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Physical Exam > Wrist and Hand > Flashcards

Wrist and Hand Flashcards

1
Q

How many extensor/flexor tendons?

A
  • 12 extensor tendon (organized in 6 compartments)

- 12 flexor tendon insert on hand/wrist

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2
Q

Triangular fibrocartilage complex (TFCC)

A
  • “wrist meniscus”
  • consists of articular disc, ulnocarpal ligament, dorsal/volar radioulnar ligaments, ECU sheath
  • Primary stabilizer of distal radioulnar joint, also contributes to ulnocarpal stability
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3
Q

What to look for on inspection?

A
  • cystic swelling on doral wrist (ganglion cyst)- will transluminate whereas a carpal bone will not
  • swelling (carpal bones, MCP, PIP, DIP)
  • erythema
  • atrophy
  • contractures (hand deformities in RA, Dupuytren’s)
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4
Q

Volkmann’s contracture

A
  • Ischemic necrosis of flexor muscles of forearm

- usually a/w brachial artery injury (i.e. supracondylar humerus fx), compartment syndrome, or improper tourniquet use

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5
Q

Wrist drop

A
  • lesion of radial nerve due to compression at the spiral groove (i.e. “Saturday night palsy) or axilla (i.e. crutch palsy) results in “wrist drop”
  • you’ll also have weak elbow extensors with compression at the axilla (triceps are radial nerve innervated)
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6
Q

Dupuytren’s contracture

A
  • Contraction of palmar fascia due to fibrosis
  • genetic predisposition
  • seen in men >40 years, DM, ETOH, epilepsy
  • Exam: contracture at MCP joint, usually in 4th finger, palpable cord present (often ring finger)–> usually not functionally limiting
  • NEJM: injection of clostridium collagenase for tx
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7
Q

What are the common RA deformities of the wrist/hand?

A
  • ulnar deviation of fingers
  • boutonniere deformity
  • swan neck deformity
  • pseudo benediction sign
  • floating ulnar head
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8
Q

What causes ulnar deviation of FINGERS in RA?

A

-caused by ECU weakness–> radial deviation of wrist–> flexor/extensor mismatch due to increased torque of ulnar finger flexors–> ulnar deviation of fingers

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9
Q

What is boutonniere deformity?

A
  • hyperextension of MCP, flexion of PIP, hyperextension of DIP
  • weakness/rupture of extensor hood causes subluxation of extensor tendons past PIP joint
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10
Q

What is swan neck deformity?

A
  • flexion of MCP, hyperextension of PIP, flexion of DIP

- caused by contracture of deep finger flexor muscles/intrinsics of hand and flexor tendons of fingers

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11
Q

What might you see on hand x-ray of RA?

A
  • ulnar deviation of fingers
  • periarticular osteopenia
  • marginal joint erosions
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12
Q

Pseudo benediction sign?

A
  • extensor tendons rupture and inability to extend 4th and 5th digits
  • elevated ulnar styloid causing mechanical irritation and rupture of 4th and 5th extensor tendons
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13
Q

Floating ulnar head?

A
  • “Piano key sign”
  • elevation of the ulnar head at the dorsum of the wrist
  • caused by rupture/insufficiency of the ulnar collateral ligament due to synovial proliferation
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14
Q

Range of motion values for wrist?

A

Flexion 80-90 degrees
Extension 70-80 degrees
Ulnar deviation 30
Radial deviation 20

*Loss of full flexion is the 1st sign of effusion of radoiocarpal joint

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15
Q

Is the palmar cutaneous nerve affected in carpal tunnel?

A

No, supplies the hand

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16
Q

Dorsal compartments of the wrist

A

1st: APL, EPB (*L, B, L, B, L)
2nd: ECRL, ECRB
3rd: EPL
4th: EDC, EIP
5th: EDM
6th: ECU

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17
Q

Dequervain’s tenosynovitis

A
  • Inflammation/irritation of extensor policies brevis and abductor policis longs (APL, EPB)
  • involves the 1st dorsal compartment
  • pain and tenderness over radial side of wrist near snuff box
  • Exam: finkelstein’s test–> thumb in palm of hand while making a fist, ulnar deviation reproduces pain
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18
Q

What is intersection syndrome?

