Wrist and Hand

Question 1

usual age group affected by CTS?

Answer 1

40-50yrs

Question 2

CTS clinical features?

Answer 2

pain and paraesthesia in median nerve distribution in hand= radial 3 and a half digits
night pain- burning, tingling and numbness, ptnt awoken and has to shake their hands or hand arm over side of bed=relieves pain, result of sleeping with a flexed wrist- position which elicits pain in phalens test.
wasting of thenar eminence in late cases, wkness of thumb abduction, sensory dulling in medial nerve territory.

Question 3

2 tests for CTS?

Answer 3

Tinel’s sign= sensory symtpoms reproduced by percussing over median nerve
Phalen’s test= holding wrist fully flexed for 1 min reproduces sensory symptoms.

Question 4

how is CTS treated?

Answer 4

treat underlying cause e.g. oral thyroxine (levothyroxine) if hypothyroidism
light splints- can be worn at night to stop wrist flexion if night pain or pregnancy related symptoms.
steroid injection into carpal tunnel can provide temporary relief if mild symptoms- but as can mask symptoms, don’t use if severe as nerve deterioration may go unoticed with ongoing compression
surgery- open surgical division of transverse carpal ligament (flexor retinaculum) under LA, or endoscopic carpal tunnel release- slightly quicker post-op rehabilitation.

Question 5

where should incision be kept to in open surgery for CTS?

Answer 5

ulnar side of thenar crease to avoid damage to palmar cutaneous and thenar motor branches of median nerve.

Question 6

only work-related syndrome proven to cause CTS?

Answer 6

hand-arm vibration syndrome- sympathetics damaged to blood vessels, disturbing blood supply and leading to nerve ischaemia.

Question 7

location of Guyon’s canal (site of ulnar nerve compression in 10% of cases)?

Answer 7

between pisiform and hook of hamate

Question 8

muscle tested to determine ulnar nerve function in hand?

Answer 8

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.

Question 9

tests for CTS?

Answer 9

Tinel’s sign= sensory symtpoms reproduced by percussing over median nerve
Phalen’s test= holding wrist fully flexed for 1 min reproduces sensory symptoms.
electrophysiology- NCSs- slowing of nerve conduction across wrist, performed if atypical symptoms.

Question 10

RFs for CTS?

Answer 10

TRAMP:
tenosynovitis, occupational trauma, wrist fractures
RA
acromegaly, amyloidosis
myxoedema, hypothyroidism
pregnancy- fluid retention- raised oestrogen and progesterone

diabetes, idiopathic

Question 11

muscle tested to determine ulnar nerve function in hand?

Answer 11

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.

Question 12

how are ulnar nerve symptoms produced in hand?

Answer 12

compression in cubital tunnel
compression in guyon’s canal
iatrogenic- nick in nerve

Question 13

muscles tested to determine ulnar nerve function in hand?

Answer 13

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.
adductor pollicis- Froment’s sign= ptnt asked to hold an object between thumb and index finger and examiner tries to pull object away, sign elicited with ulnar nerve palsy where thumb flexes via FPL to compensate for not being able to maintain hold with AP, causing a pinching effect.

Question 14

how are ulnar nerve symptoms produced in hand?

Answer 14

compression in cubital tunnel
compression in guyon’s canal
iatrogenic- nick in nerve

Question 15

how can ulnar nerve symtpoms in hand be treated?

Answer 15

decompression

transposition

Question 16

what is ‘saturday night palsy’?

Answer 16

radial nerve compressed resulting in wrist drop, due to falling asleep in awkward position e.g. with arm stretched over the back of a chair.

Question 17

most common cause of radial nerve symptoms in hand?

Answer 17

humeral fracture- mid-shaft where radial nerve runs relatively superficial in radial groove on poster. humerus.

Question 18

where is sensory supply of hand via radial nerve tested?

Answer 18

1st web space between thumb and index finger

Question 19

how can ulnar nerve symtpoms in hand be treated?

Answer 19

decompression
transposition e.g. moving ulnar nerve anterior to medial epicondyle of humerus so it isn’t stretched against this when elbow flexed.

Question 20

tment of radial nerve symptoms in hand?

Answer 20

therapy- don't want stiffness
expectant
neurolysis
nerve graft
tendon transfers

Question 21

how is motor function of radial nerve tested in hand?

