Wrist and hand Flashcards
Dequervains Tenosynovitis
Anatomy involved” Brevis sandwich”
- Extensor pollocis longus/Brevis, Abductor pollicis longus
- (+) Finkelsteins test
- most common overuse injury at wrist
- stenosing 1st compartment (EPB, APL)
Treatment for Dequervains
- Rest during initial stage (25-72% cure rate)
- Thumb spica splint- leave IP free to move
- Cortisone injection
Intersection syndrome
- Inflammatory condition of 1st and 2nd compartments, where they intersect ( APL/EPB (1st) and ECRL and ECRB)
- 4-6 cm proximal to RC joint
Dx: extended wrist, circumduct thumb
Treatment for intersection syndrome
- Rest
- Activity modification
- Splinting
- NSAIDS
- injection
1st compartment
- Extensor Pollicis brevis
2. Abductor Pollicis longus
2nd compartment
- Extensor Carpi radialis longus
2. Extensor Carpi radialis brevis
Stener Lesion
- UCL displaced under the adductor aponeurosis, healing cannot occur.
- consult with Orthopedist
bennets fracture
- Most common fx of 1st MC
- MOI: axial compressive load on a flexed thumb
- get proximal displacement of 1st metacarpal due to APL tendon attachment
Jersey Finger
Flexor digitorum profundus avulsion fx
- MOI: forced hyperextension against active flexion (going to grab jersey)
- most common at 4th MCP, sometimes 5th
- Loss o AROM at DIP joint- “make a fist”- fingertip cant touch palm
Volar plate avulsion fx
- volar plate fibrocartilage that reinforces joint capsule of MCP, PIP and DIP
- prevents hyperextension– MOI extension
- x-ray shows “V sign”
- > 40% articular surface involved in fx, surgica stabilization needed.
6 criteria to dx wrist fx in ER
- Swollen
- Pain with palpation
- Pain with AROM flex or ext
- Pain with PROM flex or ext
- Pain with gripping
- Pain with supination
Most common carpal fx *
Scaphoid
Scaphoid fx *
- x-ray usually negative, want MRI, CT, bone scan
Special test: Axial load of thumb - palpate scaphoid in snuffbox with one hand, with other, take thumb and compress into snuffbox +LR of 49- Excellent! to rule in and out
Hook of hamate fx
MOI: abutment of hook of hamate on an object (golf club handle etc)
- common in racket sports
- cant use standard x-rays need carpal tunnerl and supinated oblique views
- dx with CT and bone scan
- EXCISION HAS BETTER OUTCOME THAN ORIF (7-10 week return to sport vs 12 weeks for cast)
AVN of lunate
AVN of lunateKienbocks disease
Scapholunate injury
MOst common wrist ligament injury
MOI: fall on pronated wrist, excessive wrist ext/ulnar dev
Special Test: Watson/scaphoid shift test
- palpate scaphoid on volar aspect of hand and give dorsal pressure
- extend and ulnarly deviate wrist and let go
- (+) for clunk/pain- because no lig integrity, no spring back and once pressure released, scaphoid flexes into radius
Tx: surgery primary
Lunotriquetrial injury
MOI: Foosh
Sx: ulnar sided wrist pain
Special test: Lunotriquetrial Shear test
- give dorsal pressure to triquetrium to shear lunate dorsally. (+) painful click with instability
x-ray usually normal,
Tx: conservative, immobilization 2/2 not usually progressing to arthritis
- persistent pain –> surgery
DRUJ and TFCC
TFCC primary stabilizer of DRUJ
- consists of
- dorsal and palmar radioulnar ligament
- ulnolunate lig
- ulnotriquetrial lig
- disc
MOI: acute trauma (fall) FOOSH or sport related
Special tests: Supination lift test, press test (100% sen),
piano key sign, DRUJ ap/pa hypermobility, grind test
Tx: brace (wrist widget, compression tape to DRUJ, surgery)
Distal Radius Fx
Can be Smith, Colles or Barton Fx
Smith’s fx
- “Dinner fork deformity”
- volar displacement of distal radius
Tx: ALL NEED REDUCTION
Non-op- splint until swelling goes down then cast
Colles fx
- fx of distal radius in a DORSAL direction (vs volar for smith’s)
- also extraarticular fx (vs Barton’s)
Barton’s fx
Fx of distal radius in either a dosal or volar direction but it is an INTRAARTICULAR fx (vs smiths and colles)
Boxers fracture
fx of 5th MCP
Tx: splinting, non op > 90% success rate
Bunnell Littler
Tests for intrinsic muscle tightness (lumbricles) vs joint capsular tightness
- Test PIP flexion in both MCP flexion and ext
- if there is more flexion with MCP flexed (lumbricles on slack) then intrinsic tightness (lumbricle)tightness is indiated
