Upper extremity: Forearm, wrist and hand Flashcards
Metacarpal vs phalangeal fracture
○ 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
Metacarpal/Phalange Fractures etiology
○ Axial loading & direct trauma
○ Avulsions
Metacarpal/Phalange Fractures clinical presentation
○ Local tenderness & swelling
○ Deformity (shortening, rotation)
○ ↓ ROM
○ Possible ↓ sensation
Metacarpal/Phalange Fractures diagnosis
● Diagnosis
○ X-ray
■ Phalanges → PA & Lateral
■ Metacarpals → PA, Lateral, & Oblique
Metacarpal/Phalange Fractures Management: boxer fx
■ <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
Metacarpal/Phalange Fractures Management: nondisplaced fx
■ Cast/splint x 3 weeks (phalanges), x 4 weeks (metacarpals)
● More time = ↓ ROM/Stiffness
● Cast/splint joints above & below & adjacent bones
Metacarpal/Phalange Fractures Management: Displaced Fx & Intra-articular Fx
Refer to ortho
Metacarpal/Phalange Fractures complications
○ Joint stiffness
○ Malunion
○ Malrotation
Fracture of the Base of the Thumb
Metacarpal etiology
Traumatic
■ MVA & Bicycle accidents
“Bennett Fracture”
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
“Rolando Fracture”
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
Fracture of the Base of the Thumb
Metacarpal: clinical presentation
○ 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
Fracture of the Base of the Thumb
Metacarpal Diagnosis
○ 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
Fracture of the Base of the Thumb
Metacarpal management: Rolando fx
■ 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
Fracture of the Base of the Thumb
Metacarpal management: Bennett fx
■ 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.
Fracture of the Base of the Thumb
Metacarpal complications
○ Stiffness
○ ↓ ROM
○ Arthritis
Scaphoid Fracture etiology
○ MOI = FOOSH
■ forceful dorsiflexion &
compression of the scaphoid
against the the radius
○ young adult men
○ fall, athletic injury, MVA
Scaphoid Fracture clinical presentation
○ 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
Scaphoid Fracture diagnosis
○ 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
Scaphoid Fracture management
○ 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
Scaphoid Fracture complications
○ delay in diagnosis
○ delayed union
○ ↓ grip strength
○ ↓ range of motion
○ osteoarthritis in radiocarpal joint
Distal Radius Fracture epidemiology and etiology
● 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
Distal Radius Fracture Clinical Presentation
○ Localized pain & swelling of the wrist
○ Painful ROM
○ A “dinner fork” deformity (Colles)
○ Distal neurovascular exam
Distal Radius Fracture diagnosis
○ X-rays (PA, lateral, oblique)
○ May consider CT or MRI of wrist; in
consultation with the orthopedic or
hand surgeon
Distal Radius Fracture management
○ 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
Distal Radius Fracture Complications
○ Redisplacement of fracture
○ Mal/non-union
○ Median nerve palsy (chronic carpal tunnel
syndrome)
○ Arthritis
○ Compartment syndrome
Distal Radius Fracture referral considerations
○ 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
Finger Dislocations etiology
Trauma
______ → most common finger dislocations
PIP joints
Finger Dislocations presentation
○ “I jammed my finger”
○ Localized pain & swelling
○ Deformed finger
Finger Dislocations diagnosis
○ 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
Finger Dislocations management
○ Usually acutely managed by closed
reduction & immobilization
○ Pain medication prn
Finger Dislocations complications
○ Inadequate or delayed reduction (instability, stiffness, deformity)
○ Overaggressive attempts at reduction → fx
○ Redislocation (inadequate stabilization)
○ Muscle contracture (prolonged immobilization)
○ Infection (open fx)
Finger Dislocations referral considerations
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
Flexor/Extensor Tendon
Lacerations etiology
○ sharp object direct laceration
○ crush injury
○ avulsions
○ burns
○ animal or human bites- Infectious tenosynovitis (Fight bite)
○ deep abrasions
○ accompanied by skin injury
Flexor/Extensor Tendon Lacerations clinical presentation
○ 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
Flexor/Extensor Tendon Lacerations diagnosis
○ 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)
Flexor/Extensor Tendon Lacerations management
○ Wash out superficial wounds & splint appropriately (more info to come)
○ Tendon injuries typically will need surgical repair
Most common closed tendon injury seen in athletes
Mallet Finger
Mallet Finger etiology
○ 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
Mallet finger
Disruption of the terminal extensor mechanism at the distal interphalangeal (DIP)
Mallet Finger diagnosis
PA & lateral radiographs centered at the distal
interphalangeal (DIP) joint
Mallet Finger management
○ 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
Mallet Finger complications
○ 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
Boutonnière (Buttonhole) Deformity etiology
○ 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
Boutonnière (Buttonhole) Deformity presentation
○ Localized pain & swelling
○ Deformity
Boutonnière (Buttonhole) Deformity diagnosis
○ 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
Boutonnière (Buttonhole) Deformity management
○ 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
Boutonnière (Buttonhole) Deformity complications
○ Mal/Non-union
○ Arthritis
○ Deformity
Ulnar Collateral ligament Injury, Thumb AKA
“Gamekeeper’s or skier’s thumb”
Ulnar Collateral ligament Injury, Thumb etiology
○ 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
Ulnar Collateral ligament Injury, Thumb presentation
○ Localized pain, swelling, and/or ecchymosis of the MCP joint after a fall or blow to the thumb
Ulnar Collateral ligament Injury, Thumb diagnosis
○ 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
Ulnar Collateral ligament Injury, Thumb management
○ R.I.C.E.S.
