WRIST AND HAND Flashcards

Question

WRIST AND HAND - CONDITIONS - CARPAL TINNEL SYNDROME

Answer 1

Hx - insidious onset, paraesthesia into hand, loss of digital dexterity S&S - +ve Tinel’s and Phalen’s test, decreased sensation over median nerve distribution of the hand DDx - pronator teres syndrome, TOS, C6-C7 radiculopathy

Answer 2

Hx - aching pain above radial styloid, worse with wrist and thumb movements S&S - +ve Finkelstein’s test, audible squeeking sound with wrist movement DDx - scaphoid fracture, osteoarthritis

Answer 3

Hx - traumatic extension or abduction of thumb, pain over ulnar side of MCP joint S&S - +ve thumb abduction test, UCL instability DDx - scaphoid fracture, Bennett fracture, osteoarthritis

Answer 4

Hx - traumatic extension or flexion of wrist (FOOSH) S&S - palpable tenderness over ligaments, limited AROM and PROM, +ve Bracelet test DDx - scaphoid fracture, TFCC tear, rheumatoid or septic arthritis

Answer 5

Hx - painfull or painless lump or mass on wrist, weight bearing aggravates (push-up) S&S - palpable solid mass, may be tender to palpation DDx - infection

Answer 6

Hx - FOOSH or impact trauma to hand S&S - tenderness in wrist in line with 3rd metacarpal, visible on x-ray DDx - lunate or scaphoid fracture, osteoarthrosis

Answer 7

Hx - FOOSH or impact trauma to hand S&S - pain in anatomical snuff box with radial flexion, +ve scaphoid fracture test DDx - lunate dislocation, osteoarthrosis

Answer 8

Hx - FOOSH or impact trauma to hand with twisting S&S - local pain with ROM, possible decrease in ROM and grip strength, +ve TFCC dorsal glide DDx - lunate dislocation, ulnar styloid fracture, osteoarthrosis

Answer 9

**Artery stenosis or occlusion (peripheral vascular disease)** - Skin remains balanced for more than 5 seconds

Answer 10

- Pt seated - Instruct pt to make a fist to remove blood from the hands - Examiner then compresses the ulnar and radial arteries - Ask the pt to pump fist again to remove and excess blood - Examiner then releases one artery - Repeat test releasing the other artery

Answer 11

- Pt seated or standing - Examiner applies lateral compressive force around the distal radius & ulna - (around the location of a bracelet)

Answer 12

**Rheumatoid arthritis, OA/DJD at the wrist** - Forearm, wrist or hand pain **Ligament laxity, instability** - Abnormal ROM

Answer 13

- Pt seated or standing - Pt makes fist with thumb inside fingers - Pt ulnar deviates the wrist

Answer 14

**de Quervain’s disease** - Pain on lateral wrist

Answer 15

**SN**: 81 **SP:** 50

Answer 16

- Pt seated or standing - Examiner places thumbs over median nerve as it passes through the carpal tunnel - Examiner applies pressure for 30-60 seconds

Answer 17

**Carpal tunnel syndrome** - Pain, numbness or tingling distal to compression site

Answer 18

**SN:** 42-100 **SP:** 92-100

Answer 19

- Pt seated - Pt has wrists maximally flexed - Back of pt hands tigether in front of body so wrists are fully flexed - Maintain position for up to one minute

Answer 20

**Carpal tunnel syndrome** - Numbness or tingling over the distribution of the median nerve - Increased anterior wrist pain - Subsequent weakness of thumb opposition

Answer 21

**SN**: 10-88 **SP**: 33-100

Answer 22

- Pt seated - Pt wrists extended - Pt places palms of hands together in front of body so both wrists are extended (praying position) - Maintains position position for up to a minute

Answer 23

**Carpal tunnel syndrome, MFTP referral from forearm flexors** - Numbness or tingling over the distribution of the median nerve - Increased anterior wrist pain - Subsequent weakness of thumb opposition

Answer 24

**SN**: 45-75 **SP**: 55-96

Answer 25

- Pt seated or standing - Examiner places thenar eminence over posterior distal ulna and thumb over anterior pisiform/triquetrum - Examiner then pushes the pisiform/triquetrum posteriorly and anteriorly

Answer 26

**Triangular fibrocartilage tear or triquetral instability** - Pain or laxity in lateral ulnocarpal joint

Answer 27

**SN**: 66 **SP**: 64

Answer 28

- Pt seated - Examiner grips and stabilises pt wrist and thumb - Then examiner applies long axis compression while circumducting the thumb