Answer 21

no motor innervation to intrinsic hand msucles

wrist extensors
finger extensors
EPL, these are all muscles originating outside of the hand which control hand movements

Question 22

other considerations in ptnts presenting with nerve problem symtoms?

Answer 22

cervical spine
brachial plexus e.g. cervical rib- extra rib which reduces space of brachial plexus
nerve disorders

Question 23

why is there are high recurrence rate with Dupuytren’s disease?

Answer 23

disease has a genetic link

Question 24

what can worsen a Dupuytren’s contracture?

Answer 24

alcohol

Question 25

assoc. disorders with Dupuytren's disease?

Answer 25

Plantar fibromatosis, nodules on soles= Ledderhose's disease | Peyronie’s disease- fibrous plaques along penile shaft (fibrosis of corpus cavernosum)

Question 26

when to operate in Dupuytren's disease?

Answer 26

?threshold 30 degrees | op when hand unable to function properly and can't put hand completely flat on a table

Question 27

op for Dupuytren's affecting MCPJs?

Answer 27

easy to correct Fasciotomy Segmental fasciectomy Full Fasciectomy

Question 28

problem with Dupuytren's affecting PIPJs?

Answer 28

``` more difficult to correct than if affects MCPJs Full fasciectomy Additional releases – Collaterals – Volar plate Skin graft (FT) Recurrence Garrod’s pads= lumps on dorsum of finger joints ```

Question 29

what is trigger finger?

Answer 29

finger 'jumps', 'clicks' or gets stuck in flexion, further effort allows snapping into full extension pain on movement, and tenderness over 'nodule' occurs with thickening of flexor tendon which becomes temporarily trapped at entrance to its sheath, and then passes constriction with a snap on forced extension classified as a stenosing tenosynovitis can be passively straightened location of A1 pulley= the 1st annular ligament of the finger more common in diabetics may be assoc. with joint OA and RA

Question 30

tment of trigger finger?

Answer 30

steroid injection at entrance of tendon sheath-can inject into nodule of tissue, and just above the nodule, should work within hours to days surgical release- fibrous sheath incised to allow tendon to move freely must avoid injuring digital nerve in case of thumb, which runs close to sheath

Question 31

name given to disease in which irritation of tendons around base of thumb occurs?

Answer 31

DeQuervain's tenosynovitis

Question 32

what test can be used to diagnose DeQuervain's tenosynovitis?

Answer 32

Finkelstein's test= examining physician grasps the thumb, keeping it tucked close to palm, and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (stab of pain over radial styloid) de Quervain's syndrome/disease is likely.

Question 33

location of bouchard's nodes?

Answer 33

hard outgrowths on PIPJs in OA

Question 34

name given to a ganglion located in the finger?

Answer 34

mucous cyst | may be long history, pain if caught

Question 35

how does a giant cell tumour of the tendon sheath in the hand present?

Answer 35

long history of a slowly increasing in size painless solid lump rapid increase in size-suspect malignancy solid in contrast to cystic with a ganglion

Question 36

what happens with an enchondroma?

Answer 36

bone is replaced by cartilage

Question 37

what do we look for on a hand and wrist examination?

Answer 37

scars, swelling, alignment, muscle wasting symmetrical or asymmetrical abnormalities? nails- psoriasitic changes- pitting, onchyolysis nailfold vasculitis joint affected? rashes, LT steroid use- skin thinning, bruising? palms- finger pulp, palmar erythema, scars from carpal tunnel release

Question 38

what is ulnar impaction/abutment syndrome?

Answer 38

degenerative wrist condition caused by the ulnar head impacting upon the ulnar-sided carpus with injury to the triangular fibrocartilage complex (TFCC) ulna typically impacts on the lunate

Question 39

presentation of ulnar impaction syndrome?

Answer 39

chronic or subacute ulnar-sided wrist pain exacerbated by activity. There is often associated swelling and limitation of forearm and wrist movement. Anything that results in relative increase in ulnar variance such as firm grip, pronation and ulnar deviation of the wrist, can exacerbate the symptoms.

Question 40

predisposing factors to ulnar impaction syndrome?

Answer 40

+ve ulnar variance/increased dorsal tilt of distal radius- may be congenital or due to previous fracture premature physis closure radial head resection

Question 41

what is the radial height measurement?

Answer 41

normally around 11 mm measured on PA radiograph as distance between 2 perpendicular lines, 1 drawn through radial styloid process and 1 through distal articular surface of head of ulna

Question 42