A
  • tenosynovitis of radial wrist extensors (ECRL and ECRB) which also affects EPB/APL
  • occurs at the “intersection” of 1st and 2nd dorsal compartments in the distal forearm on radial aspect
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19
Q

What causes intersection syndrome?

A
  • Caused by repetitive wrist flexion/extension activities

- Seen in weight lifters, rowers, gymnasts, etc.

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20
Q

What do you see on exam in intersection syndrome?

A
  • Swelling and tenderness at the intersection of 1st and 2nd dorsal compartments (3-6 cm proximal to radiocarpal joint, occurs proximal to Dequervain’s)
  • pain with resisted wrist extension
  • May have pain/crepitus in this area with passive ulnar/radial deviation of wrist
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21
Q

What is the MC site of osteoarthritis in the UE?

A
  • 1st CMC joint of thumb

- Exam reveals tenderness over joint space, crepitus, and possibly decreased ROM

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22
Q

What test can you do for CMC osteoarthritis?

A

-CMC grind test: axial load applied to thumb with rotation, abduction, adduction

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23
Q

What do you see on the hand with osteoarthritis?

A
  • bouchard’s nodes (proximal)

- herbedon nodes (distal)

24
Q

What is osteonecrosis/AVN of the lunate called?

A

Kienbock’s disease

25
Q

What is the etiology of Kienbock’s disease?

A
  • unknown
  • thought to be caused by repeated stress/trauma
  • increased risk in people with shortened ulna (i.e. negative ulnar variance)
26
Q

What exam do you see in Kienbock’s disease?

A
  • pain over ulnar side of wrist on palpation, swelling over dorsal aspect, decreased grip strength
  • MRI is diagnostic
27
Q

What should you think of with fall on dorsiflexed wrist- “fall forward”?

A

Scaphoid fracture

28
Q

What is the risk a/w scaphoid fx?

A

-high risk of osteonecrosis and nonunion due to blood supply only to distal 1/3 of bone

29
Q

What exam do you see with scaphoid fx?

A
  • tenderness in anatomical snuff box, + swelling

- scaphoid compression test: axial load on thumb causes pain over scaphoid

30
Q

What are the borders of the anatomical snuff box?

A
  • radial- APL, EPB
  • ulnar- EPL
  • base- scaphoid bone
31
Q

Treatment for scaphoid fx?

A
  • initial films often negative, if tenderness in snuff box after fall, treatment as if fracture and re-image in 2 weeks
  • treatment: immobilization vs. surgery
32
Q

What is jersey finger?

A
  • tendon injury/avulsion to flexor digitorum profundus (FDP)
  • Mechanism: sudden extension of the DIP when flexed
  • occurs in football and wrestling when finger gets caught in jersey

*occurs during eccentric contracture

33
Q

What exam do you see with jersey finger?

A
  • patient unable to actively flex the DIP joint- need to hold PIP in extension during test
  • also with tenderness and swelling in the area
  • treatment: usually surgical

*eccentric

34
Q

What is mallet finger?

A
  • tendon injury/avulsion of the extensor tendon to DIP joint

- Mechanism: sudden forced flexion f DIP when extended

35
Q

What exam do you see with mallet finger?

A
  • DIP joint is flexed at rest and patient unable to actively extend
  • tenderness and swelling over DIP
  • treatment: immobilization (continuous for 6 weeks) vs. surgical
36
Q

What is trigger finger?

A
  • patient reports finger “locking” with flexion

- inflammatory nodule in flexor tendon gets caught in A1 pulley

37
Q

What do you see on exam with trigger finger?

A

-catching or locking of finger with active flexion and extension, palpable nodule near MCP joint which is often tender

38
Q

What is the injury in gamekeeper (chronic) and skier’s (acute) thumb?

A

UCL (ulnar collateral ligament) injury in the thumb

39
Q

What is the mechanism of injury in UCL (ulnar collateral ligament) injury in the thumb?

