Wrist & Hand Flashcards
Remind yourself of the bony anatomy of the wrist
Which bones contribute to the wrist joint?
- Radius
- Carpal ones: scaphoid, lumate, triquetrum
- Articular disc
*REMEMER: ulna does not contribute to wrist joint as it is separated from articulation with carpal bones by fibrocartilaginous ligament called articular disc
State the 4 ligaments of the wrist joint that you need to be aware of; for each state:
- Where they are found in relation to wrist joint
- Where they run from and to
- Role
-
Palmar radiocarpal
- Palmar side
- Radius to both rows of carpal bones
- Stability & ensure hand follows forearm in supination
-
Dorsal radiocarpal
- Dorsum side
- Radius to both rows of carpal bones
- Stability & ensure hand follows forearm in pronation
-
Ulnar collateral
- Medial side
- Ulnar styloid process ot triquetrum & pisiform
- Prevents excess lateral deviation of hand
-
Radial collateral
- Lateral side
- Radial styloid process to scaphoid & triquetrum
- Prevent excessive medial deviation of hand
Remind yourself of blood supply to wrist
The wrist joint receives blood from branches of the dorsal and palmar carpal arches, which are derived from the ulnar and radial arteries
What is meant by a distal radial fracture?
Fracture through the radial metaphysis with or without articular involvement
What are the names of the three most common types of radial fracture?
- Colle’s fracture
- Smith’s fracture
- Barton’s fracture
What is the typical mechanism of injury for #distal radius?
What is a Colle’s fracture, include:
- Intra- or extra- articular
- Angulation
- Specific MOI
- Appearance
- Extra-articular fracture of distal radius with dorsal angulation & dorsal displacement within 2cm of articular surface. *By definition also includes an avulsion fracture of ulnar styloid however this isn’t always present in fractres that are described as ‘Colle’s fractures’
- Fall forwards with outstretched hand in front; forces wrist into supination
- Dinner fork deformity
What is a Smith’s fracture, include:
- Intra- or extra- articular
- Angulation
- Specific MOI
- Appearance
- Extra-articular fracture of distal radius with volar (palmar) angulation with or without volar displacement
- Falling backwards and putting hand out behind body; forcing wrist into prontation
- Garden fork
Summarises mechanism of injury for Colle’s fracture & Smith’s fracture
What is a Barton’s fracture?
- Intrarticular fracture of distal radius with associated dislocation of radio-carpal joint
- Can be volar (more common) or dorsal
Describe the typical presentation of distal radius fractures
- History of trauma
- Immediate pain
- Deformity
- Swelling
- Neurological dysfunction e.g. parasthesia or weakness
What can you ask pt to do to test the motor function of the following nerves in their hand:
- Median nerve
- Ulnar nerve
- Radial nerve
- Median nerve: abduction of thumb
- Ulnar nerve: adduction of thumb
- Radial nerve: extension of IPJ of thumb
What investigations are required for a suspected distal radius fracture?
- Plain radiograph (AP, lateral, oblique)
- ?CT or MRI for complex fractures
What 4 measurements on plain radiograph can help with diagnosis of distal radius fracture?
State the normal measurements for these
- Radial height 10-12mm
- Radial inclination 20-23 degrees
- Radial (volar) tilt 11-12 degrees
- Ulnar variance 0 to -2 mm
*Think rule of 11s
How do you measure the following:
- Radial height
- Radial inclination
- Radial (volar) tilt
- Radial height- C: draw line at level of ulnar aspect of articular surface and on radial styloid. Distance between these. AP VIEW.
- Radial inclination- B: draw line on articular surface of radius at level of ulnar aspect of distal radius then draw a tangent from radial styloid. AP VIEW
- Radial (volar tilt)- A: draw line perpendicular to long axis of radius then draw line along slope of dorsal to volar surface. LATERAL VIEW.
- Ulnar variation: draw 1 lineat level of articular surface of ulna, perpendicular to ulnar shaft. Draw second line at level of lnate fossa of radisu, perpendicular to radial shift. Distance between.
