Wrist And Hand

Question 1

What is a Colles’ fracture?

Answer 1

A, extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface.

It occurs through FOOSH, typically in osteoporotic patients.

Question 2

What is a Smith’s fracture?

Answer 2

An extra-articular fracture of the distal radius, with volar angulation (with or without volar displacement).

Typically occurs from falling backwards on an outstretched hand.

Question 3

What is a Barton’s fracture?

Answer 3

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

(it can be dorsal or volar).

Question 4

What imaging should be requested for a suspected distal radius fracture?

What are the 3 important parameters to look at?

Answer 4

Plain film radiographs AP and lateral of the wrist. (Sometimes CT / MRI for operative planning).

Three important parameters:
Radial height (>11mm)
Radial inclination (<22 degrees)
Volar tilt (<11 degrees)

Question 5

How should a distal radius fracture be managed?

Answer 5

A to E assessment
Analgesia
Closed reduction (under conscious sedation with a haematoma / Bier’s block).
Immobilisation with below elbow backslab.
Physiotherapy.

Surgical management - (if displaced / unstable) ORIF or K wire fixation.

Question 6

What imaging would you request for a suspected scaphoid fracture?

Answer 6

A ‘scaphoid series’ = plain film radiographs AP, lateral and oblique views.

Sometimes if we clinically suspect a scaphoid fracture but there are no signs on x ray we will do another x ray 10-14 days later to check.

Question 7

How are scaphoid fractures managed?

Answer 7

undisplaced fractures - immobilisation in a plaster with thumb splint. (However undisplaced proximal fractures have a high risk of AVN so surgical treatment may be needed).

Displaced fractures - surgical fixation (percutaneous variable-pitched screw).

Question 8

What are the risk factors for developing carpal tunnel syndrome?

Answer 8

Female
Increasing age
Pregnancy
Obesity
Previous injury to the wrist
Diabetes 
RA
Hypothyroidism 
Occupations with repetitive Hand / wrist movements (vibrating tools).

Question 9

What are the two special tests for carpal tunnel syndrome?

Answer 9

Tinel’s test - percussing over the median nerve reproduces sensory symptoms.

Phalen’s test - holding wrist in full flexion for one minute reproduces symptoms.

Question 10

What investigations would you do for a suspected carpal tunnel syndrome?

Answer 10

The diagnosis is clinical.

However we can sometimes do nerve conduction studies

Question 11

What is the management for carpal tunnel syndrome?

Answer 11

Conservative - wrist splint (worn at night to prevent wrist flexion). Also physiotherapy, can sometimes try steroid injections.

Surgical - (only in severely limiting cases where previous treatments have failed). Carpal tunnel release surgery.

Question 12

What is Dupuytren’s contracture?

Answer 12

Contraction of the longitudinal palmar fascia. It most commonly affects the ring and little finger.

Occurs due to fibrotic hyperplasia and altered collagen matrix, which leads to thickening and contraction of the palmar fascia.

Question 13

What are the risk factors for Dupuytren’s contracture?

Answer 13

Smoking
Alcoholic liver cirrhosis
Diabetes mellitus
Occupation - use of vibrational tools / heavy manual work

Question 14

What is the special test for Dupuytren’s contracture?

Answer 14

Hueston’s test - if the patient is unable to lay their palm flat on a tabletop, this is a positive test.

Question 15

How is Dupuytren’s contracture managed?

Answer 15

Conservative management -(for early disease) hand therapy, injectable CCM

Surgical management - (later stage) fasciectomy under local / general.

Question 16

What is Quervain’s Tenosynovitis?

Answer 16

Inflammation of the tendons within the first extensor compartment of the wrist.

(Extensor pollicis brevis and abductor pollicis longus).

Question 17

How should De Quervain’s tenosynovitis be managed?

Answer 17

Conservative - avoid repetitive wrist actions, wrist splint, sometimes steroid injections.

Surgical - (if fails to respond to conservative) surgical decompression of the extensor compartment - making an incision into the tendon sheath to give more space for the tendons.

Question 18

What is a ganglionic cyst? And how is it diagnosed?

Answer 18

Soft tissue lumps that occur along any joint / tendon, filled with synovial fluid.

It is a clinical diagnosis, however USS or MRI can be done if there is uncertainty.

Question 19

How should a ganglionic cyst be managed?

Answer 19

if the cyst is not causing any pain / reduced ROM, we monitor it as they often disappear spontaneously.

If they are, we aspirate it or excise it.

Question 20

What is stenosis going flexor tenosynovitis?

Answer 20

Trigger finger - when the finger / thumb locks in flexion, preventing a return to extension.

Question 21

How should trigger finger be managed?

Answer 21

Conservative management - (mild cases) activity advice and a split which holds the finger in extension at night. Can sometimes try steroid injections.

Surgical - (severe cases) percutaneous trigger finger release / surgical decompression.