what is the radial inclination?

Answer 42

usually 22 degrees is equal to the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius loss will increase load across lunate

Question 43

what is radial tilt?

Answer 43

measured on lateral radiograph angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin. averages 11 degrees volar tilt ? what is acceptable in fracture** no more than 15 degrees dorsal tilt?

Question 44

what is dexterity in the hands?

Answer 44

ability to coordinate small movements of the hands

Question 45

people in which there is a higher than usual incidence of Dupuytren's?

Answer 45

DM AIDS ptnts with epilepsy receiving phenytoin therapy

Question 46

what is Dupuytren's?

Answer 46

thickening of the palmar fascia, nodular hypertrophy, producing contractures of commonly the ring and little fingers more common in males, familial pain unusual

Question 47

what must Dupuytren's be distinguished from?

Answer 47

skin contracture- where a previous laceration is usually obvious tendon contracture- where 'cord' moves on passive flexion of finger

Question 48

how is Dupuytren's treated if extensive hand involvement?

Answer 48

Z -shaped incision that does not cross directly over a skin crease *surgical incisions should never cross flexor creases. Thickened part of fascia is excised. Hand then splinted for a few days and active movement then encouraged, night splinting for a few months may reduce recurrence.

Question 49

alternative to surgery for significant Dupuytren's?

Answer 49

injection of collagenase to dissolve cord

Question 50

what is an intrinsic-plus deformity?

Answer 50

flexion of MCPJs with extension of IPJs and thumb adduction occurs with intrinsic muscle shortening after trauma or infection can release intrinsic muscle where cross MCPJs

Question 51

what is mallet finger and how is it treated?

Answer 51

flexion deformity of distal IPJ, ptnt cannot straighten terminal joint but passive movement is normal due to injury at attachement of extensor tendon to terminal phalanx DIPJ should be splinted with proximal joint free- splint in extension for 6 weeks. May then after 6-8 wks wear a night splint

Question 52

why might long thumb extensor (EPL) rupture?

Answer 52

after fraying where it crosses the wrist e.g. after a Colle's fracture- distal radial fragment displaced radially, dorsally and dorsal tilt or in RA treat with tendon transfer using EI

Question 53

how can dropped fingers be treated?

Answer 53

can directly repair extensor tendon if only 1 finger affected, or distal portion of tendon can be attached to an adjacent finger extensor

Question 54

what is a Boutonniere deformity?

Answer 54

flexion deformity of PIPJ due to interruption of central slip of extensor tendon. lateral slips separate and head of prox phalanx pops through the gap seen after trauma or in RA

Question 55

what is a swan-neck deformity?

Answer 55

PIPJ hyperextended and DIPJ flexed | due to imbalance of extensor versus flexor action in finger

Question 56

name for infection under the nail fold?

Answer 56

paronychia

Question 57

how should hand be positioned for splintage after draining fascial space or tendon sheath infections, in order for ligaments to be at their longest and splintage therefore least likely to result in stiffness?

Answer 57

wrist slightly extended MCPJs in 70 degrees of flexion IPJs extended thumb abducted

Question 58

tment for dislocated proximal IP joint of ring finger?

Answer 58

manipulative reduction | and buddy strapping splintage

Question 59

what is De Quervain's disease?

Answer 59

tenosynovitis of the 1st dorsal compartment of the extensor retinaculum at the wrist. there is synovial inflammation causing secondary thickening of the sheath and compartment stenosis usually seen in women aged between 30 and 50

Question 60

presentation of De Quervain's disease?

Answer 60

may be history of unaccustomed activity e.g. cutting with scissors, quite common shortly after childbirth pain, sometimes swelling, localised to radial side of wrist tendon sheath feels thick and hard tenderness most acute at very tip of radial styloid

Question 61

clinical indications of scaphoid fracture?*

Answer 61

tenderness over AS painful dorsiflexion pain on rotation of thumb difficulty with wrist plantarflexion?

Question 62

tment of de quervain's disease?

Answer 62

US therapy or corticosteroid injection into tendon sheath, may splint wrist may need to operate to cut the thickened tendon sheath- must be careful not to injure dorsal sensory branches of radial nerve- can cause intractable dysaesthesia

Question 63

main stabiliser of distal radio-ulnar joint?

Answer 63

triangular fibrocartilage complex (TFCC)