○ Partial tears & Nondisplaced avulsion fx
○ Complete tears, Displaced avulsion fx, Subluxation & Articular fx
Ulnar Collateral ligament Injury, Thumb complications
○ Chronic instability is a major complication of UCL rupture.
○ Degenerative joint changes
○ Weakness of power grasp
○ ↓ dexterity of fine pincher-type movements
○ Stiffness
○ Pain
Dupuytren Contracture
○ Progressive, benign fibroproliferative disease of palmar fascia characterized by palmar
nodules & cords & digital flexion contracture
○ Cause: unknown
Dupuytren Contracture clinical presentation
○ ↓ 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
Dupuytren Contracture diagnosis
○ 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
Dupuytren Contracture Management
○ Physical rehabilitation
○ Night splints
○ Corticosteroid injection
○ Surgery
○ collagenase Clostridium histolyticum (Xiaflex) injection (US guided)
Fingertip infections “Felon” etiology
○ Infection of the pulp of the finger tip,
usually 2° to a puncture wound
○ Staphylococcus aureus is the most
common organism
Fingertip infections clinical presentation
○ 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)
Fingertip infections diagnosis
○ Clinical diagnosis
○ X-ray
Fingertip infections management
○ 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
Fingertip infections complications
○ Osteomyelitis
○ Nail deformity
○ Tendon rupture
○ Sepsis
○ Scarring
○ Recurrence
Fingertip infections
“Paronychia” etiology
○ 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
Fingertip infections
“Paronychia” clinical presentation
○ 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
Fingertip infections
“Paronychia” diagnosis
○ 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.
Fingertip infections
“Paronychia” management
○ Early diagnosis
■ May resolve with warm water soaks QID
○ Extensive cellulitis
■ amoxicillin-clavulanate (Augmentin®)
■ clindamycin (Cleocin®)
■ trimethoprim-Sufamethoxazole (Bactrim®)
○ Abscess
■ I&D
■ Ortho referral
Stenosing Tenosynovitis, flexor tendon(s) AKA
“trigger finger”
Stenosing Tenosynovitis, flexor tendon(s) etiology
○ Flexor tendon or 1 st annular pulley becomes
thickened & narrowed 2° chronic inflammation
○ Causes finger to lock/snap during flexion
Stenosing Tenosynovitis, flexor tendon(s) presentation
○ 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
Stenosing Tenosynovitis, flexor tendon(s) diagnosis
○ 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
Stenosing Tenosynovitis, flexor tendon(s)
“Trigger Finger” management
○ 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
Stenosing Tenosynovitis complications
○ Flexion contracture
○ Medication adverse effects
○ Digital sensory nerve damage (injections, surgery)
○ Infection (injections, surgery)
De Quervain Tenosynovitis etiology
○ 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
De Quervain Tenosynovitis presentation
○ Localized pain & swelling over the radial styloid
○ Pain with pinching & gripping
○ May be a history of repetitive movement activities
de Quervain Tenosynovitis diagnosis
○ Clinical diagnosis
○ tenderness over distal portion of radial styloid, plus pain on
passive thumb flexion/adduction or active resisted thumb
abduction
○ Finkelstein Test
Finkelstein Test
To test de Quervain Tenosynovitis
passively flex thumb across palm
■ flex fingers over thumb
■ passively deviate wrist to ulnar side
■ (+) pain
de Quervain Tenosynovitis management
○ Conservative management
■ 2 weeks in a thumb spica
■ NSAIDs
○ Corticosteroid injection may be most effective
option
Ganglion Cyst etiology
○ Unknown
○ Possibly trauma or mucoid degeneration
Ganglion Cyst clinical presentation
○ “I’ve got this bump that won’t go away”
■ “Bible bump”
○ Typically painless
○ Aggravated by activity
○ Often vary in size
○ Common locations
Ganglion Cyst Diagnosis
○ 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 (-)
Ganglion Cyst management
○ Splinting & NSAIDS
○ Closed rupture (sharp blow with a heavy object “aka the family bible”)
○ Needling
