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phase iii orthopaedics > wrist & hand > Flashcards

wrist & hand Flashcards

1
Q

side effects of H&L injection

A

1) hypopigmentation of skin
2) lipoatrophy
3) infection
4) tendon rupture
5) nerve injury

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2
Q

hand indications for H&L

A

1) RA
2) CTS
3) trigger finger
4) de quervain’s tenosynovitis

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3
Q

classification of nerve injury

A

seddon’s classification

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4
Q

seddon’s classification of nerve injury

A

1) neuropraxia (e.g. saturday night palsy)
- mechanical pressure causing segmental demyelination
- recovery takes place without wallerian degeneration
- motor > sensory involvement

2) axonotmesis (e.g. nerve injury after closed fractures/dislocations)
- loss of relative continuity of axon and myelin covering
- small extent of wallerian degeneration

3) neurotmesis (severe, stretch, contusions, lacerations)
- destruction of endoneural tubes with subsequent scarring impairing regenerating axons from entering distal segment to reach target organs
- functionally impaired
- surgical repair essential and quality of recovery imperfect

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5
Q

sunderland classification of nerve injuries

A

I: seddon’s neuropraxia (conduction block)
II: seddon’s axonotmesis (axonal distruption)
III: axonal + endoneural distruption
IV: axonal + perineural distruption
V: seddon’s neurotmesis - complete transection with loss of continuity

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6
Q

motor supply of AIN

A

1) flexor pollicis longus
2) radial 1/2 of FDP
3) pronator quadratus

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7
Q

motor supply of median nerve proper

A

1) PT
2) FCR
3) FDS
4) PL
5) L1, L2

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8
Q

motor supply of recurrent motor branch of median nerve

A

thenar muscles

1) APB
2) OP
3) FPB

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9
Q

significance of APB

A

APB is the thena muscle solely supplied by median nerve 99% of time (FPB, OP may receive cross supply from ulnar nerve)

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10
Q

positive phalen’s sign

A

numbness felt over radial 3.5 digits reproduced when hands togged in inverted prayer position

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11
Q

common areas of lesion for median nerve

A

1) high lesion - pronator tunnel syndrome
2) AIN lesion = trauma at elbow/forearem
3) low lesions - carpal tunnel/cut at wrist

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12
Q

signs of HIGH median nerve lesion

A

= benediction sign (inability to flex PIPJ and DIPJ of index)

  • carpal tunnel
  • loss of FDS, FDP, intrinsics
  • sensory loss over thenar eminence, lateral 3.5
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13
Q

why can middle finger flex in lesion of median nerve? (radial 0.5 of FDP by AIN)

A

small/ring/middle finger share a common FDP body

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14
Q

signs of AIN lesion (median nerve)

A
  • loss of FPL, PQ, radial half of FDP (might have partial benediction sign)
  • no sensory loss (AIN has no cutaneous innervation)
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15
Q

signs of LOW lesion of median nerve

A
  • wasting of thenar eminence
  • loss of thumb abduction and opposition
  • sensory loss over lateral 3.5 fingers on volar aspect (skin over thenar eminence spared)
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16
Q

anatomical boundaries of carpal tunnel

A

radial side: scaphoid + trapezium
ulnar side: pisiform + hook of hamate
volar: flexor retinaculum

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17
Q

contents of carpal tunnel

A 
flexor digitorum profundus (4)
flexor digitorum superficialis (4)
flexor pollicis longus 
flexor carpi radialis tendon
median nerve
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18
Q

pathophysiology of CTS

A

pressure on nerve > BF obstruction in vasa nervorum > venous congestion + edema > fibroblast proliferation in nerve > inefficiency of cell transport mechanism + sodium pump > nerve conduction impairment

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19
Q

causes of CTS

A

1) anatomical abnormalities: bone/st impingement
2) physiological abnormalities
- fluid imbalance (6): pregnancy, menopause, cardiac/renal failure, obesity, hypothyroid, amyloidosis
- inflammatory: RA
trauma: previous wrist fracture
- metabolic: gout
- neuropathic: DM, alcohol
- endocrine: hypothyroidism

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20
Q

differentials for CTS

A

1) cervical nerve root lesion
2) thoracic outlet syndrome
3) AIN syndrome (sensory intact!)

