9.1% excellent outcomes

44
Q

Mallet Finger complications

A

○ Swan Neck Deformity
■ may occur if mallet finger & extensor tendon
imbalance occurs leading to hyperextension
deformity at proximal interphalangeal joint
○ Refer to ortho if avulsion fx involves >30% of joint or inability to achieve full passive extension

45
Q

Boutonnière (Buttonhole) Deformity etiology

A

○ Rupture of the central portion of the extensor tendon at the
insertion point on the middle phalanx, preventing extension
○ MOI
■ Axial loading of finger (aka “I jammed my finger”)
■ Laceration over central slip near proximal interphalangeal (PIP) joint
■ Chronic: capsular distension in RA

46
Q

Boutonnière (Buttonhole) Deformity presentation

A

○ Localized pain & swelling
○ Deformity

47
Q

Boutonnière (Buttonhole) Deformity diagnosis

A

○ Elsons test (← Link)
○ X-ray (AP, lateral, & oblique)
■ Central slip injuries associated with fractures of the dorsal aspect of the distal or middle phalanges & volar interphalangeal dislocations

48
Q

Boutonnière (Buttonhole) Deformity management

A

○ Apply a finger splint to the affected digit with the proximal interphalangeal (PIP) in full
extension; keep the distal interphalangeal (DIP) mobile
○ Excellent prognosis with conservative, non-operative management
■ proximal interphalangeal (PIP) splint in full extension for 6 weeks

49
Q

Boutonnière (Buttonhole) Deformity complications

A

○ Mal/Non-union
○ Arthritis
○ Deformity

50
Q

Ulnar Collateral ligament Injury, Thumb AKA

A

“Gamekeeper’s or skier’s thumb”

51
Q

Ulnar Collateral ligament Injury, Thumb etiology

A

○ Classic mechanism of injury → forced abduction & hyperextension of the thumb,
○ 1 st descriptions of the injury occurred when hunters twisted the necks of game to kill them
○ Concurrent avulsion fracture of the proximal phalanx, is common

52
Q

Ulnar Collateral ligament Injury, Thumb presentation

A

○ Localized pain, swelling, and/or ecchymosis of the MCP joint after a fall or blow to the thumb

53
Q

Ulnar Collateral ligament Injury, Thumb diagnosis

A

○ Diminished ability to pinch
■ The pt holds a piece of paper with the thumb & forefinger, & the examiner tries to pull it away
(Normally, should not be able)
○ Valgus Stress Test (Laxity >35° or >15° of the uninjured side, + rupture)
○ X-ray, 3 views (AP, lateral, & oblique)
○ MRI & US can specifically evaluate the UCL for equivocal cases

54
Q

Ulnar Collateral ligament Injury, Thumb management

A

○ R.I.C.E.S.
○ Partial tears & Nondisplaced avulsion fx
○ Complete tears, Displaced avulsion fx, Subluxation & Articular fx

55
Q

Ulnar Collateral ligament Injury, Thumb complications

A

○ Chronic instability is a major complication of UCL rupture.
○ Degenerative joint changes
○ Weakness of power grasp
○ ↓ dexterity of fine pincher-type movements
○ Stiffness
○ Pain

56
Q

Dupuytren Contracture

A

○ Progressive, benign fibroproliferative disease of palmar fascia characterized by palmar
nodules & cords & digital flexion contracture
○ Cause: unknown

57
Q

Dupuytren Contracture clinical presentation

A

○ ↓ ROM
○ Loss of dexterity
○ Getting the hand “caught” when trying to place it in a pocket
○ Patients describe a progressive feeling of a “knot” or “thickening” on the palmar surface or on the digits, typically the proximal palmar aspect.
○ 4 th digit is most frequently affected, followed by the 5 th digit

58
Q

Dupuytren Contracture diagnosis

A

○ Clinical diagnosis
○ Palmar skin nodules, may resemble callus
■ Abnormal cords can extend distally (sometimes proximally) to the nodule
● Seldom tender
○ US can demonstrate thickened palmar fascia

59
Q

Dupuytren Contracture Management

A

○ Physical rehabilitation
○ Night splints
○ Corticosteroid injection
○ Surgery
○ collagenase Clostridium histolyticum (Xiaflex) injection (US guided)

60
Q

Fingertip infections “Felon” etiology

A

○ Infection of the pulp of the finger tip,
usually 2° to a puncture wound
○ Staphylococcus aureus is the most
common organism

61
Q

Fingertip infections clinical presentation

A

○ Localized severe pain & swelling in the finger tip pad
○ Red
○ Tense
○ Differentiate Felon from a Herpetic Whitlow
○ Vesicles/ulcerations on erythematous base
■ “Dew drop on a rose petal”
○ No Incision & Drainage (I&D)
■ (Self-limiting infection)

62
Q

Fingertip infections diagnosis

A

○ Clinical diagnosis
○ X-ray

63
Q

Fingertip infections management

A

○ No evidence of osteomyelitis
■ Outpatient incision & drainage, with
a digital block
○ Radiographic evidence of osteomyelitis
■ Partial/complete resorption of the distal tuft of the phalanx
■ Refer to Ortho hand specialists for aggressive surgical debridement

