Wrist and Hand Flashcards
Important conditions regarding Vascular?
cardiac referral, raynaud’s disease, and compartment syndrome
What are the major symptoms of cardiac referral?
chest pain and sweating frequent in men and women, woman are more than 2x as likely to have pain between shoulder blades. woman can also experience nausea, vomiting, and short of breath
what is raynaud’s disease?
arteriole small artery/arteriole constriction in hands and feet
who is most likely to experience Raynaud’s disease?
F > M, 15-40 years old
what are the symptoms of Raynaud’s disease?
typically bilateral, hands blanch, become cyanotic, turn red. usually last 15-20 mins, alleviate with warm water
what is raynaud’s disease more common with?
RA, occlusive vascular disease, smokers, B-blocker use
What are the 2 types of Raynaud’s and their cause?
Primary- vasospastic disorder
secondary- due to underlying cause
What is Buerger’s disease?
vasculitis of arteries/veins in hands and feet
what is their a high correlation of with buerger’s disease?
smoking or use of tobacco
who is most likely to get Burger’s disease?
20-40 year old males
what are the symptoms of Buerger’s disease?
pain from claudication/reduced flow leads to reduced oxygen. commonly digital, palmar and ulnar arteries most affected in hands. may also have edema, cold sensitivity, rubor, cyanosis, trophic skin changes and paresthesias
what does acute compartment syndrome most commonly affect?
volar forearm and hand
what is acute compartment syndrome caused by?
fracture, penetrating trauma/combat injuries, high pressure injection injury, and surgery
what are the 5 p’s?
pain, paresthesia, paresis, pallor, pulselessness
what is a normal compartment pressure?
0-10mmHg
what is a compartment pressure indicating need for a fasciotomy?
greater than 30 mmHg
about what percent of individuals with radiographic OA experience significant symptoms?
50%
how do patients with osteoarthritis present?
pain, swelling, morning stiffness, muscle weakness with difficultly gripping and twisting objects, and osteophyte formation at dorsal aspect of IP joints
what is the treatment for osteoarthritis?
NSAIDs, steroid injections, or arthroplasty
what are Heberden’s nodes and where are they found?
osteoarthritic enlargement of DIP
what are Bouchard’s nodes and where are they found?
osteoarthritis enlargement of PIP
what is rheumatoid arthritis?
systemic disease, involved inflammation of synovial joints and tendon sheaths, autoimmune, wrist and hand biomechanics often adversely affected
what are the two deformities of rheumatoid arthritis?
ulnar drift at MCP’s and RD at wrist
Bouchard’s nodes- swelling and thickening of PCP and PIP synovium
what are signs of an infection?
temp >100ºF, Bp > 160/95 mmHg, resting pulse >100 bpm, resting respiration > 25 Bpm, fatigue, inflammation, and elevated lab values
what are the common spaces on the hand for infection?
mid-palmar space, web space, thenar space
signs of a hand infection?
swelling, pain, tender, redness, warmth, loss of motion, swelling can cause bone splaying
Risks with hand infections?
risk of osteomyelitis/septic arthritis, sepsis and amputation. immunosuppressed pts are at greatest risk
what are Kanavel’s 4 cardinal signs of a flexor sheath infection?
finger/hand held in slight flexion
swelling
tenderness over tendon sheath
pain on passive extension
what is the earliest sign of flexor sheath infection?
pain on passive extension
what is ascending lymphangitis?
inflammation of the lymphatic channels that occur as a result of infection at a distal site
what is the visible cue for ascending lymphangitis?
a red line down the lymphatic pathway of the dorsal side of the arm into the 2nd and 3rd digit
what is a ganglion cyst?
a benign thin walled, cystic, synovial lined lesion containing thick, clear mucinous fluid
where are ganglions cysts usually found?
dorsum of the wrsit
what are the treatments for a ganglion cyst?
nothing, aspiration, surgical excision, DO NOT smack with book
what is a pancoast tumor?
a tumor of the pulmonary apex
what is the major risk factor responsible for pancoast tumors?
cigarette smoking
what is the average age and most common gender for a pancoast tumor?