Answer 29

**Trapeziometacarpal arthritis or DJD scaphoid fracture** - Pain or crepitus

Answer 30

- Pt seated - Examiner gently taps over the carpal tunnel and ulnar tunnel with fingertips or reflex hammer

Answer 31

**Median neuropathy** - Paraesthesia (numbness, tingling, shooting electrical pain) along the median nerve distribution **Ulnar neuropathy** - Paraesthesia (numbness, tingling, shooting electrical pain) along the ulnar nerve distribution

Answer 32

**SN**: 23-97 **SP**: 53-100

Answer 33

Congenital variations - Embryonic abnormalities of the upper limb are likely to affect the one segment (or the whole) of the limb - Congenital conditions often appear together in the forearm, wrist and hand

Answer 34

- Congenital - Birth defects - Club foot, Cleft lip, Cleft palette - Acquired - Trauma, Rheumatoid arthritis, Cerebral palsy

Answer 35

- Congenital - There at birth - Sometimes not seen till after - Not seen before 10 years in Madelung’s deformity - Acquired - Older people

Answer 36

Congenital variations - Radial dysplasia - Infant is born with the wrist in marked radial deviation - There is absence of the whole or part of the radius, and usually also the thumb - Madelung’s deformity - The lower radius curves forwards (ventrally) carrying the carpus and hand with it but leaving the distal end of the ulna projecting on the back of the wrist - Although the abnormality is present at birth the deformity is rarely seen before the age of 10 - Function is usually undisturbed

Answer 37

Acquired deformities - Physical injuries can result in malunited fractures or subluxation of the distal radioulnar joint - Non-traumatic deformities are seen typically in rheumatoid arthritis and cerebral palsy

Answer 38

Congenital variations - Radial dysplasia - Treatment in the neonate consists of gentle stretching and splinting - Serious cases can be treated by distraction prior to a tension-free soft tissue correction which has less effect on growth of the carpus and distal ulna - Prolonged splintage is still needed to avoid recurrence of the deformity - Madelung’s deformity - Treatment may be unnecessary

Answer 39

Acquired deformities - Physical injuries - Osteotomy of the radius or stabilisation of the ulna may be needed

Answer 40

- Quite rare in the wrist

Answer 41

- No vaccination - Trauma - Immunodeficiency - Low socioeconomic status

Answer 42

- Middle age

Answer 43

- Pain and stiffness come on gradually - The hand feels weak - Forearm looks wasted - Wrist is swollen and feels warm - Involvement of the flexor tendon compartment may give rise to a large fluctuant swelling that crossed the wrist into the palm - Movements are restricted and painful - X-ray examination shows localised osteoporosis and irregularity of the radiocarpal and intercarpal joints and sometimes bone erosion

Answer 44

- Antituberculosis drugs are given - Wrist is splinted - If an abscess forms, it must be drained

Answer 45

- Rheumatoid arthritis is an inflammatory condition that affects the peripheral joints symmetrically - After the metacarpophalangeal joints, the wrist is the most common site of rheumatoid arthritis

Answer 46

- Age - Likelihood increases with age - Sex - Women affected more than men - Genetics - Smoking - Obesity

Answer 47

- 30 – 50

Answer 48

- Pain, swelling and tenderness may at first be localised to the radioulnar joint, or to one of the tendon sheaths - Sooner or later the whole wrist becomes involved, and tenderness is much more ill defined - In late cases the wrist is deformed and unstable - X-rays show the characteristic features of osteoporosis and bony erosions - Tel-tale signs are usually more obvious in the metacarpophalangeal joints

Answer 49

- Management in the early stages consists of splintage and local injections of corticosteroids combined with systemic treatment - Persistent synovitis may call for synovectomy and soft-tissue stabilisation of the wrist - In the late stage, tendon ruptures at the wrist, joint destruction, instability, and deformity may require reconstructive surgery

Answer 50

- Quite uncommon - Always a worry when someone fractures their lunate - After injury or stress the lunate bone sometimes develops a patchy avascular necrosis

Answer 51

- Relative shortening of the ulna - Negative ulnar variance - Injury - Stress

Answer 52

- Young adult

Answer 53

- Ache and stiffness in the wrist - Tenderness is localised to the centre of the wrist on the dorsum - Wrist extension may be limited - Earliest signs of osteonecrosis can be detected only by MRI - Typical x-ray signs are increased density in the lunate and later, flattening and irregularity of the bone - There may also be features of osteoarthritis of the wrist

