Wrist and Hand Flashcards
what are the different types of distal radius fracture and what type is most common
Smith’s, Colles, Barton’s fractures
Colles fracture is most common
what is the main mechanism of distal radius fractures and who is at highest risk
FOOSH is the main mechanism
elderly people/people with osteoporosis are at a higher risk
describe a Colles fracture
extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement
describe a Smith’s fracture
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
describe a Barton’s fracture
intra-articular fracture of the distal radius with associated dislocation of the radiocarpal joint (either volar or dorsal)
what distinguishes a bartons fracture from a smith or colles fracture
Barton’s fracture is intra-articular
whereas Smith and Colles are both extra-articular
risk factors for distal radius fractures
risk factors relating to osteoporosis;
- female gender
- increasing age
- prolonged steroid use
- smoking or alcohol excess
- early menopause
what signs can you do that test the function of the 3 nerves in the hand
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
management of distal radial fractures
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
what is the most common carpus bone of the wrist to be fractured
scaphoid
describe the blood supply of the scaphoid bone and why its important
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
management of a scaphoid fracture
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
what is the main important complication of scaphoid fractures
risk of avascular necrosis
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
place in interim cast and immobilise
MRI of wrist
what is the main artery that supplies blood to the scaphoid
dorsal branch of the radial artery
what is carpal tunnel syndrome
condition involving compression of the median nerve within the carpal tunnel of the wrist
what nerve is affected in carpal tunnel syndrome and what symptoms does this induce
median nerve
pain, numbness and paresthesia in the lateral 3.5 digits
risk factors for carpal tunnel syndrome
obesity, female gender, increasing age, previous injury to wrist, repetitive hand or wrist movements
also associated with diabetes, rheumatoid and hypothyroidism
why is the palm often spared (no symptoms) in carpal tunnel syndrome
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
what tendon creates the carpal tunnel by running superiorly from the pisiform to the scaphoid
flexor retinaculum (transverse carpal ligament)
sign of later stage carpal tunnel syndrome
weakness in thumb abduction/wasting of thenar eminence due to denervation atrophy of the thenar muscles
management of carpal tunnel syndrome
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
what is a Dupuytrens contracture
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
describe the pathophysiology and disease progression of a dupuytrens contracture
thickening and contraction of the plantar fascia
- initial pitting and thickening of the palmar skin and underlying subcut tissue, with loss of mobility of overlying skin
- firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing
- cord then develops, resembling a tendon, which begins to contract over months to years
- contraction of the cord pulls on the MCP and PIP joints, leading to progressive flexion deformity in the fingers
risk factors for a dupuytrens contracture
smoking (3x more common), alcoholic liver cirrhosis, diabetes and certain occupations
considered idiopathic
what are the most common fingers involved in a dupuytrens contracture
ring and little finger
what specific test can you do to test for a dupuytrens contracture
Hueston’s test (tabletop test) - if a patient is unable to lay their hand flat on a tabletop then this is a positive test
investigations into dupuytrens contracture
diagnosis is clinical however patients should have routine bloods, LFTs and glucose/HbA1c, to asses for potential risk factors
management of dupuytrens contracture
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
what is the most common surgical approach to a dupuytrens contracture
regional fasciectomy - whereby the entire cord is removed
what are ganglionic cysts
non-cancerous soft tissue lumps that occur along any joint or tendon
how do ganglionic cysts arise
from degeneration within the joint capsule or tendon sheath of the joint, subsequently becoming filled with synovial fluid
where is the most common place to get a ganglionic cyst
dorsal aspect of the wrist
clinical features of a ganglionic cyst
smooth, spherical painless lump adjacent to the affected joint
can appear suddenly or grow over time
the lump is soft and will transilluminate
management of ganglionic cysts
if no pain; monitor as sometimes they can disappear spontaneously
if pain; aspiration (associated with high recurrence rates) or cyst excision
what is De Quervain’s tenosynovitis
inflammation of the tendons within the first extensor compartment of the wrist, resulting in pain and swelling
what tendons are inflamed in De Quervains Tenosynovitis
extensor pollicis brevis
extensor pollicis longus
(extensor compartment 1 - latera side)
clinical features of DQ tenosynovitis
pain near the base of the thumb with an associated swelling
movements involving pinching or grasping are particularly painful and difficult
management of DQ tenosynovitis
conservative; wrist splint, steroid injections, lifestyle modification
surgical; for those failing to respond to conservative treatment, surgical decompression of the extensor compartment
what is ‘trigger finger’ (stenosing flexor tenosynovitis)
condition in which the finger or thumb click or lock when in flexion, preventing a return to flexion
pathophysiology of trigger finger
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
management of a trigger finger
conservative; small splint, steroid injections
surgical; percutaneous trigger finger release or surgical decompression
clinical features of trigger finger
painless clicking/snapping/catching of the affected digit when attempting extension