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21
Q

management of CTS

A

1) conservative
- lifestyle modification: reduce repeated activity
- occupational therapy: splint wrist in neutral position (helps with night symptoms)
- supplements: vit B complex
- phamacological: NSAIDs, H&L injection

2) surgery
- CT release

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22
Q

complications of CT release

A

1) scar
2) failure of relief
3) nerve injury: palmar cutaneous branch of median nerve (supf to flexor retinaculum) and motor branch of thenar

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23
Q

why is there sparing of sensation at dorsum of hand in ulnar nerve lesion at wrist?

A

cutaneous branch to dorsum of hand given off before the wrist

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24
Q

motor supply of ulnar nerve proper

A

1) ulnar 1/2 of FDP

2) FCU

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25
Q

motor supply of deep motor branch of ulnar nerve

A

1) hypothenar muscles (abd digiti minimi, opponens digiti minimi, flexor digiti mini brevis)
2) interossei
3) medial 2 lumbricals
4) adductor pollicis
5) deep head of flexor pollicis brevis

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26
Q

wartenburg sign

A

little finger abducted as adduction ability of dorsal interossei lost
- extension action of extensor digiti minimi pulls little finger into abduction

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27
Q

common sites of lesion of ulnar nerve

A

1) high lesion - cubital tunnel, ulnar subluxation

2) low lesion = wrist laceration, guyon’s canal

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28
Q

signs of HIGH ulnar nerve lesion (majority)

A
  • sensory loss in volar AND dorsal aspect of medial 1.5 fingers
  • positive tinel’s test posterior to medial epicondyle
  • minimal clawing: medial half of FDP no longer working to facilitate clawing
  • wartenburg sign
  • radial deviation of wrist on flexion (unopposed FCR)
  • wasting of intrinsic muscles
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29
Q

first sign of ulnar nerve lesion

A

wasting of 1st dorsal interosseous muscle

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30
Q

management of high ulnar nerve lesion

A

1) anterotransposition

2) cubital tunnel release

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31
Q

signs of LOW ulnar nerve lesion (deep motor branch of ulnar)

A
  • froment’s sign positive
  • wartenburg sign positive
  • ulnar claw pronounced due to unopposed FDS and FDP (loss of 3rd and 4th lumbrical + interossei which flex MCP and extend IPJ)
  • sensory loss over volar 1.5 fingers
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32
Q

why middle and index finger not flexed in ulnar claw?

A

lateral lumbricals supplied by median nerve

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33
Q

management of cubital tunnel syndrome

A

1) simple decompression
2) medial epicondylectomy (if a/w non union of epicondyle fracture)
3) anterior tranposition of ulnar nerve

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34
Q

motor supply of radial nerve

A

1) posterior interosseous nerve

2) radial nerve proper

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35
Q

muscles innervated by PIN

A

1) ECRB
2) supinator
3) EDC
4) EDM
5) extensor indicis
6) ECU
7) EPL
8) EPB

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36
Q

muscles innervated by radial nerve proper

A

1) triceps
2) brachialis
3) brachioradialis
4) ECRL

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37
Q

most distal extensor muscle supplied by PIN

A

extensor indicis

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38
Q

second most distal extensor muscle supplied by PIN

A

EPL (if EPL function intact, all other muscles supplied by radial nerve should be intact)

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39
Q

common sites of radial nerve lesion

A

1) very high
- axilla: saturday night palsy, crutch palsy
- mid humeral level: spiral groove during humeral shaft #
- at/below elbow

2) radial tunnel syndrome (at level of epicondyles)
3) low lesion (at elbow)

40
Q

signs of VERY HIGH radial nerve lesion

A
  • wrist drop
  • finger drop
  • sensory loss over anatomical snuffbox + dorsum of lateral 3.5
  • muscle wasting over forearm extensor compartment + triceps (very high lesion)
41
Q

signs of LOW radial nerve lesion > injury to PIN

A
  • finger drop: inability to extend MCP joints and thumb

- radial deviation (ECU knocked out)