Answer 54

- The TFCC (triangular fibrocartilage complex) fans out from the base of the ulnar styloid process to the medial edge of the distal radius

Answer 55

- People who are active - People who frequently use - Racquet, Bat, Club, Gymnastics - Over 50 = Degenerative tear - Chronic inflammation - Rheumatoid arthritis, Gout

Answer 56

- Affects about 50% of people over 70 years - Uncommon in people under 30

Answer 57

- Chronic pain in the wrist may be related to an old ‘sprain’ in which a more serious injury to the TFCC was overlooked - Symptoms are - Pain - Loss of grip strength - Clicking in supination of the forearm

Answer 58

- Chronic degeneration of the TFCC may be associated with a relatively long ulna, impaction of the ulnar head against the ulna side of the lunate and ulnocarpal arthritis - Positive ulna variance in the wrist means the TFCC is stretched and thin

Answer 59

- Positive ulna variance - Increased ulna length relative to the radius - Risk factors for developing positive ulnar variance - Congenital positioning of the ulnar articular surface more distally than the radial articular surface - Acquired radial shortening secondary to trauma - Eg. a malunion of the radius after a distal radius fracture - Excessive dynamic ulnar variance greater than normal distal movement of the ulna during forearm pronation and gripping

Answer 60

- Over 70 normally

Answer 61

- X-ray exam shows a relatively long ulna - In late cases there may be arthritic changes in the ulnolunate articulation - Tenderness dorsally just distal to ulnar head - Tenderness just volar to the ulnar styloid process - Positive ulnar variance while static or dynamic - Painful passive ulnar deviation and forceful pronation - Decreased flexion, extension, radial and ulnar deviation - Decreased grip strength

Answer 62

- The wrist functions as a system of intercalated segments stabilised by ligaments and by the scaphoid which bridges the 2 rows of carpal bones

Answer 63

- Acute traumatic events - Chronic repetitive stress - Microcrystal deposits secondary to another underlying disease

Answer 64

- Young and middle-aged people

Answer 65

- Following trauma to the carpus, there may be partial collapse of the ‘bridge’ structure - This is not always recognised at the time - Some years after the trauma pt complains of progressive pain and weakness in the wrist - Most easily spotted example of carpal instability is a rupture of the scapho-lunate ligament - This appears on the x-ray as an unusual gap between the scaphoid and lunate and foreshortening of the scaphoid image

Answer 66

- The best form of treatment is prevention - Acute wrist sprains should be carefully assessed for signs of carpal displacement and instability

Answer 67

- The extensor retinaculum contains 6 compartments which transmit tendons lined with synovium

Answer 68

- Sex - Women - Middle age - Childbirth

Answer 69

De Quervain’s disease - 30 – 40 years

Answer 70

**Tenosynovitis** - Can be caused by unaccustomed movement - Can also occur spontaneously **Other types of extensor tenosynovitis** - Tenosynovitis of extensor carpi radialis brevis or extensor carpi ulnaris may cause pain and point tenderness just medial to the anatomical snuffbox or immediately distal to the head of the ulna

Answer 71

**De Quervain’s disease** - May be a history of unaccustomed activity - Pain and sometimes swelling are localised to the radial side of the wrist - Tendon sheath feels hard and thick - Tenderness is most acute at the very tip of the radial styloid - Occasionally pt will describe triggering, snapping or catching that occurs with motion of the thumb - The pathognomonic sign is elicited by Finkelstein’s test

Answer 72

- Early treatment including rest, anti-inflammatory medication and injection of corticosteroids may break the cycle **Other types of extensor tenosynovitis** - Splintage and corticosteroid injections are usually effective **De Quervain’s disease** - In the early stages symptoms can be relieved by ultrasound therapy or a corticosteroid injection into the tendon sheath - Resistant cases need an operation

Answer 73

- 50% to 70% of soft tissue masses of the hand and wrist are diagnosed as ganglion cysts - A ubiquitous ganglion is seen most commonly on the back of the wrist

Answer 74

- Sex - Women 3 times more likely than men - Injury to the wrist or finger joint - Inflammation or irritation in the tendons or joints - Repetitive activities that use the rest and fingers - Chronic illness - Arthritis

Answer 75

- Young adult

Answer 76

- Pt presents with a painless lump usually on the back of the wrist but sometimes on the front - Occasionally there is a slight ache - The lump is well defined, cystic, and not tender - About 10% of pt will give a history of trauma