- if there is the same ROM with MCP flexed or ext, think capsular tightness
- normal is more PIP flexion with MCP ext
Swan neck deformity
- PIP hyperextension, DIP flexion
Tx: usually surgery
Boutenniere’s
- PIP flexion, DIP hyperextended
Rupture of central band, puts tension on distal phalanx causing it to hyperextend
Tx: conservative. Splinting and exercise
OA at the hand CPR (5)
- Hand pain, aching or stiffness
- hard tissue enlargement of 2 or more of 10 selected joints
- < 3 cm swollen MCP joints
- Hard tissue enlargement of 2 more more DIP joints
- deformity of 2 or more of 10 selected joints
Mallet Finger
- avulsion of distal slip of extensor tendon
- cant fully extend DIP actively
- can passively extend DIP
MOI: tip of finger into rapid forced flexion
Compartment 3
Extensor Pollicis longus
Compartment 4
Extensor digitorum, and extensor indices
Compartment 5
Extensor digit minimi
Compartment 6
Extensor carpi ulnaris
What passes through the carpal tunnel
4 tendons of flexor digitorum superficialis
4 tendons of flexor digitorum profundis
1 tendon of flexor hallicis longus
1 median nerve
Safe position for splinting of the hand
wrist extended
MCP slightly flexed
IP joints extended
thumb palmarly abducted
Distal row vs proximal carpal row
distal row stable, very litte movement. Proximal row more mobile.
Heberdens nodes
osteophyte that forms at DIP jt
bouchards nodes
osteophytes that form at PIP joint
Gamekeepers thumb
disruption of UCL at thumb; complete tear can lead to a steners lesion
Carpal mechanics
- proximal row moves opposite motion (with radial deviation, proximal row moves ulnarly)
- Distal row moves in that same direction (with radial deviation, the distal row moves radially)
concave/convex distal radius and carpal
CONCAVE distal radius on convex carpal
Finger pulleys
Either cruciate (3) or annular (5) - they keep the tendons close to the bone (like traveling through a tunnel), if a pulley is ruptured tendon bowstrings A2 and A4 pulleys MOST imPORTANT at the levels of the proximal and middle phalanges
Trigger finger can be at A1
OK sign
AIN - anterior interosseus nerve lesion- brings pulp of fingers (tear shape) vs tip to tip circular shape
2 strand flexor tendon repair
early passive protocol (Kleinert, duran)
4, 6, 8 strand repair
active ROM protol early
flexor tendon immobilization
slight wrist flexion, MP flexion, IP Ext
VISI and DISI
Volar/Dorsal intercollated carpal instability- can lead to midcarpal row subluxation (lunate)- tilted in a dorsal direction (DISI)
Depuytren’s disease
contracture of distal palmar crease fascia –> flexion contractures at MP or PIP joints
Ape hand
Median nerve injury
Claw hand
Ulnar nerve injury
sign of benediction
high median nerve injury- ACTIVE test- looks like claw hand but claw hand is resting position. You ask pt to make a fist and then they go and present like claw hand., resting they look normal
Carpal Tunnel prediction rule
- age > 45
- shaking hands relieves symptoms
- CTQuestionaire score > 1.9
- decreased thumb sensation
- Wrist ratio AP/ML > .67
DISI injury
dorsal intercollated segmental instability
- Scapho-lunate lig injury
(think in relation to lunate)
- scaphoid normally wants to move volarly
- if there is a disruption to SL lig, the scaphoid will keep going volarly and the triquetrium are DORSAL in relation
VISI injury
volar intercollagted segmental instability
- triquetrial-lunate lig injury
- normally triquetrium wants to keep moving dorsally
- if there is damage to the TL lig, the SL lig still intact which wants to move volarly, Triquetrium moves dorsally, but all in relation to lunate
Ligament of struthers injury
Pronator teres WEAKNESS to differentiate bw PT syndrome
- pain at elbow
- because its proximal to PT, PT is affected! weakness of PT and pain at elbow think L of struthers injury not PT!
Recurrent branch of median N
2 LOAF
2 lumbricles
Opponens pollicus
Abductor pollicus brevis
Flexor pollicus brevis
Froment’s sign
ULNAR NERVE ISSUE!
- KEY CHUCK GRIP!
(+) flexion of IP at thumb due to ADD pollicus weakness
AIN innervations
think OK sign
- flexor digitorum profundus
- flexor pollicus longus
- pronator quadratus
