Upper Lim - wrist

Question 1

What is De Quervain’s tenosynovitis?

Answer 1

Inflammation of the tendon sheaths within the first compartment, which contains the

(1) abductor pollicis longus (APL)
(2) extensor pollicis brevis (EPB)

Question 1

Which tendons are affected in De Quervain’s tenosynovitis?

Answer 1

Abductor pollicis longus (APL) and extensor pollicis brevis (EPB)

Question 2

Who is most commonly affected by De Quervain’s tenosynovitis?

Answer 2

Women aged 30–50 years, particularly those who are pregnant or have rheumatoid arthritis (RA)

Question 3

What is the typical cause of De Quervain’s tenosynovitis?

Answer 3

It is usually a repetitive strain injury

Question 4

What are the key symptoms of De Quervain’s tenosynovitis?

Answer 4

1. Pain over the radial styloid process at the wrist
2. Often radiating proximally into the forearm
3. Sometimes associated with swelling and redness

Question 5

What test is used to diagnose De Quervain’s tenosynovitis?

Answer 5

Finkelstein’s test

= where the patient makes a fist over the thumb, and the hand is ulnar deviated to reproduce pain

= The examiner pulls the patient’s thumb into ulnar deviation and longitudinal traction, which causes pain over the radial styloid process if tenosynovitis is present

Question 6

What imaging investigations can be used to rule out other conditions?

Answer 6

Ultrasound (USS) and X-ray to exclude carpometacarpal (CMC) joint osteoarthritis, which can mimic De Quervain’s tenosynovitis

Question 7

What are the conservative management options for De Quervain’s tenosynovitis?

Answer 7

Splinting, rest, physiotherapy, analgesics, NSAIDs, and steroid injections

Question 8

A 32-year-old woman presents with a 4-week history of pain along the radial side of her right wrist that worsens when lifting her child or gripping objects. She reports no trauma or systemic symptoms.

Examination reveals tenderness over the radial styloid and pain on the ulnar deviation of the wrist with the thumb tucked into the palm.

Which structures are most likely affected?

Answer 8

Abductor pollicis longus and extensor pollicis brevis tendons

Question 9

A 40-year-old woman presents to the clinic with pain on the radial side of her right wrist. She reports difficulty gripping objects and mentions that her pain worsens when lifting her infant.

On examination, there is tenderness over the radial styloid process, and she experiences pain when moving her thumb, particularly when abducting the thumb against resistance.

An X-ray demonstrates soft-tissue swelling over the radial styloid only.

Which clinical test would be most appropriate to confirm the diagnosis?

Answer 9

Finkelstein test

Question 10

A 34-year-old medical secretary reports pain on the thumb side of her right wrist, ongoing for the past week. She also reports that right wrist appears more swollen than her left. On examination, she has pain over her radial styloid on forced flexion of the thumb

What is the most likely diagnosis?

Answer 10

Tenosynovitis

Question 11

‘Pain on the radial side of the wrist/tenderness over the radial styloid process’ atomically means the answer will be… ?

Answer 11

De Quervain’s tenosynovitis

Question 12

Is Tinel’s test positive in De Quervain’s tenosynovitis?

Answer 12

No, it is usually negative as there is no nerve involvement

Question 13

A 36-year-old woman presents with a 6 week history of a painful wrist. On examination pain over the radial aspect of the wrist is is elicited by forced adduction and flexion of the thumb.

What is the most likely diagnosis?

Answer 13

De Quervain’s tenosynovitis

Question 14

A 35-year-old female presents with pain on the radial side of the wrist and tenderness over the radial styloid process. On examination, abduction of the thumb against resistance is painful, and when the thumb is flexed across the palm, pain is reproduced by movement of the wrist into flexion and ulnar deviation.

What test is this describing?

Answer 14

Finkelstein’s test

Question 15

What is the most frequently fractured carpal bone?

Answer 15

The scaphoid

Question 15

What is the most common mechanism of injury for a scaphoid fracture?

Answer 15

A fall on an outstretched hand (FOOSH)

Question 16

Where is the pain typically located in a scaphoid fracture?

Answer 16

In the anatomical snuffbox

Question 17

What forms the medial border of the anatomical snuffbox?

Answer 17

The extensor pollicis longus tendon

Question 18

Which nerve supplies the anatomical snuffbox?

Answer 18

The radial nerve

Question 19

What imaging views are used to assess a scaphoid fracture?

Answer 19

AP, lateral, and two oblique X-ray views

Question 20

Why might a scaphoid fracture be missed on an initial X-ray?

Answer 20

It can be radiographically occult, requiring a repeat X-ray after 10 days or an MRI for confirmation

Question 21

How is a scaphoid fracture managed conservatively?

Answer 21

With a cast for 6-8 weeks

Question 22

What surgical options are available for scaphoid fractures?

Answer 22

Percutaneous screw fixation or open reduction and internal fixation (ORIF)

Question 23

What is the main complication of a scaphoid fracture?

Answer 23

Avascular necrosis (AVN) is due to disruption of the blood supply from the dorsal carpal branch of the radial artery

Question 24

What are other complications of a scaphoid fracture?

Answer 24

Non-union and early wrist osteoarthritis (OA)

Question 25

What are the typical symptoms of a scaphoid fracture?

Answer 25

Pain along the radial aspect of the wrist, at the base of the thumb, and loss of grip/pinch strength

Question 26

How are displaced scaphoid waist and proximal scaphoid pole fractures managed?

