Upper extremity: Forearm, wrist and hand

Question 1

Metacarpal vs phalangeal fracture

Answer 1

○ 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

Question 2

Metacarpal/Phalange Fractures etiology

Answer 2

○ Axial loading & direct trauma
○ Avulsions

Question 3

Metacarpal/Phalange Fractures clinical presentation

Answer 3

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

Question 4

Metacarpal/Phalange Fractures diagnosis

Answer 4

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

Question 5

Metacarpal/Phalange Fractures Management: boxer fx

Answer 5

■ <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

Question 6

Metacarpal/Phalange Fractures Management: nondisplaced fx

Answer 6

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

Question 7

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

Answer 7

Refer to ortho

Question 8

Metacarpal/Phalange Fractures complications

Answer 8

○ Joint stiffness
○ Malunion
○ Malrotation

Question 9

Fracture of the Base of the Thumb
Metacarpal etiology

Answer 9

Traumatic
■ MVA & Bicycle accidents

Question 10

“Bennett Fracture”

Answer 10

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

Question 11

“Rolando Fracture”

Answer 11

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

Question 12

Fracture of the Base of the Thumb
Metacarpal: clinical presentation

Answer 12

○ 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

Question 13

Fracture of the Base of the Thumb
Metacarpal Diagnosis

Answer 13

○ 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

Question 14

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

Answer 14

■ 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

Question 15

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

Answer 15

■ 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.

Question 16

Fracture of the Base of the Thumb
Metacarpal complications

Answer 16

○ Stiffness
○ ↓ ROM
○ Arthritis

Question 17

Scaphoid Fracture etiology

Answer 17

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

Question 18

Scaphoid Fracture clinical presentation

Answer 18

○ 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

Question 19

Scaphoid Fracture diagnosis

Answer 19

○ 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

Question 20

Scaphoid Fracture management

Answer 20

○ 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

Question 21

Scaphoid Fracture complications

Answer 21

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

Question 22

Distal Radius Fracture epidemiology and etiology

Answer 22

● 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

Question 23

Distal Radius Fracture Clinical Presentation

Answer 23

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

Question 24

Distal Radius Fracture diagnosis

Answer 24

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

Question 25

Distal Radius Fracture management

Answer 25

○ 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

Question 26

Distal Radius Fracture Complications

Answer 26

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

Question 27

Distal Radius Fracture referral considerations

Answer 27

○ 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

Question 28

Finger Dislocations etiology

Answer 28

Trauma

Question 29

______ → most common finger dislocations

Answer 29

PIP joints

Question 30

Finger Dislocations presentation

Answer 30

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

Question 31

Finger Dislocations diagnosis

Answer 31

○ 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

Question 32

Finger Dislocations management

Answer 32

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

Question 33

Finger Dislocations complications

Answer 33

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

Question 34

Finger Dislocations referral considerations

Answer 34

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

Question 35

Flexor/Extensor Tendon Lacerations etiology

Answer 35

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

Question 36

Flexor/Extensor Tendon Lacerations clinical presentation

Answer 36

○ 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

Question 37

Flexor/Extensor Tendon Lacerations diagnosis

Answer 37

○ 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)

Question 38

Flexor/Extensor Tendon Lacerations management

Answer 38

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

Question 39

Most common closed tendon injury seen in athletes

Answer 39

Mallet Finger

Question 40

Mallet Finger etiology

Answer 40

○ 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

Question 41

Mallet finger

Answer 41

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

Question 42

Mallet Finger diagnosis

Answer 42

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

Question 43

Mallet Finger management

Answer 43

○ 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

Question 44

Mallet Finger complications

Answer 44

○ 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

Question 45

Boutonnière (Buttonhole) Deformity etiology

Answer 45

○ 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

Question 46

Boutonnière (Buttonhole) Deformity presentation

Answer 46

○ Localized pain & swelling ○ Deformity

Question 47

Boutonnière (Buttonhole) Deformity diagnosis

Answer 47

○ 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

Question 48

Boutonnière (Buttonhole) Deformity management

Answer 48

○ 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

Question 49

Boutonnière (Buttonhole) Deformity complications

Answer 49

○ Mal/Non-union ○ Arthritis ○ Deformity

Question 50

Ulnar Collateral ligament Injury, Thumb AKA

Answer 50

“Gamekeeper’s or skier’s thumb”

Question 51

Ulnar Collateral ligament Injury, Thumb etiology

Answer 51

○ 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

Question 52

Ulnar Collateral ligament Injury, Thumb presentation

Answer 52

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

Question 53

Ulnar Collateral ligament Injury, Thumb diagnosis

Answer 53

○ 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

Question 54

Ulnar Collateral ligament Injury, Thumb management

Answer 54

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

Question 55

Ulnar Collateral ligament Injury, Thumb complications

Answer 55

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

Question 56

Dupuytren Contracture

Answer 56

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

Question 57

Dupuytren Contracture clinical presentation

Answer 57

○ ↓ 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

Question 58

Dupuytren Contracture diagnosis

Answer 58

○ 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

Question 59

Dupuytren Contracture Management

Answer 59

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

Question 60

Fingertip infections “Felon” etiology

Answer 60

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

Question 61

Fingertip infections clinical presentation

Answer 61

○ 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)

Question 62

Fingertip infections diagnosis

Answer 62

○ Clinical diagnosis ○ X-ray

Question 63

Fingertip infections management

Answer 63

○ 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

Question 64

Fingertip infections complications

Answer 64

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

Question 65

Fingertip infections “Paronychia” etiology

Answer 65

○ 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

Question 66

Fingertip infections “Paronychia” clinical presentation

Answer 66

○ 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

Question 67

Fingertip infections “Paronychia” diagnosis

Answer 67

○ 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.

Question 68

Fingertip infections “Paronychia” management

Answer 68

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

Question 69

Stenosing Tenosynovitis, flexor tendon(s) AKA

Answer 69

"trigger finger"

Question 70

Stenosing Tenosynovitis, flexor tendon(s) etiology

Answer 70

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

Question 71

Stenosing Tenosynovitis, flexor tendon(s) presentation

Answer 71

○ 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

Question 72

Stenosing Tenosynovitis, flexor tendon(s) diagnosis

Answer 72

○ 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

Question 73

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

Answer 73

○ 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

Question 74

Stenosing Tenosynovitis complications

Answer 74

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

Question 75

De Quervain Tenosynovitis etiology

Answer 75

○ 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

Question 76

De Quervain Tenosynovitis presentation

Answer 76

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

Question 77

de Quervain Tenosynovitis diagnosis

Answer 77

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

Question 78

Finkelstein Test

Answer 78

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

Question 79

de Quervain Tenosynovitis management

Answer 79

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

Question 80

Ganglion Cyst etiology

Answer 80

○ Unknown ○ Possibly trauma or mucoid degeneration

Question 81

Ganglion Cyst clinical presentation

Answer 81

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

Question 82

Ganglion Cyst Diagnosis

Answer 82

○ 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 (-)

Question 83

Ganglion Cyst management

Answer 83

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