Wrist and Hand

Question 1

what are the different types of distal radius fracture and what type is most common

Answer 1

Smith’s, Colles, Barton’s fractures

Colles fracture is most common

Question 2

what is the main mechanism of distal radius fractures and who is at highest risk

Answer 2

FOOSH is the main mechanism

elderly people/people with osteoporosis are at a higher risk

Question 3

describe a Colles fracture

Answer 3

extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement

Question 4

describe a Smith’s fracture

Answer 4

extra-articular fracture of the distal radius with volar angulation (opposite to Colles’)

occurs when someone falls backwards and puts their hand out to stop them

Question 5

describe a Barton’s fracture

Answer 5

intra-articular fracture of the distal radius with associated dislocation of the radiocarpal joint (either volar or dorsal)

Question 6

what distinguishes a bartons fracture from a smith or colles fracture

Answer 6

Barton’s fracture is intra-articular

whereas Smith and Colles are both extra-articular

Question 7

risk factors for distal radius fractures

Answer 7

risk factors relating to osteoporosis;

• female gender
• increasing age
• prolonged steroid use
• smoking or alcohol excess
• early menopause

Question 8

what signs can you do that test the function of the 3 nerves in the hand

Answer 8

okay sign (index and thumb opposition) - median nerve (anterior interosseous nerve)

Thumbs up (thumb extension) - radial nerve

Frogment’s sign (adduction of the thumb) - ulnar nerve

Question 9

management of distal radial fractures

Answer 9

Conservative:

resus and stabilise

all displaced fractures require closed reduction under anaesthetic

following reduction - stable and successfully reduced fractures should be placed in a below elbow backslab cast

physiotherapy

Surgical:

significantly displaced or unstable fractures require surgical intervention, also intra-articular fractures require the same

options include; ORIF with plating or K wire fixation

patient then placed in cast to ensure immobility

Question 10

what is the most common carpus bone of the wrist to be fractured

Answer 10

scaphoid

Question 11

describe the blood supply of the scaphoid bone and why its important

Answer 11

supplied by branches of the radial artery - dorsal and volar branch

dorsal branch supplies 80% of the blood and enters the scaphoid distally before travelling in a retrograde fashion towards the proximal end

consequently fractures of the scaphoid can result in avascular necrosis and subsequent degenerative wrist disease

the more proximal the fracture the higher the risk of AVN

Question 12

management of a scaphoid fracture

Answer 12

conservative; undisplaced fractures not involving the proximal pole of the scaphoid require strict immobilisation in a plaster

surgical; displaced fractures fixed operatively using a percutaneous variable-pitched screw

Question 13

what is the main important complication of scaphoid fractures

Answer 13

risk of avascular necrosis

Question 14

if a patient has had 2 negative x-rays of the wrist but is still showing clinical signs of a scaphoid fracture what are the next steps

Answer 14

place in interim cast and immobilise

MRI of wrist

Question 15

what is the main artery that supplies blood to the scaphoid

Answer 15

dorsal branch of the radial artery

Question 16

what is carpal tunnel syndrome

Answer 16

condition involving compression of the median nerve within the carpal tunnel of the wrist

Question 16

what nerve is affected in carpal tunnel syndrome and what symptoms does this induce

Answer 16

median nerve

pain, numbness and paresthesia in the lateral 3.5 digits

Question 17

risk factors for carpal tunnel syndrome

Answer 17

obesity, female gender, increasing age, previous injury to wrist, repetitive hand or wrist movements

also associated with diabetes, rheumatoid and hypothyroidism

Question 18

why is the palm often spared (no symptoms) in carpal tunnel syndrome

Answer 18

because the sensory supply to the palm (palmar cutaneous branch of the median nerve) branches proximal to the flexor retinaculum passing over the carpal tunnel

Question 19

what tendon creates the carpal tunnel by running superiorly from the pisiform to the scaphoid

Answer 19

flexor retinaculum (transverse carpal ligament)

Question 20

sign of later stage carpal tunnel syndrome

Answer 20

weakness in thumb abduction/wasting of thenar eminence due to denervation atrophy of the thenar muscles

