Wrist

Question 1

Discuss the relevance of the following areas to mechanism of injury of the wrist:

FOOSH

Answer 1

-Trauma, such as FOOSH is the most common MOI for TFCC injury.

Question 2

Discuss the relevance of the following areas to mechanism of injury of the wrist:

Position of hand - flexion/extension/ulnar or radial deviation

Answer 2

The hand is usually in a pronated position during the fall when TFCC injury results from FOOSH

Question 3

What key information is required to assess for red flags?

Answer 3

The presence of constitutional symptoms, such as fevers, night sweats, chills, malaise, weight loss or chronic fatigue or bilateral wrist symptoms, strongly suggests that the problem is systemic

The basic indications for emergent (ie immediate) referral remain unchanged and include any persistent vascular or neurologic deficit, open fracture, development of any significant complications such as signs of infection.
Unstable fractures and those at high risk of complications should be referred to a hand surgeon.

Question 4

What key information is required to assess for yellow flags?

Answer 4

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Question 5

What key information is required in the setting of chronic wrist problems?

Answer 5

Obtaining a thorough history is important for determining the source of chronic wrist pain. When evaluating chronic wrist pain, the following questions are of particular importance:
1. Is the pain associated with any systemic features? Does pain occur in both wrists or in other joints in addition to the wrist?
The presence of systemic features or pain in both wrists or additional joints suggests that the pain may stem form a systemic illness.
2. What is the patient’s age?
Degenerative conditions such as OA are more likely to be seen in older patient.
3. Did pain begin following trauma? If so what was the MOI?
Wrist injuries can be missed during an initial evaluation.
4. Which is the patient’s dominant hand?
5. Location of pain
6. Aggravating and easing factors
7. Description of pain
8. Occupation and sporing activities
9. Functional limitations

Question 6

what key information would you ask to differentiate atraumatic wrist pain/injury from non musculoskeletal causes?

Answer 6

Determining whether an effusion is present is an important part of the evaluation of the patient with acutely painful wrist unrelated to trauma or overuse. Localised warmth, erythema, and swelling over the wrist suggest a joint effusion and the need to aspirate the wrist joint to evaluate for infection and inflammatory disease. If the wrist is aspirated, it is critical that all necessary tests be performed on the synovial fluid obtained. If the joint fluid examination is benign and the patient is not systemically ill, advanced imaging may be pursued on a routine timeline, and if necessary laboratory analysis may consist of a few simple screens for systemic infection. However, systemic symptoms or concerning synovial fluid results should prompt urgent evaluation.
A history of repeated flares or swelling in both wrists, or other joints in addition to the wrist, particularly if these flares are increasing severe, suggests a rheumatologic or autoimmune condition.

Question 7

What key information in a patient’s past medical history is important in wrist injuries/problems?

Answer 7

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Question 8

What key information in a patient’s medication history is important in wrist injuries/problems?

Answer 8

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Question 9

What key information in a patient’s social history is important is wrist injuries/problems?

Answer 9

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Question 10

What is the relevance of determining any intervention to date?

Answer 10

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Question 11

What is the relevance of determining the compensable status or health insurance status of the patient?

Answer 11

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Question 12

What is the relevance of determining the first aid/pre hospital treatment?

Answer 12

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Question 13

What is the relevance of determining the last intake of food or fluids?

Answer 13

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Question 14

Name the vascular supply of the upper limb

Answer 14

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Question 15

How would you assess the neurovascular status of the wrist and hand?

Answer 15

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Question 16

What are the relevance of any local skin changes/open or punctured wounds to the upper limb?

Answer 16

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Question 17

When is an assessment of vital signs indicated?

Answer 17

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Question 18

What are the most common non-musculoskeletal presentations of wrist pain?

Answer 18

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Question 19

Essential anatomy of the distal radius

Answer 19

Volar tilt: the normal radiocarpal joint angle on the lateral view ranges from 1-23 degrees in a palmar direction.

Radial tilt: The normal angulation of the radioulnar joint, seen on the PA view of the wrist is 15-30 degrees. The evaluation of this angle is essential when treating fractures of the distal forearm because failure or incomplete reduction with loss of this angle will result in an inhibition of ulnar hand motion.