Answer 77

- Often disappears after some months so there is no rush with treatment - If the lesion continues to be troublesome, it can be aspirated; if it recurs, excision is justified - Pt should be told there is a 30% risk of recurrence even after careful surgery

Answer 78

- Commonest and best known of all the nerve entrapment syndromes - In the normal carpal tunnel, there is barely room for all the tendons and median nerve, so any swelling is likely to result in compression and ischaemia of the nerve

Answer 79

- Sex - Women affected more than men - Menopause - Myxoedema - Anatomic factors - Metabolic factors - Inflammatory causes - Postural changes

Answer 80

- 40 – 50 years

Answer 81

- History is most helpful in diagnosis - Pain and paresthesia occur in the distribution of the median nerve in the hand - In mild to moderate stages of the syndrome, pt will note the paresthesias are intermittent - Numbness will become more constant as the syndrome progresses - Pt will present with complaints of numbness and tingling of the hand - Pt will often note diffuse hand numbness - Night after night pt is woken with burning pain, tingling and numbness - Pt tend to seek relief by hanging the arm over the side of the bed or shaking the arm - However just changing the position of the wrist will usually help - Early on there is little to see but there are two helpful tests - Tinel’s sign - Phalen’s test - In late cases there is wasting of the thenar muscles, weakness of thumb abduction and sensory dulling in the median nerve territory

Answer 82

- Light splints that prevent wrist flexion can help those with night pain or with pregnancy related symptoms - Steroid injection into the carpal canal provides temporary relief

Answer 83

Medial epicondyle via common flexor tendon

Answer 84

Base of 2nd and 3rd metacarpals (anterior side)

Answer 85

Flexion of wrist Radial flexion (abduction) of wrist

Answer 86

Median nerve (C6-C7)

Answer 87

Referral is pain and tenderness that centers in the radial aspect of the anterior wrist

Answer 88

Elbow straight, extend wrist and use opposite hand to ulnar deviate wrist

Answer 89

Resisted wrist flexion Wrist curls

Answer 90

Medial epicondyle via common flexor tendon

Answer 91

Palmar aponeurosis Flexor retinaculum

Answer 92

Flexion of wrist

Answer 93

Median nerve (C7-C8)

Answer 94

Referral pattern is superficial needle-like prickling pain over the palm extending to the base of the thumb and the distal palm, but not intot he digits

Answer 95

With elbow straight, extend wrist and use opposite hand to spread palm

Answer 96

Resisted wrist flexion Wrist curls

Answer 97

**Humeral head** - medial epicondyle via common flexor tendon **Ulnar head** - medial aspect of olecranon and proximal 2/3 of medial ulna

Answer 98

Pisiform and hamate bones via pisohamate ligament Base of 5th metacarpal via pisometacarpal ligament

Answer 99

Flexion of wrist Ulnar flexion of wrist

Answer 100

Ulnar nerve (C7-C8)

Answer 101

Referral pattern is pain and tenderness to the ulnar side of the anterior aspect of the wrist with some similar spillover in the same general area

Answer 102

With elbow straight, extend wrist and use opposite hand to radially deviate wrist

Answer 103

Resisted wrist flexion Wrist curls

Answer 104

**Humeral-ulnar head** - medial epicondyle via common flexor tendon and coronoid process of ulna, medial collateral ligament **Radial head** - oblique line of radius along its upper anterior border

Answer 105

Base of middle phalanges of fingers 2-5

Answer 106

Flexion of fingers 2-5

Answer 107

Median nerve (C7-C8)

Answer 108

Referral pattern is shooting pain and tenderness over the anterior forearm and fingers that correspond to the area of the muscle belly

Answer 109

Elbow straught wrist extended, use opposite hand to pull middle phalanges posteriorly

Answer 110

Resisted finger flexion Wrist curls with finger extension Finger curls Grip strength exercises

Answer 111

Anterior and medial surface of ulna Interosseous menbrane

Answer 112

Base of distal phalange of fingers 2-5

Answer 113

Flexion of fingers

Answer 114

Median nerve (C8-T1) Ulnar nerve (C8-T1)

Answer 115

Referral pattern is shooting pain and tenderness to the anterior forearm and fingers that correspond to the area of the muscle belly

Answer 116

Elbow straight, wrist extended, use opposite hand to pull distal phalanges posteriorly