42
Q

where is PIN given out

A

between 2 heads of supinator @ level of elbow

43
Q

differentials for cystic and soft lumps

A

1) ganglions
2) lipomas
3) vascular malformation

44
Q

differentials for firm lumps

A

1) neuroma
2) PVNS
3) fibroma

45
Q

differentials for hard lumps

A

1) osteochondroma

2) bone tumors

46
Q

description for characteristics of a lump

A

S(4): size, shape, site, surface
E: edge
C(2): consistency, colour
T(3): tender, transillumination, temperature
O: others - mobility, fluctuance, pulsatile
R: relations/related signs

47
Q

common sites for ganglion

A

1) dorsal wrist - scapholunate junction
2) volar wrist - scapholunate, scaphotrapezoid
3) volar MCPJ
4) dorsal DIPJ

48
Q

significance of big ganglion cyst in GH joint

A

almost always associated with rotator cuff tear

49
Q

treatment for ganglion

A

1) conservative: usually resolves spontaneously after some months
2) surgery
- aspiration (high recurrence)
- excision if recurrence: cosmesis/pain

50
Q

commonest hand lump

A

ganglion

51
Q

types of PVNS

A

1) diffuse form: affects entire synovial lining of joint, bursa, tendon sheath
- large joints (knee> hip> ankle, shoulder)

2) localised/nodular form: affects tendon sheath around small joints of hands and feet

52
Q

alternative name for PVNS

A

giant cell tumor of tendon sheath

53
Q

most common site of PVNS

A

volar aspect near DIPJ (often index and middle)

54
Q

XR findings of PVNS

A

secondary OA changes!

  • joint swelling
  • periarticular erosions
  • joint space narrowing
  • subchondral cyst
  • osteophyte formation
55
Q

treatment of PVNS

A

synovectomy

if refractory to repeated surgery: low dose RT

56
Q

commonest primary bone tumor of hand

A

enchondroma

57
Q

causes of ruptured extensor pollicis longus

A

1) colle’s fracture

2) RA

58
Q

treatment of ruptured extensor pollicis longus

A

tendon transfer

59
Q

pathoanatomy of boutonneire deformity

A

flexion deformity of PIPJ due to interruption of cetnral slip of extensor tendon > lateral slips separate > head of proximal phalanx pops up in btw lateral slips

60
Q

treatment of boutonneire deformity

A 
post traumatic: repairable
chronic deformity (RA): unrepairable
61
Q

swan neck deformity

A

flexion deformity of DIPJ (+hyperext of PIPJ) due to imbalance of extensor vs flexor action in finger

62
Q

treatment of swan neck deformity

A

tendon rebalancing + joint stabilsation

63
Q

tendons in first extensor compartment

A

abductor pollicis longus + extensor pollicis brevis

64
Q

tendons in 2nd extensor compartment

A

extensor carpi radialis longus + brevis

65
Q

point of tenderness in de quervain’s disease (1st extensor compartment)

A

tip of radial styloid

66
Q

point of tenderness in tenosynovitis of 2nd extensor compartment

A

just medial to anatomical snuffbox

67
Q

positive finkelstein test

A

1) CMCJ OA

2) de quervain’s tenosynovitis

68
Q

management of de quervain’s tenosynovitis

A

1) conservative
- lifestyle modification: rest, reduce painful movements
- occupational therapy: thumb spica for 1 mth
- physiotherapy
- pharmacological: nsaids
- H&L injection

2) surgical
- decompressoin of 1st compartment tendon sheath

69
Q

complications of tendon sheath release for de quervain’s tenosynovitis

A

1) infection
2) superficial radial nerve palsy
3) snapping of extensor tendon
4) APL + EPB adherence

70
Q

differentials for radial sided wrist pain

A

1) intersection syndrome
2) de quervain’s disease
3) wartenburg’s syndrome (compression of superficial branch of radial nerve)
4) scaphoid fracture
5) scapholunate instability
6) 1st CMCJ OA

71
Q

common fingers involving in trigger finger

A

ring, middle, thumb of dominant hand

72
Q

risk factors for trigger finger

A

1) overuse
2) trauma
3) DM
4) RA
5) gout

73
Q

classification for trigger finger (stenosing tenovaginitis)

A

green’s classification

74
Q

stages in green’s classification

A

I: pretriggering
- tenderness over A1 pulley region; triggering not demonstrable on PE

II: triggering
- demonstrable catching but patient can actively extend digit

III: triggering and locking
- demonstrable locking:
IIIA: requires passive extension
IIIB: inability to actively flex (requires passive flexion)