Radial length: A third measurement, radial length is also taken from the PA view of the wrist. It is the distance from the tip of the radial styloid to the distal articular surface of the ulna. Normal radial length is 12 mm.

Question 20

What special views may be required?

Answer 20

The minimum number of radiographic views includes a PA, lateral and oblique with the wrist in a neutral position.
The carpal bones are visualised best in the PA view. The 3 carpal arcs should be identified. The 1st arc is outlined by the proximal joint surface of the scaphoid, lunate and triquetrum. The 2nd arc is made up of the distal joint surfaces of the proximal row. The 3rd arc consists of the proximal articular surface of the capitate and hamate. Any disruption of these arcs suggests injury - fracture, dislocation or both. In addition, the spacing between the carpal bones is normally constant, independent of wrist positioning.

The oblique view is useful as it demonstrates the radial structures better. This radiograph is obtained with the wrist in 45 degrees of pronation.

The lateral view is first assessed for adequacy. The ulnar should not project >2mm dorsal to the radius.

A line drawn through the centre of the lunate and the centre of the scaphoid should make an angle between 30-60 degrees. This angle is known as the scapholunate angle.

Question 21

When would a CT scan be indicated for a patient with wrist injury/problem?

Answer 21

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Question 22

When would an ultrasound for a patient with wrist injury/problem?

Answer 22

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Question 23

When would you consider obtaining blood investigations for a patient with wrist injury/problem?

Answer 23

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Question 24

Colles’ fracture

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 24

The distal radius is one of the most frequently fractured long bones and the extension type (Colle’s fracture) is the most common distal radius fracture. Most distal forearm fractures result from FOOSH. The amount of communition and location of the fracture line is dependent on the force of the fall and brittleness of the bone. A supinating force often results in an associated ulnar fracture. Extension fractures of the distal radius are often associated with several significant injuries including ulnar styloid and neck fractures, carpal fractures, distal radioulnar subluxation, flexor tendon injuries, median and ulnar nerve injury.

Examination typically reveals pain, swelling and tenderness of distal forearm. The displaced angulated fracture typically resembles a dinner fork. Documentation of the neurological status with special emphasis on median nerve function should be stressed. Elbow pain may be indicative of proximal radioulnar joint subluxation or dislocation.
Nondisplaced and nonangulated fractures with near normal radial tilt, volar tilt and radial length need only immobilisation is a sugar tong splint. For displaced or angulated with loss of normal anatomical alignment, closed reduction is performed.

When reduction is complete, the forearm is immobilised and median nerve function is retested. Postreduction radiograph are obtained to ensure proper positioning. After reduction, the arm should be kept elevated for 72 hours to keep the swelling at a minimum. Fingers and shoulder exercises should begin immediately.

Colles fractures, even when managed appropriately, frequently results in long-term complications. Nondisplaced fractures are immobilised for 4-6 weeks whereas displaced fractures that are adequately reduced require 6-12 weeks of immobilisation.
Complications associated with distal radius fractures are reported with a frequency between 2-30%. These complications include neuropathies, degenerative arthritis, malunion, tendon injury, compartment syndrome and CRPS.
Early adequate reduction of the fracture is the most important means of avoiding complications.

Question 25

Smith’s fracture

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 25

Several mechanisms result in distal forearm flexion fractures, including a fall on the supinated forearm with the hand in DF, a punch with the fist clenched and the wrist slightly flexed or a direct blow to the dorsum or distal radius with the hand flexed and the forearm in pronation.
Pain and swelling will be apparent over the volar aspect of the wrist. The clinical appearance of this fracture is described as a garden spade deformity. The presence and function of the radial artery and median nerve should be examined and documented. These fractures require emergent orthopaedic referral for reduction.

Question 26

Barton’s fracture

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 26

These fractures are intra-articular and involve the dorsal or volar rim of the radius. Barton’s fracture most commonly involve the dorsal rim of the distal radius, and typically a triangular fragment of bone is noted on xray. Extreme dorsiflexion of the wrist accompanied by a pronating force may result in a dorsal rim fracture. Carpal bone injury or dislocations along with damage to the sensory branches of the radial nerve may occur. On examination the distal dorsal radius is tender and swollen. Occasionally, radial nerve sensory branches may be compromised and present as paraesthesia in the area of distribution.
The therapy selected depends on the size of the fracture fragment and the degree of displacement. Nondisplaced barton’s fracture should be placed in a sugar-tong splint with the forearm in a neutral position. A large displaced fragment with subluxation or dislocation of the carpal bones requires procedural sedation followed by a closed manipulative reduction. If the fracture is stable and in a good position, a sugar-tong splint with the forearm in a neutral position is recommended. If the fracture is unstable or reduced inadequately, ORIF is indicated.
Frequent complications include arthritis secondary to intra-articular involvement as well as those complications associated with Colle’s fractures.