64
Q

Fingertip infections complications

A

○ Osteomyelitis
○ Nail deformity
○ Tendon rupture
○ Sepsis
○ Scarring
○ Recurrence

65
Q

Fingertip infections
“Paronychia” etiology

A

○ Most common hand infection in the United States
(~35%)
○ Women > Men (3:1)
○ Etiology
○ Infection of the tissue surrounding the fingernail
■ Staphylococcus aureus is the most common
organism

66
Q

Fingertip infections
“Paronychia” clinical presentation

A

○ Localized pain & swelling
■ Typically one side/base of nail
● If it extends all the way around it is called a “run-around-abscess”
○ Typically the history includes:
■ Recent manicure
■ Hangnail
■ Ingrown nail
■ Nail biting
■ Thumb sucking

67
Q

Fingertip infections
“Paronychia” diagnosis

A

○ Clinical exam is usually sufficient
○ Fluctuant paronychia can provide fluid to culture
○ Tzanck smear if suspecting a herpetic whitlow
■ Use scrapings of an unroofed vesicle. (+) Presence of multinucleated giant cells, often
with visible viral inclusions.
○ X-ray unnecessary unless osteomyelitis suspected, foreign body suspected or trauma.

68
Q

Fingertip infections
“Paronychia” management

A

○ Early diagnosis
■ May resolve with warm water soaks QID
○ Extensive cellulitis
■ amoxicillin-clavulanate (Augmentin®)
■ clindamycin (Cleocin®)
■ trimethoprim-Sufamethoxazole (Bactrim®)
○ Abscess
■ I&D
■ Ortho referral

69
Q

Stenosing Tenosynovitis, flexor tendon(s) AKA

A

“trigger finger”

70
Q

Stenosing Tenosynovitis, flexor tendon(s) etiology

A

○ Flexor tendon or 1 st annular pulley becomes
thickened & narrowed 2° chronic inflammation
○ Causes finger to lock/snap during flexion

71
Q

Stenosing Tenosynovitis, flexor tendon(s) presentation

A

○ locking of finger or thumb in flexion
■ resistance to re-extension in mid arc when
digit flexed
○ clicking
○ finger pain
○ ↓ ROM in patients with rheumatoid flexor
tenosynovitis
○ Most common in the thumb & 4 th digit

72
Q

Stenosing Tenosynovitis, flexor tendon(s) diagnosis

A

○ Clinical diagnosis
■ locking of digit in flexed position
■ history of snapping/clicking
○ In patients with rheumatoid flexor tenosynovitis(1)
■ digital triggering or stiffness
■ palpable swelling on volar aspect of digit
■ PROM > AROM
■ fixed joint stiffness in chronic cases
○ Imaging not necessary

73
Q

Stenosing Tenosynovitis, flexor tendon(s)
“Trigger Finger” management

A

○ Initially, short course of NSAIDS & activity modification
○ Corticosteroid injection into the tendon sheath (NOT THE TENDON → predisposes to rupture)
○ Splinting effective in 50-70% of cases
○ Surgery for severe or resistant cases
● Injection

74
Q

Stenosing Tenosynovitis complications

A

○ Flexion contracture
○ Medication adverse effects
○ Digital sensory nerve damage (injections, surgery)
○ Infection (injections, surgery)

75
Q

De Quervain Tenosynovitis etiology

A

○ repetitive activity involving pinching with thumb while
moving wrist
■ friction where tendons form sharp angle over radial
styloid causes thickening of tendons in flexor sheath,
leading to tenderness & swelling
○ Trauma

76
Q

De Quervain Tenosynovitis presentation

A

○ Localized pain & swelling over the radial styloid
○ Pain with pinching & gripping
○ May be a history of repetitive movement activities

77
Q

de Quervain Tenosynovitis diagnosis

A

○ Clinical diagnosis
○ tenderness over distal portion of radial styloid, plus pain on
passive thumb flexion/adduction or active resisted thumb
abduction
○ Finkelstein Test

78
Q

Finkelstein Test

A

To test de Quervain Tenosynovitis
passively flex thumb across palm
■ flex fingers over thumb
■ passively deviate wrist to ulnar side
■ (+) pain

79
Q

de Quervain Tenosynovitis management

A

○ Conservative management
■ 2 weeks in a thumb spica
■ NSAIDs
○ Corticosteroid injection may be most effective
option

80
Q

Ganglion Cyst etiology

A

○ Unknown
○ Possibly trauma or mucoid degeneration

81
Q

Ganglion Cyst clinical presentation

A

○ “I’ve got this bump that won’t go away”
■ “Bible bump”
○ Typically painless
○ Aggravated by activity
○ Often vary in size
○ Common locations

82
Q

Ganglion Cyst Diagnosis

A

○ Clinical diagnosis
■ Smooth, mobile, mildly tender to pressure
■ It will transilluminate
● differentiate cystic from solid mass
○ X-ray will r/o bony pathology
■ Most films will be (-)

83
Q

Ganglion Cyst management

A

○ Splinting & NSAIDS
○ Closed rupture (sharp blow with a heavy object “aka the family bible”)
○ Needling

MSK Exam 2 (5 decks)

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