A

-valgus stress to thumb (may be acute or chronic)

40
Q

What do you see on exam with UCL (ulnar collateral ligament) injury in the thumb?

A

-tenderness over ulnar side of MCP joint with swelling, increased laxity and pain with values stress

41
Q

What is sterner lesion?

A
  • aponeurosis of adductor policies muscle which lies between the MCP joint and the distal end of UCL ligament
  • prevents spontaneous healing of UCL injury
42
Q

Who is at increased risk for CTS?

A

-CHF/ESRD, thyroid disease, pregnancy, etc.

43
Q

What do you see on exam with CTS?

A

-decreased sensation (digits 1-3, radial side of 4th), APB weakness, thenar atrophy

44
Q

What are the 3 provocative tests for CTS?

A
  • Phalen’s: wrist flexion for 60 secs
  • Tinel’s: percussion of median n. at wrist
  • Hand elevation test: hold hands above head for 2 minutes

*Positive test for all is reproduction of paresthesias in medical nerve distribution

45
Q

What do patient’s report with TFCC injury?

A

-pain on ulnar side of wrist, clicking/catching with wrist movement, decreased grip strength, can be acute or chronic

46
Q

What do you see on exam with patient’s with TFCC injury?

A
  • tender on ulnar side of wrist on dorsal aspect just distal to ulnar styloid
  • pain/clicking with ROM
  • decreased grip strength with pain
  • pain with axial loading of carpal bones with wrist in ulnar deviation
  • pain with resisted radial wrist deviation
47
Q

What are the special tests for TFCC injury?

A
  • press test: patient uses hand to “lift” up from chair
  • supination lift test: attempt to lift table/desk from undersurface
  • ulnar impaction test: axial compression with WE and ulnar deviation
48
Q

What is positive ulnar variance?

A
  • distal articular surface of the ulna is more distal when compared to the articular surface of the radius
  • a/w thinning of the TFCC
49
Q

How do you test for scaphoid-lunate instability?

A
  • Scaphoid shift test (i.e. Watson test): passively move hand from extension and ulnar deviation to flexion with radial deviation while applying force on volar aspect of scaphoid bone
  • palpable clunk is a + test and indicated laxity of scaphoid ligaments or scapholunate instability
50
Q

How do you test for lunate-triquetrium instability?

A
  • Reagan’s test (i.e. shuck test): stabilize triquetrum with one hand, with the other move lunate anterior and posterior, + test is pain, instability, or crepitus– compare side to side
  • Kleinman Shear test: also assesses for instability between lunate and triquetrum- similar to Reagan’s except only use thumbs
51
Q

What is Murphy’s sign?

A
  • patient makes a fist, if head of 3rd MC aligns with 2nd and 4th MC
  • test is positive and indicated lunate dislocation
52
Q

What is the mid carpal shift test? (aka Lichtman’s test)

A
  • tests for instability
  • provide solar directed force over distal capitate with passive ulnar deviation of wrist
  • positve test is pain with “clunk”
53
Q

What is the glide test?

A
  • assesses for instability of various joints
  • stabilize forearm with one hand, other hand over carpal bones, provide anterior/posterior/side to side stress
  • positive test is pain or instability, compare side to side
54
Q

What is the normal cap refill time?

A

less than 2 seconds

55
Q

What are 2 vascular tests?

A
  • Allen test: occlude both radial and ulnar artery until pallor, release ulnar artery and look for resolution- indicated adequate supply of blood to hand from ulnar artery; okay to proceed with radial artery blood draw
  • Adson’s test: palpate radial artery, arm is passively extended and externally rotated while patient looks to that side; + test is diminished or absent radial pulse, may indicate vascular thoracic outlet syndrome
56
Q

What is the Bunnel-Littler Test?

A
  • used to differentiate PIP contracture due to either hand intrinsic muscle tightness or capsular tightness
  • passively flex PIP joint with MCP in extension and flexion
  • decreased PIP flexion only with MCP extension= intrinsic hand tightness
  • decreased PIP flexion in both MCP extension/flexion= capsular tightness

Physical Exam (7 decks)

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