Question 27

Scaphoid fracture

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 27

Scaphoid is the most commonly fractured carpal bone (6-70%). The blood supply to the scaphoid penetrates the cortex on the dorsal surface near the tubercle waist area. Therefore, there is no direct blood supply to the proximal portion of the bone. Scaphoid fractures are divided into 4 types: middle third (waist), proximal third, distal third and tubercle fractures. The more proximal the fracture line, the higher incidence of complications.
MOI: Scaphoid fractures commonly result from forceful hyperextension of the wrist (FOOSH)
Examination: On examination, there is maximum tenderness at the anatomic snuffbox. Axial compression of the thumb and supination against resistance may also elicit pain from a scaphoid fracture.
Imaging: A fracture may not be demonstrated for up to 6 weeks post injury. Up to 30% of scaphoid fractures are not demonstrated on any view in the acute setting.
Treatment: A long-arm thumb spica splint should be applied for nondisplaced fractures. The splint should extend from IP joint of the thumb to an area proximal to the elbow, with the elbow in 90 degrees of flexion.
After 6 weeks, short-arm spica cast is applied for the remaining duration of immobilisation, totalling 8-12 weeks. Due to their higher rates of complications, proximal-third fractures are immobilised for a greater duration (12-16 weeks).
Displaced scaphoid fractrues should be placed in a splint and referred to a hand surgeon for ORIF.

Question 28

Ulnar styloid fracture

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 28

Fractures of the distal ulna are frequently associated with distal radius fractures and may contribute to the need for operative intervention. Approximately 60% of distal radius extension fractures are associated with ulnar styloid fractures and 60% of ulnar styloid fractures are associated with fractures of the ulnar head or neck. Ulnar styloid fractures signify avulsion by the ulna collateral ligament complex. Ulnar head or neck fractures may create an unstable DRUJ and therefore these fractures should be referred to an Orthopaedic surgeon

Question 29

Shaft of radius/ulnar fractures

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 29

The clinician should be aware of the essential anatomy of the distal radius in order to assess 3 important measurements seen on radiographs of the wrist: volar tilt, radial tilt and radial length.
Volar tilt: the normal radiocarpal joint angle on the lateral view ranges from 1-23 degrees in a palmar direction (volar tilt). Fractures associated with volar angulation generally result in good functional recovery whereas fractures associated with dorsal angulation of the radiocarpal joint will have a poor functional recovery if reduction is not accomplished.
Radial tilt: the normal angulation of the radioulnar joint, seen on the PA view of the wrist is 15-30 degrees (radial tilt). The evaluation of this angle is essential when treating fractures of the distal forearm because failure or incomplete reduction with loss of this angle will result in an inhibition of ulnar hand motion.
Radial length: this measurement is drawn parallel to the radial shaft and is the distance from the tip of the radial styloid to the distal articular surface of the ulna. Normal radial length is 12mm. Loss of radial length that is not restored after closed reduction may be an indication for operative management.

Question 30

Radio-ulnar joint injury/dislocation

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 30

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Question 31

Fracture of the carpal bones

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 31

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Question 32

Flake fracture of Triquetral

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 32

Triquetral fracture typically occurs from a hyperextension injury with the wrist in ulnar deviation. The patient presents with a history of injury and pain at the ulnar aspect of the wrist. On examination, there is usually pain and point tenderness dorsally or along the ulnar border of the wrist 1-2cm distal to the most distal aspect of the ulnar. Wrist extension may reproduce or exacerbate pain.
Triquetrum injuries are frequently associated with scaphoid fractures, scapholunate instability, distal radius and ulnar styloid fractures and ulnar nerve injuries.
Treatment: wrist immobilisation for 4-6 weeks.
Transverse fractures should be referred for orthopaedic review.