Question 21

management of carpal tunnel syndrome

Answer 21

conservative; wrist splint (preventing flexion), physiotherapy, corticosteroid injections

surgical; carpal tunnel release surgery - decompress the carpal tunnel by cutting through the flexor retinaculum, reducing the pressure on the median nerve

Question 22

what is a Dupuytrens contracture

Answer 22

condition involving the contraction of the longitudinal palmar fascia

develops at the MCP and interphalangeal joints and can severely limit digital movement and reduce patients quality of life

Question 23

describe the pathophysiology and disease progression of a dupuytrens contracture

Answer 23

thickening and contraction of the plantar fascia

1. initial pitting and thickening of the palmar skin and underlying subcut tissue, with loss of mobility of overlying skin
2. firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing
3. cord then develops, resembling a tendon, which begins to contract over months to years
4. contraction of the cord pulls on the MCP and PIP joints, leading to progressive flexion deformity in the fingers

Question 24

risk factors for a dupuytrens contracture

Answer 24

smoking (3x more common), alcoholic liver cirrhosis, diabetes and certain occupations

considered idiopathic

Question 25

what are the most common fingers involved in a dupuytrens contracture

Answer 25

ring and little finger

Question 26

what specific test can you do to test for a dupuytrens contracture

Answer 26

Hueston’s test (tabletop test) - if a patient is unable to lay their hand flat on a tabletop then this is a positive test

Question 27

investigations into dupuytrens contracture

Answer 27

diagnosis is clinical however patients should have routine bloods, LFTs and glucose/HbA1c, to asses for potential risk factors

Question 28

management of dupuytrens contracture

Answer 28

conservative; hand therapy, stretches

surgical; excision of diseased fascia, typically indicated in those with functional impairment.

the most commonly used surgical procedure is a fasciectomy - whereby varying amounts of the cord are removed

finger amputation considered in severe patients

Question 29

what is the most common surgical approach to a dupuytrens contracture

Answer 29

regional fasciectomy - whereby the entire cord is removed

Question 30

what are ganglionic cysts

Answer 30

non-cancerous soft tissue lumps that occur along any joint or tendon

Question 31

how do ganglionic cysts arise

Answer 31

from degeneration within the joint capsule or tendon sheath of the joint, subsequently becoming filled with synovial fluid

Question 32

where is the most common place to get a ganglionic cyst

Answer 32

dorsal aspect of the wrist

Question 33

clinical features of a ganglionic cyst

Answer 33

smooth, spherical painless lump adjacent to the affected joint

can appear suddenly or grow over time

the lump is soft and will transilluminate

Question 34

management of ganglionic cysts

Answer 34

if no pain; monitor as sometimes they can disappear spontaneously

if pain; aspiration (associated with high recurrence rates) or cyst excision

Question 35

what is De Quervain’s tenosynovitis

Answer 35

inflammation of the tendons within the first extensor compartment of the wrist, resulting in pain and swelling

Question 36

what tendons are inflamed in De Quervains Tenosynovitis

Answer 36

extensor pollicis brevis

extensor pollicis longus

(extensor compartment 1 - latera side)

Question 37

clinical features of DQ tenosynovitis

Answer 37

pain near the base of the thumb with an associated swelling

movements involving pinching or grasping are particularly painful and difficult

Question 38

management of DQ tenosynovitis

Answer 38

conservative; wrist splint, steroid injections, lifestyle modification

surgical; for those failing to respond to conservative treatment, surgical decompression of the extensor compartment

Question 39

what is ‘trigger finger’ (stenosing flexor tenosynovitis)

Answer 39

condition in which the finger or thumb click or lock when in flexion, preventing a return to flexion

Question 40

pathophysiology of trigger finger

Answer 40

most cases preceded by flexor tenosynovitis - leading to inflammation of the tendon and sheath

subsequent localised nodal formation on the tendon

when the fingers flex the node passes underneath the ‘pulley’ however when the patient attempts to extend their finger the node is unable to pass back underneath the ‘pulley’ and becomes locked in a flexed position

Question 41

management of a trigger finger

Answer 41

conservative; small splint, steroid injections

surgical; percutaneous trigger finger release or surgical decompression

Question 42

clinical features of trigger finger

Answer 42

painless clicking/snapping/catching of the affected digit when attempting extension