60s and male
what are the symptoms of pancoast tumors?
severe and unrelenting should and arm pain along with distribution of the 8th cervical and 1st and 2nd thoracic nerve trunks, horner’s syndrome, atrophy of the intrinsic hand muscles
what is horner’s syndrome?
ptosis (drooped eyelid), miosis (constriction of pupil), and anhidrosis (lack of sweating)
what is affected with neurapraxia?
myelin affected
what is affected with axonotmesis?
axon affected
what is affected with neurotmesis?
myelin and axon
what is demyelination?
reduction in the thickness of myelin, demyelinating neuropathies
what is lost in a grade 1 neurapraxia?
myelin
what is lost in a grade 2 axonotmesis?
axon
what is lost in a grade 3 neurotmesis?
endoneurium
what is lost in a grade 4 neurotmesis?
perineurium
what is lost in a grade 5 neurotmesis?
epi, peri and endoneurium
which grades are recoverable for nerve injuries?
grades 1 and 2
carpal tunnel syndrome is which nerve?
median
guyons canal is which nerve?
ulnar
wartnenberg syndrome is which nerve?
radial
which is the most prevalent entrapment neuropathy?
carpal tunnel syndrome
what are intrinsic risk factors for CTS?
BMI over 30, female, age over 50, DM and OA are most important
what is the main extrinsic risk factor for CTS?
forceful hand exertions
T/F: computer uses do have an increased risk of CTS when compared to the general population or industrial workers?
False they do not
symptoms of CTS?
Paraesthesia and/pain in palmar surface of thumb, index, middle and lateral border of 4th digit, nocturnal Paraesthesia, pain at wrist, weakness in thenar muscles, may have wasting or atrophy in thenar eminence
what are the commonly weak muscles due to CTS?
abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis
what sensory signs that may arise from CTS?
decreased or absent sensation in thumb, index finger, middle finger and lateral border of 4th digit
why isn’t there loss of sensation in the palm with CTS?
because the superficial branch doesn’t go through carpal tunnel so it will still innervate the palm
what motor signs will someone with CTS have?
weakness and/or atrophy in ABP, OP, FPB
how will someone with CTS reflexes be?
normal
what is the number 1 management step of CTS?
splint/brace
what else can we do for CTS?
PT
what are the symptoms of guyon’s canal nerve entrapment?
weakness and atrophy of ulnar intrinsic hand muscles, complaints of numbness on palmar aspect of hand as well as digits 5 and medial border of digit 4
why is there no sensory complaint on the dorsum of the hand with guyon’s canal?
because there is a dorsal branch of the ulnar nerve that branches off before
what is a common group of people to experience guyons canal?
bike riders because the pinky rubbing up against the handle
what muscles are significantly weak with guyon’s canal?
abductor digiti minimi, and fourth dorsal interosseous muscle
ulnar claw hand and wattenberg’s sign are signs of?
guyons canal entrapment
are there normal reflexes with guyon’s canal entrapment?
yes
wrist watch or handcuff neuropathy is a sign of?
wartenberg syndrome
symptoms of wartenberg syndrome?
Paraesthesia and/or pain along anatomic snuff box, thumb, and dorsum of digits 2-3 and lateral border 4, may be worse with gripping or use of hand
T/F there is no weakness with wartenberg syndrome
true because it is only a sensory nerve
are there any reflexes affected with wartenberg syndrome?
no
the radial nerve affected at the elbow and proximal describes which pathology?
wrist drop
what is wrist drop?
paralysis of the wrist and finger extensor muscles from temporary compression of the radial nerve
how long does ischemic wrist drop last?
minutes to hours
how long does demyelinating/axonal wrist drop last?
weeks to months
how much does nerve grow a day?
1mm
which reflex is diminished or absent with wrist drop?
brachioradialis
what is trigger finger?
thickening of flexor tendon sheath, as a patient flexes finger, tendon stick out. there is a palpable notch
what happened with trigger finger?
they are unable to extend finger actively, can flex actively and extend passively (snapping)
causes of trigger finger?
idiopathic, RA/DM, usually worse in morning
what is DeQuervian’s tenosynovitis?
tenosynovitis of the first dorsal compartment usually from repetitive trauma with RD with thumb in grip
what two muscles are generally affected in DeQuervian’s tenosynvitis?
extensor pollicis brevis and abductor pollicis longus
what is the common complaint with DeQuervian’s tenosynovitis?
wrist pain radiating from the radial side of the wrist up the proximal forearm and distally into the thumb
what is the test for DeQuervian’s Tenosynovitis?
finkelstein’s test
what is the conservative treatment for DeQuervian’s?
rest, NSAIDs, splint, modality, education and joint mobs
what is Duputren’s contracture?
hyperproliferation of type 3 collagen scar tissue in the palms and digits. nodules or cords that can progress to contraction at the MCP and PIP joint with hyperextension of the DIP joints
T/F Duputren’s contracture is painful?