Question 33

Fracture of the lunate

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 33

The most common lunate fractures are lunate body fractures and dorsal avulsion fractures.

Question 34

Fracture of the hook of hamate

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 34

Fractures of the hook of the hamate often result from a FOOSH. They may be misdiagnosed initially as a wrist sprain and can present with chronic pain localised over the hypothenar eminence; swelling may be minimal or absent.

Question 35

Fracture of the trapezium

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 35

Trapezium fractures are uncommon, but trauma involving axial loading of the thumb or a direct blow may cause such injuries. The patient typically presents with minimal swelling, but may have significant discomfort. There is pain and weakness with pinching. Pain with resisted wrist flexion from a dorsiflexed start position or tenderness at the base of the thenar eminence may indicate a fracture of the trapezial ridg

Question 36

Fracture of pisiform

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 36

most commonly the pisiform is injured in a fall on the outstretched hand with the wrist in extension or if the heel of the hand is used like a hammer to strike an object. When the wrist is in this position, the pisiform is compressed between the FCU tendon and triquetrum. These mechanisms can create an avulsion fracture of the distal aspect of the pisiform, a linear fracture, or a chondral injury to its dorsal surface. Patients present with pain and swelling at the palmar and ulnar aspect of the wrist. Tenderness is present directly over the pisiform and over the hypothenar eminence.

Question 37

Kienbock’s disease of the lunate

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 37

AVN of the lunate resulting in progressive collapse of the lunate. The mechanism is unclear but possibly related to undiagnosed lunate fracture, repetitive trauma, or abnormal biomechanical loading patterns at the radiocarpal joint.
The most common symptoms are dorsal wrist pain with mild swelling.

Question 38

AVN (capitate and scaphoid)

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 38

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Question 39

Wrist complex instabilities

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 39

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Question 40

Dislocation of lunate/perilunar

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 40

The normal articulation of the radius, lunate, capitate and 3rd MC makes up a straight line. In a perilunate dislocation, the capitate is dislocated, usually dorsally, in relation to the lunate. With a lunate dislocation, the lunate is volarly dislocated in relation to the distal radius.

MOI: hyperextension with ulnar deviation

All lunate and perilunate dislocations should be immobilised with the wrist in neutral position in a volar splint and referred immediately for reduction and definitive care.

Question 41

Repetitive strain injury

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 41

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Question 42

Acute extensor tenosynovitis (infective)

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 42

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Question 43

Wrist sprain

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 43

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Question 44

TFCC sprain/tear

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 44

TFCC stabilise the distal radioulnar joint and ulnocarpal articulations. Acute injury to the TFCC involves tears of the fibrocartilage articular disc and the tissue that connects the disc to the triquetrum and other carpals. Trauma, such as FOOSH is the most common MOI. The hand is usually in a pronated position during the fall. Wrist pain along the ulnar aspect of the wrist is the primary symptoms of TFCC injury. Pain typically increases with any activity that requires forearm rotation and ulnar deviation of the wrist.

Treatment is initially conservative with NSAIDs, immobilisation in slight flexion and ulnar deviation, followed by physical therapy.
Arthroscopic repair may be required.

Question 45

Carpal tunnel syndrome

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 45

CTS refers to a complex of signs and symptoms brought on by compression of the median nerve as it travels through the carpal tunnel. CTS is usually a chronic condition but there are circumstances when acute CTS can develop, such as fractures and fracture-dislocations at the wrist, or hemorrhagic or vascular disorders. Patients commonly experience pain and paraesthesia, and less commonly weakness, in the median nerve distribution. Symptoms are typically worse at night. Positive Phalen or Tinel tests suggest the diagnosis.

Question 46

Ganglions

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 46

A ganglion cyst is the most common tumor of the hand and consists of a synovial cyst originating from either a joint or the synovial lining of a tendon that has herniated.

The onset is almost always insidious.

Question 47

Scaphoid-lunate instability

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 47

A fall back onto an outstretched, extended wrist that disrupts the supporting ligaments forces the carpal bones shift dorsally. Depending upon the amount of force involved and the position of the wrist during the fall, a range of possible injuries may occur. Of the potential ligamentous injuries, disruption of the ligaments stabilising the lunate and scaphoid bones is most common. Patients may complain of swelling and pain over the dorsoradial aspect of the wrist, grip weakness, and painful or decreased wrist motion. Tenderness over the scapholuate junction is common. The scaphoid shift test can help detect ligamentous instability

On xray PA view, there is widening of he scapolunate joint space (>3mm is abnormal and is named Terry Thomas Sign).