Discuss the management of distal radius fractures
- Closed reduction (under analgesia- commonly haematoma block) then put in below-elbow backslab cast
- Repeat x-ray in 1 week to check for displacement
- If no displacement, apply full cast and then physiotherapy
- If significantly displaced or unstable will require surgical intervention
- ORIF with plating or K-wire fixation
- Cast for a few weeks to ensure immbolisation
State some potential complications of distal radius fractures
- Malunion leading to reduced motion & pain
- Median nerve compression (more common if malunion)
- OA
What is the typical mechanism of injury for scaphoid fractures?
High energy injuries- typically in men aged 20-30. FOOSH with forced dorsiflexion
Describe the blood supply to the scaphoid
- Supplied by branches of radial artery
- Dorsal radial artery supplies 80% of blood
- Retrograde blood flow therefore fratures can compromise blood supply so risk of AVN
- The more proximal the scaphoid fracture, the higher the risk of AVN
Describe the typical presenation of scaphoid fractures
- History of trauma
- Sudden onset wrist pain
- Bruising
- Tenderness around scaphoid tubercle and floor of antomical snuffbox
- Pain on telescoping of thumb (compression of thumb longitudiinally)
What investigations should you do in suspected scaphoid fractures?
- Plain radiograph “scaphoid series” (AP, lateral & oblique)
- *NOTE: scaphoid fractures not always detected on initial radiographs so if still have clinical suspicion immoblise wrist in thumb splint and redo x-ray in 10-14 days. If stil unsure treat as fracture and organise MRI of wrist*
Discuss the management of scaphoid fractures, include:
- Undisplaced
- Undisplaced proximal
- Displaced
- Undisplaced: immobilisation with thumb spica splint
- Undisplaced proxmial: high risk of AVN therefore surgical treatment indicated- especially if in dominant hand
- Displaced: ORIF with screw
State some potential complications of scaphoid fractures
- AVN
- Non-union
What is carpal tunnel syndrome?
Symptoms due to compression of median nerve within the carpal tunnel
State some risk factors for carpal tunnel syndrome
- Female
- Age (45-60yrs)
- Pregnancy
- Obesity
- Previous injury to wrist
- Repetitive hand or wrist movements
- Hypothyroid
- RA
- Diabetes
Describe the typical presentation of carpal tunnel syndrome
- Pain, numbness, parasthesia in median nerve sensory distribution (NOTE: palm often spared)
- Symptoms worse at night
- Symptoms relieved by handing arm over side of bed or shaking
- Weakness of thumb abduction & wasting of thenar eminence
- Positive Tinel’s test or positive Phalen’s test
What investigations may be done for suspected CTS?
- Diagnosis= clinical
- May do nerve conduction studies to confirm emdaiin nerve damage (but normal NCS does not rule out CTS)
Discuss the management of carpal tunnel syndrome
Conservative
- Wrist splint (worn at night)
- Physiotherapy
- Corticosteroid injections into carpal tunnel
Surgical
- Carpal tunnel release surgery to decompress carpal tunnel (cut through flexor retinaculum to reduce pressure on median nerve)
State some potential complications of carpal tunnel release surgery
- Persistent CTS symptoms
- Infection
- Scar formation
- Nerve damage
- Trigger thumb
(90% report good outcomes post-surgery)
Explain why the palm is often spared in carpal tunnel syndrome
Palmar cutenaous branch of median nerve branches proximal to flexor retinaculum and passes over carpal tunnel
What is Dupuytren’s contracture?
Describe the progression of the disease
Benign thickening and contraction of the longitudinal palmar fascia. Disease progression:
- Pitting & thickeninig of palmar skin and underlying subcutaneous tissue
- Painless nodule forms- increase in size
- Cord develops
- Cord contracts over time and pulls on MCP and PIP leading to progressive flexion deformity in fingers
State some risk factors for dupuytrene’s contracture
- Smoking
- Alcoholic liver disease
- Diabetes
- Occupational exposure (e.g. vibrating tools)
- Idiopathic (?genetic & environmental)
Describe the typical presentation of dupuytrene’s contracture
- Nodular defomrity
- Cords/thickened band
- Reduced range of motion or complete loss of movement
- Ring and little finger most commonly affected
- Positive Hueston’s test (can’t lie hand flat on table)
What investigations might you consider for duputren’s contracture?