False painless
which digit is Duputren’s contracture usually in?
4th
what is the etiology of duputren’s contracture
no single etiology, older men of north european descent (55 yo) associations include alcohol, smoking, manual labor, diabetes, and epilepsy medications
what is the medical management of duputrens contracture?
surgical excision of all abnormal palmar fascia
when is surgery indicated for duputrens contracture?
> 30 degrees MCP flexion deformity and 10 degrees of DIP flexion deformity
what is keinbocks disease?
avascular necrosis of lunate. the isolated collapse of the lunate due to vascular insufficiency
T/F there is a low incidence of Keinbocks disease?
true
what is the age range for keinbocks disease?
young adults 15-40
what is the cause of keinbocks disease?
single injury or multiple compression forces distributing blood supply
what is the gold standard for keinbocks disease?
MRI
what is preiser’s disease?
avascular necrosis of scaphoid
what percent of scaphoid fractures do we see Presisers disease and which pole fracture has a higher rate?
15-30%, proximal pole fractures have higher incidence of AVN
what is the clinical presentation of Preisers disease?
wrist pain at rest and motion, tenderness over scaphoid, decreased strength common, collapse common as bone becomes more necrotic
what is the common treatment for preisers disease?
immobilization and surgical debridement
what is gout
a metabolic disorder of uric acid leading to hyperuricemia
when do we see damage in the hand with gout?
in the chronic phases of the disease
acute phase of gout
seen in the big toe 50% of all initial attacks
what are the three phases of gout?
acute, recurrent, and chronic
what is syndactyly?
webbing of the fingers most commonly 3rd and 4th
what is the treatment for syndactyly?
surgical repair before 1 year old
what is radial club hand?
radius missing
how does radial club hand present?
radial deviation of hand, shortening and/or curvature of ulna
what is the MOI for mallet finger?
unexpected passive flexion of the DIP joint causes avulsion or rupture of the extensor mechanism as it attaches to the distal phalanx
what is the MOI for mallet finger?
unexpected passive flexion of the DIP joint causes avulsion or rupture of the extensor mechanism as it attaches to the distal phalanx
what is the clinical picture for mallet finger?
flexion of DIP joint at rest, unable to actively extend DIP joint
treatment of mallet finger?
rigid splint used to immobilize DIP splint. placed in slight hyperextension for 6 weeks. if splinting doesn’t work then surgery
T/F you should always get an xray with mallet finger
TRUE
what can ensure a better outcome. ofmallet finger?
if avulsion vs tendon rupture
what is boutonniere deformity result from?
a rupture of central tendinous slip of extensor hood
what is the observed boutonniere deformity?
extension of MCP and DIP joint and flexion of PIP joint
what does boutonniere injury commonly occur with?
trauma, RA-degeneration of central extensor tendon
where will the point of maximal tenderness be for boutonniere injury?
dorsally where the tendon insertion is torn
what is the treatment for boutonniere injury?
splinting of PIP in an extension splint for 6 weeks. acetaminophen and NSAIDs for pain and inflammation
what is gamekeeper thumb?
aka skiers thumb. Degeneration of the ulnar collateral ligament of the MCP joint of the thumb
which is the most common ligamentous injury of the hand?
gamekeepers thumb -UCL
how does a patient with gamekeepers thumb present?
with pain, tenderness, ecchymosis, and swelling near medial MCP of thumb, may have instability of the joint and weakness with grasping objects
why should xrays or MRI be ordered for gamekeepers thumb?
to rule out existence of fracture or dislocation, MRI to rule out complete tear- if completely torn need surgery
treatment of gamekeepers thumb?
immobilization for 6 weeks in thumb spica splint
which side of the hand is the OR side for tendon laceration and what does it mean?
palmar side- means need to get surgery
how many hours after post op of flexor tendon repair should you wait to do passive finger flexion and active extension?
48-72
which is initiated first with flexor tendon repairs: active flexion or extension
active extension
finger sprains
“I jammed my finger”
First rule out fracture/dislocation
Then make sure it is not a boutonniere
All the rest can be buddy taped
how and where do colles fractures occur?
distal radius fracture with posterior displacement from FOOSH
how do patients with a colles fracture present?
dinner fork deformity, distal and dorsal wrist pain, swelling of the wrist, increased angulation of the distal radius, inability to grasp objects