Associated injuries: part of a perilunate or lunate dislocation, conjuction with a scaphoid fracture or distal radius fracture

Patients should be placed in a thumb spica splint and referred to a hand surgeon.

Question 48

OA of the wrist

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 48

OA is a common cause of pain at the base of the thumb MC. Although OA is a chronic condition, relatively rapid increases in symptoms may lead to patients to present for evaluation complaining of ‘acute’ wrist pain. Inspection of the hand may reveal a prominent CMC joint. Symptoms often include diffuse pain that is aggravated by sustained grasping or pinching or by forceful use of the thumb

Question 49

CRPS

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 49

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Question 50

nerve entrapment - Guyon’s cannel

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 50

Injury to the terminal branches of the ulnar nerve at the wrist typically present with hand weakness and atrophy, loss of dexterity and variable sensory involvement.

The condition often develops after prolonged compression of the ulnar nerve during activities such as cycling or racquet sports.

Physical examination is often unremarkable with this condition.

Question 51

Carpal tunnel syndrome

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 51

This syndrome involves the compression of the median nerve at the wrist and is the most common peripheral neuropathy. The carpal tunnel is a confined space between the carpal bones and the transverse carpal ligament.
The condition is most common in postmenopausal women and is usually idiopathic but may follow fractures, crush injuries, RA, pregnancy, diabetes or thyroid disease. Any condition causing chronic swelling of the hand and wrist may lead to this syndrome.

Patients often complain paraesthesia and numbness over the distribution of the median nerve.
The patient may be awakened from sleep with pain in the hand due to fluid retention that occurs at night. When this happens, the patient should be instructed to elevate the hand.
Symptoms develop after repetitive gripping or sustained wrist flexion.

Classic physical examination findings include the Tinels and Phalen signs.
The most predictive signs and symptoms of carpal tunnel syndrome appear to be symptom location in the median nerve distribution, diminished pain perception along the palmar aspect of the index finger, and weak thumb abduction.

The majority of patients respond to conservative measures. Otherwise surgical release is needed.

Question 52

De Quervains syndrome

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 52

de quervain’s tenosynovitis refers to entrapment tendonitis or tenosynovitis of the APL or EPB tendons at the styloid process of the radius. Chronic overuse is the usual cause but acute exacerbations can occur. Patients with de Quervains tenosynovitis typically note pain at the radial side of the wrist during pinching grasping or thumb and wrist movement. Pain may radiate to the thumb or along the volar aspect of the wrist

Question 53

Inflammatory arthropathies

What management is appropriate in ED setting?
What type of injury would require the involvement of the Orthopaedic team?
How would you know when to refer to outpatients, further imaging as an outpatient or request for an urgent review?
How would you control swelling of the affected area? (remember removal of jewellery)
When would IV fluids be indicated?
Describe the type of immobilisation used for the management of wrist injuries/problems and for what indications
How would you provide adequate pain control on discharge?

Answer 53

Inflammatory arthritis is characterised by an influx of inflammatory cells, such as monocytes/macrophages, lymphocytes and granulocytes, from the blood stream into the synovial membrane or their accrual in the synovial fluid, and is frequently associated with hyperplasia of synovial fibroblasts. This inflammatory process causes pain, swelling (and in some instances redness) of the joint, frequently associated with reduced mobility and functional impairment.
Inflammatory arthritis contrasts from osteoarthritis, which is regarded a degenerative joint disease.

Patients with inflammatory arthritis in whom a specific diagnosis cannot be readily established should be referred for consultation with specialist (rheumatologist) as soon as possible.

Treatment of patients with undifferentiated early inflammatory arthritis, in whom a specific diagnosis cannot be established after evaluation by an expert in rheumatologic disease is based largely upon the well-established treatments used for RA and spondyloarthritis. The goal of early therapy, before being able to make a definitive diagnosis, is the suppression of inflammation and the prevention of persistent or recurrent inflammation and joint damage.