- Diagnosis= clinical
May do tests to look for risk factors (e.g. HbA1c, LFTs)
Discuss the management of dupuytren’s contracture
Treatment depends on stage of presentation and degree of functional disability.
Conservative
- Hand therapy (keep hand active, stretching exercises daily)
- Injectable CCM
Surgical
- Excision of diseases fascia
Discuss the prognosis of dupuytren’s contracture
- Most eventually require surgery
- Surgery has good functional outcomes BUT 2/3 have re-occurence afer operation
What is De Quervain’s tenosynovitis?
Inflammation of tendons within the first extensor compartment of the wrist (therefore inflammation of tendons of extensor pollicis brevis & abductor pollicis longus)
State some risk factors for De Quervain’s tenosynovitis
- Age (30-50yrs)
- Female
- Pregnancy
- Repetitive wrist actions
Describe the typical presentation of De Quervain’s tenosynovitis
- Pain near base of thumb
- Difficulty with grapsing or pinching
- Swelling near bae of thumb
- Palpable thickening base of thumb area
- Finkelstein’s test positive
What investigations may be done for De Quervain’s tenosynovitis?
Clinical diagnosis
*May do x-ray to rule out other diagnoses e.g. CMC joint arthritis
Discuss the management of De Quervain’s tenosynovitis
- Lifestyle: avoid repetitive moveements
- Wrist splints
- Steroid injections
- Surgical decompression of extensor compartment
What are ganglionic cysts?
Why do they occur?
Where do they commonly occur?
Who common in?
- Soft tissue lumps that occur along any joint or tendon.
- They arise from degeneration within joint capsule or tendon and become filled with fluid
- Hands & feet
- Femals 20-40yrs
State some risk factors for ganglionic cysts
- Female
- OA
- Previous joint or tendon injury
Describe the typical appearance of ganglionic cysts
- Smooth, spherical painless lump
- Sudden appearance or gradual
- Transilluminate
- May restrict ROM at joint
- +/- associated neurological symptoms if compressing nerve
What investigations may be done for ganlionic cysts?
- Diagnosis= clinical
May do imaging if unsure/to rule out other pathology e.g. x-ray, USS, aspirated fluid sent for microscopy & cytology
Dicuss the management for ganglionic cysts
- If not causing pain: monitor and will likely disappear spontaneously
- If causing pain and/or limiting movement:
- Aspiration
- Steroid injection
- Cyst excision (often reserved for symptomatic caes with recurrence following aspiration)
What is trigger finger?
- Also called stenosing flexor tenosynovitis
- Finger or thumb click or lock when in flexion preventing return to extension
Explain the pathophysiology of trigger finger
- Repetitive movements can lead to inflammation of tendon and sheath (flexor tenosynovitis)
- Localised nodes form distal to the pulley
- When fingers are flexed, node moves proximal to the pulley
- But then when pt attemptsto extend the digit the node fails to as sunder the pulley so finger becomes locked in flexed position
- A1 pulley most commonly affected
State some risk factors for trigger finger
- Prolonged gripping and use of hand
- RA
- Diabetes
- Female
- Age
Describe typical presentation of trigger finger
- Painless clicking/snapping/catching when try to extend finger (on examination feel proximal aspect of phalanx when moving finger to feel for any clicking)
- Over time may become painful over MCP joint
Discuss the management of trigger finger
- Finger splint to wear at night (holds finger in extension- smooths out roughened portion of tendion as it keeps roughened part in the tunnel)
- Steroid injections
- Percutaneous trigger finger release (use needle to release tunnel)
- Surgcal decompression of tendon tunnel