Answer 26

Surgical fixation

Question 26

What are additional clinical signs of a scaphoid fracture?

Answer 26

1. Wrist joint effusion 2. Pain on telescoping the thumb = longitudinal compression 3. Tenderness over the scaphoid tubercle 4. Pain on ulnar deviation of the wrist

Question 26

What is the most sensitive clinical sign of a scaphoid fracture?

Answer 26

Maximal tenderness over the anatomical snuffbox

Question 27

A 16-year-old rugby player is brought into the emergency department following an accident on the field. On examination, the doctor finds tenderness over the anatomical snuffbox. There is also tenderness over the scaphoid tubercle. What neurovascular structure is most likely to be compromised?

Answer 27

Dorsal carpal arch of the radial artery

Question 28

A 33-year-old gentleman comes to see you with right wrist pain three weeks after falling off his bike onto an outstretched hand. He attended the emergency department that day and had x-rays of his wrist which are reported as normal. He was discharged with analgesia and no follow-up. Today, he is complaining of persistent pain without improvement. On examination the wrist appears normal. There is no gross swelling or erythema. He has slightly limited range of movement in the wrist which appears to be due to pain. He is tender over the anatomical snuff box. What is the appropriate action?

Answer 28

Refer to hospital for urgent orthopaedic/emergency department review = The mechanism and examination are highly suspicious for a scaphoid fracture. Conservative management with splinting, analgesia and physiotherapy are all inappropriate due to the risk of avascular necrosis due to the blood supply to the scaphoid bone

Question 29

What is the most common cause of a distal radial fracture?

Answer 29

A fall on an outstretched hand (FOOSH)

Question 30

How is a Colles fracture characterised?

Answer 30

A distal radius fracture with posterior displacement of the distal fragment

Question 31

How is a Smith fracture characterised?

Answer 31

A distal radius fracture with anterior displacement of the distal fragment

Question 32

What is Barton's fracture?

Answer 32

An intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Question 33

What are the common symptoms of a distal radial fracture?

Answer 33

Wrist pain, swelling, and deformity

Question 34

What classic deformity is seen in a Colles fracture?

Answer 34

Dinner fork deformity

Question 35

What imaging is used to diagnose a distal radial fracture?

Answer 35

X-ray (AP, lateral, oblique)

Question 36

What is a major nerve complication of a Colles fracture?

Answer 36

Median nerve compression due to nerve stretch or bleeding into the carpal tunnel

Question 37

What complication can result from malunion of a distal radial fracture?

Answer 37

Impaired grip strength due to loss of extension

Question 38

'Dinner fork Deformity' The 3 D's stand for what?

Answer 38

Dorsally Displaced Distal radius = Colles fracture - wrist

Question 39

A 74-year-old woman attends her GP practice due to difficulty bending her left index finger. The patient reports a 3-week history of persistent weakness of their left index finger, most noticeable when they are bending their finger. On examination, the patient has weakness in the flexion of the thumb and index finger. Past medical history includes type 2 diabetes mellitus, osteoarthritis, and a recent left Colles fracture. What is the most likely cause?

Answer 39

Median nerve injury

Question 40

A 69-year-old woman presents to the emergency department following a fall. She was doing groceries when she slipped over the wet floor and fell over both of her wrists. The pain in her right forearm started immediately and did not settle with paracetamol. On examination, she looks in pain. There is tenderness and swelling of the right distal forearm, associated with a reduced range of motion of the right wrist. Neurovascular examination is normal. The left limb is intact. An x-ray reveals a Colles' fracture. What would you expect to see on her x-ray?

Answer 40

Dorsally displaced distal radius fracture

Question 41

A 19-year-old boy is brought into the emergency department after a collision during a university rugby game which caused him to land on an awkward position on his arm. He is unable to report how he exactly fell as the collision occurred so suddenly. He subsequently has an x-ray performed which reveals a transverse fracture of the radius 1.5cm proximal to the radio-carpal joint as well as posterior displacement of the distal fragment. Examination of the elbow joint reveals no significant signs. What type of fracture has this patient sustained?

Answer 41

Colles' fracture

Question 42

A 55-year-old woman presents to the emergency department after a fall. Her son describes how his mother tripped forward over an exposed tree root onto her extended arms. After the fall, she has been cradling her right arm and complaining of severe pain. You request an x-ray which shows a fracture of the distal radius with posterior displacement. The tip of the ulnar is also fractured. The fracture is across the metaphysis of the radius and there is no involvement of the articular cartilage. What is the name of this kind of fracture?

Answer 42

Colle's fracture

Question 43

What is the initial management for most distal radius fractures with displacement, like a Colles' fracture?

Answer 43

closed reduction

Question 44

A 30-year-old female patient complains of a one-month history of pain at the base of the left thumb and pain on thumb abduction. She has recently given birth, and her daughter is currently 5 months old. Her family history is significant for osteoarthritis in the hands Given the likely diagnosis, what is the most appropriate management?

Answer 44

Splinting of thumb and wrist = patient has De Quervain's tenosynovitis

Question 45

A 35-year-old woman presents to the clinic with pain and swelling at the base of her thumb and along the radial aspect of her wrist. She reports that the pain is exacerbated when she moves her thumb or grasps objects. What is the most likely cause of her symptoms?

Answer 45

De Quervain's tenosynovitis