Answer 117

Resisted finger flexion Wrist curls with finger extension Finger curls Grip strength exercises

Answer 118

Radius (middle anterior surface) Interosseous membrane

Answer 119

Base of distal phalanx of thumb (anterior aspect)

Answer 120

Flexion of thumb

Answer 121

Median nerve (C7-C8)

Answer 122

Referral pattern is shooting pain and tenderness over the anterior thumb and thenar region

Answer 123

Elbow straight, wrist extended, use opposite hand to pull distal phalanx of thumb into extension

Answer 124

Resisted thumb flexion Stress ball Grip strength exercises

Answer 125

Lower lateral supracondylar ridge

Answer 126

Base of 2nd metacarpal

Answer 127

Extension of wrist Radial flexion (abduction) of wrist

Answer 128

Radial nerve (C5-C6)

Answer 129

Referral pattern is initially pain over the lateral epicondyle and followed by pain radiating down toward the forearm, wrist and posterior hand

Answer 130

Elbow straight, wrist flexed and pronated, use opposite hand to apply flexion pressure over the shaft of 2nd metacarpal

Answer 131

Resisted wrist extension Wrist roller Reverse wrist curl

Answer 132

Lateral epicondyle via common extensor tendon

Answer 133

Base of 3rd metacarpal

Answer 134

Extension of wrist Radial flexion (abduction) of wrist

Answer 135

Radial nerve (C7-C8)

Answer 136

Main referral pattern is pain over the posterior forearm, wrist, and posterior hand that may eventually involve the lateral epicondyle

Answer 137

Elbow straight, wrist flexed and pronated, use opposite hand to apply flexion pressure over the shaft of 3nd metacarpal

Answer 138

Resisted wrist extension Wrist roller Reverse wrist curl

Answer 139

Lateral epicondyle of humerus via common extensor tendon

Answer 140

Phalanges 2-5 (dorsal expansion hood)

Answer 141

Extension of fingers 2-5 Extension of wrist

Answer 142

Radial nerve (C7-C8)

Answer 143

Referral pattern is over the distal posterior forearm and to the digits that correspond to that area of the muscle

Answer 144

Elbow straight, wrist flexed and hand in a fist, use opposite hand to apply flexion pressure

Answer 145

Resisted wrist extension Wrist roller Reverse wrist curl Elastic band exercise

Answer 146

Lateral epicondyle of humerus via common extensor tendon

Answer 147

Middle and distal phalanges of 5th digit

Answer 148

Extension of little finger Extension of wrist

Answer 149

Radial nerve (C6-C8)

Answer 150

Posterior surfaces of ulna, radius and interosseous membrane

Answer 151

Base of 1st metacarpal

Answer 152

Abduction of thumb Radial deviation

Answer 153

Radial nerve (C7-C8)

Answer 154

Referral pattern is pain and tenderness over the distal posterior forearm, wrist and thumb

Answer 155

Curl thumb into fist and ulnar deviate wrist (Finklestein's test)

Answer 156

Resisted wrist abduction Wrist hammer curl Elastic band exercises

Answer 157

Posterior distal 1/3 surfaces of radius Interosseous membrane

Answer 158

Base of proximal phalanx of thumb

Answer 159

Extension of proximal phalanx

Answer 160

Radial nerve (C7-C8)

Answer 161

Referral pattern is shooting pain and tenderness over the posterior wrist and thumb

Answer 162

Ulnar deviate wrist and use opposite hand to flex thumb

Answer 163

Resisted wrist extension Wrist roller Reverse wrist curl Elastic band exercises

Answer 164

Posterior middle 1/3 of ulna Interosseous membrane

Answer 165

Distal phalanx of thumb

Answer 166

Extension of thumb

Answer 167

Radial nerve (C7-C8)

Answer 168

Referral pattern is pain and tenderness over posterior wrist and thumb

Answer 169

Ulnar deviate wrist and use opposite hand to flex thumb

Answer 170

Resisted wrist extension Wrist roller Reverse wrist curl

Answer 171

Posterior distal 1/3 of ulna Interosseous mambrane

Answer 172

Base of middle and distal phalanx of index finger

Answer 173

Extension of index finger Extension of hand at wrist

Answer 174

Radial nerve (C7-C8)

Answer 175

Referral pattern is pain and tenderness over the posterior forearm, wrist and index finger

Answer 176

Wrist flexed, with index finger curled into fist

Answer 177

Resisted wrist extension Wrist roller Reverse wrist curl