IV: contracture
- fixed flexion contraction of PIPJ

75
Q

differential diagnosis for trigger finger

A
  • RA
  • septic arthritis
  • suppurative tenosynovitis
  • tumor of tendon sheath
  • dislocation
  • dupuytrens contracture
76
Q

management of trigger finger

A

1) conservative
- lifestyle modification: reduce trauma
- occupational therapy: splint PIPJ
- H&L injection into tendon sheath

2) surgical
- division of A1 pulley (indication: failure of injection therapy/stage 4)

77
Q

clinical sign of infectious tenosynovitis of flexor tendon sheath in hand

A

kanavel’s sign

78
Q

describe kanavel’s sign

A

1) slightly flexed position of affected finger
2) fusiform swelling over affected region
3) tenderness on percussion along tendon sheath
4) tenderness on extension of affected finger

79
Q

most common organism implicated in infection of the hand

A

s. aureus

80
Q

management of hand infections

A

1) antibiotics
- flucloxacillin
- severe cases: fusidic acid or cephalosporin

2) rest and elevation
3) analgesics
4) drainage + debridement > wound culture
5) splintage (position of safe immobilisation where ligaments at greatest length)
6) physiotherapy

81
Q

management of suppurative tenosynovitis

A

1) IV antibiotics
2) surgical drainage w 2 incisions (proximal + distal end of sheath)
3) irrigation with saline or ringer’s lactate w fine catheter
4) dressing + splinting

82
Q

commonest complication of hand fracture

A

tendon adhesion

83
Q

complications of wrist fracture

A

1) early
- difficult reduction
- compartment syndrome
- EPL tendon rupture
- acute CTS
- finger swelling with venous/lymphatic block

2) late
- malunion/radial shortening
- frozen shoulder (shoulder hand syndrome)
- post traumatic arthritis
- CTS
- complex regional pain syndrome

84
Q

cause of deformity post hand fracture

A

malunion

85
Q

most commonly fractured carpal bone

A

scaphoid (75%)

86
Q

scaphoid fracture extra/intra articular

A

ALWAYS INTRAarticular

87
Q

investigations for scaphoid fracture

A

1) XR
- 5 views: AP, lateral, scaphoid, 2 oblique (semipronated + semisupinated)

2) MRI
- diagnosis of occult scaphoid fracture + AVN

88
Q

management of scaphoid fracture

A

1) initial
- scaphoid plaster (below elbow to below MCP & IPJ) & sling

2) fracture of scaphoid tubercle
- don’t require splintage
- crepe bandage + movement encouraged

3) displaced/unstable fracture or delayed/nonunion
- ORIF with scaphoid compression screw
- nonunion: OF + bone graft
- acute #: percutaneous fixation

89
Q

complications of scaphoid fracture

A

1) AVN of proximal pole > secondary radiocarpal OA
- blood supply of proximal pole: radial artery
2) non union
3) OA

90
Q

management of AVN of proximal pole of scaphoid

A

1) removal entire proximal row of carpal bones (carpectomy)

2) remove scaphoid + fuse proximal to distal row (4 corner fusion)

91
Q

MOI of mallet finger

A

rupture of extensor tendon of terminal phalanx as fingertip forcibly bend during active extension

92
Q

management of mallet finger

A

1) conservative: soft tissue injury
- mallet splint

2) avulsion fracture
- extra articular or involving <2/3 of joint: conservative
- intra articular or involving >2/3 of joint: surgical reduction

93
Q

management of displaced metacarpal shaft fracture

A

ORIF with plates/K wire

94
Q

complications of lunate/perilunate dislocation

A

1) difficulty in reduction > AVN > secondary OA
2) CTS
3) improper periunate reduction > secondary lunate dislocation

95
Q

management of lunate/perilunate dislocation

A

1) closed reduction
- reduce + percutaneous K wire
- plaster slab

2) open reduction
- carpus exposed through anterior approach (concomittant CT decompression)
- reduced
- held in place by K wire

96
Q

XR finding of lunate dislocation

A

AP view: lunate appears triangular instead of quadrilateral (crescent moon shape of bone becomes obvious)

lateral view:

  • dislocated lunate tilted forward and displaced infront of radius
  • capitate and metacarpal bones line in line with radius

phase iii orthopaedics (6 decks)

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