wrist & hand Flashcards
side effects of H&L injection
1) hypopigmentation of skin
2) lipoatrophy
3) infection
4) tendon rupture
5) nerve injury
hand indications for H&L
1) RA
2) CTS
3) trigger finger
4) de quervain’s tenosynovitis
classification of nerve injury
seddon’s classification
seddon’s classification of nerve injury
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
sunderland classification of nerve injuries
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
motor supply of AIN
1) flexor pollicis longus
2) radial 1/2 of FDP
3) pronator quadratus
motor supply of median nerve proper
1) PT
2) FCR
3) FDS
4) PL
5) L1, L2
motor supply of recurrent motor branch of median nerve
thenar muscles
1) APB
2) OP
3) FPB
significance of APB
APB is the thena muscle solely supplied by median nerve 99% of time (FPB, OP may receive cross supply from ulnar nerve)
positive phalen’s sign
numbness felt over radial 3.5 digits reproduced when hands togged in inverted prayer position
common areas of lesion for median nerve
1) high lesion - pronator tunnel syndrome
2) AIN lesion = trauma at elbow/forearem
3) low lesions - carpal tunnel/cut at wrist
signs of HIGH median nerve lesion
= 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
why can middle finger flex in lesion of median nerve? (radial 0.5 of FDP by AIN)
small/ring/middle finger share a common FDP body
signs of AIN lesion (median nerve)
- loss of FPL, PQ, radial half of FDP (might have partial benediction sign)
- no sensory loss (AIN has no cutaneous innervation)
signs of LOW lesion of median nerve
- 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)
anatomical boundaries of carpal tunnel
radial side: scaphoid + trapezium
ulnar side: pisiform + hook of hamate
volar: flexor retinaculum
contents of carpal tunnel
flexor digitorum profundus (4) flexor digitorum superficialis (4) flexor pollicis longus flexor carpi radialis tendon median nerve
pathophysiology of CTS
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
causes of CTS
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
differentials for CTS
1) cervical nerve root lesion
2) thoracic outlet syndrome
3) AIN syndrome (sensory intact!)
management of CTS
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
complications of CT release
1) scar
2) failure of relief
3) nerve injury: palmar cutaneous branch of median nerve (supf to flexor retinaculum) and motor branch of thenar
why is there sparing of sensation at dorsum of hand in ulnar nerve lesion at wrist?
cutaneous branch to dorsum of hand given off before the wrist
motor supply of ulnar nerve proper
1) ulnar 1/2 of FDP
2) FCU
motor supply of deep motor branch of ulnar nerve
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
wartenburg sign
little finger abducted as adduction ability of dorsal interossei lost
- extension action of extensor digiti minimi pulls little finger into abduction
common sites of lesion of ulnar nerve
1) high lesion - cubital tunnel, ulnar subluxation
2) low lesion = wrist laceration, guyon’s canal
signs of HIGH ulnar nerve lesion (majority)
- 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
first sign of ulnar nerve lesion
wasting of 1st dorsal interosseous muscle
management of high ulnar nerve lesion
1) anterotransposition
2) cubital tunnel release
signs of LOW ulnar nerve lesion (deep motor branch of ulnar)
- 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
why middle and index finger not flexed in ulnar claw?
lateral lumbricals supplied by median nerve
management of cubital tunnel syndrome
1) simple decompression
2) medial epicondylectomy (if a/w non union of epicondyle fracture)
3) anterior tranposition of ulnar nerve
motor supply of radial nerve
1) posterior interosseous nerve
2) radial nerve proper
muscles innervated by PIN
1) ECRB
2) supinator
3) EDC
4) EDM
5) extensor indicis
6) ECU
7) EPL
8) EPB
muscles innervated by radial nerve proper
1) triceps
2) brachialis
3) brachioradialis
4) ECRL
most distal extensor muscle supplied by PIN
extensor indicis
second most distal extensor muscle supplied by PIN
EPL (if EPL function intact, all other muscles supplied by radial nerve should be intact)
common sites of radial nerve lesion
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)
signs of VERY HIGH radial nerve lesion
- wrist drop
- finger drop
- sensory loss over anatomical snuffbox + dorsum of lateral 3.5
- muscle wasting over forearm extensor compartment + triceps (very high lesion)
signs of LOW radial nerve lesion > injury to PIN
- finger drop: inability to extend MCP joints and thumb
- radial deviation (ECU knocked out)
where is PIN given out
between 2 heads of supinator @ level of elbow
differentials for cystic and soft lumps
1) ganglions
2) lipomas
3) vascular malformation
differentials for firm lumps
1) neuroma
2) PVNS
3) fibroma
differentials for hard lumps
1) osteochondroma
2) bone tumors
description for characteristics of a lump
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
common sites for ganglion
1) dorsal wrist - scapholunate junction
2) volar wrist - scapholunate, scaphotrapezoid
3) volar MCPJ
4) dorsal DIPJ
significance of big ganglion cyst in GH joint
almost always associated with rotator cuff tear
treatment for ganglion
1) conservative: usually resolves spontaneously after some months
2) surgery
- aspiration (high recurrence)
- excision if recurrence: cosmesis/pain
commonest hand lump
ganglion
types of PVNS
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
alternative name for PVNS
giant cell tumor of tendon sheath
most common site of PVNS
volar aspect near DIPJ (often index and middle)
XR findings of PVNS
secondary OA changes!
- joint swelling
- periarticular erosions
- joint space narrowing
- subchondral cyst
- osteophyte formation
treatment of PVNS
synovectomy
if refractory to repeated surgery: low dose RT
commonest primary bone tumor of hand
enchondroma
causes of ruptured extensor pollicis longus
1) colle’s fracture
2) RA
treatment of ruptured extensor pollicis longus
tendon transfer
pathoanatomy of boutonneire deformity
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
treatment of boutonneire deformity
post traumatic: repairable chronic deformity (RA): unrepairable
swan neck deformity
flexion deformity of DIPJ (+hyperext of PIPJ) due to imbalance of extensor vs flexor action in finger
treatment of swan neck deformity
tendon rebalancing + joint stabilsation
tendons in first extensor compartment
abductor pollicis longus + extensor pollicis brevis
tendons in 2nd extensor compartment
extensor carpi radialis longus + brevis
point of tenderness in de quervain’s disease (1st extensor compartment)
tip of radial styloid
point of tenderness in tenosynovitis of 2nd extensor compartment
just medial to anatomical snuffbox
positive finkelstein test
1) CMCJ OA
2) de quervain’s tenosynovitis
management of de quervain’s tenosynovitis
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
complications of tendon sheath release for de quervain’s tenosynovitis
1) infection
2) superficial radial nerve palsy
3) snapping of extensor tendon
4) APL + EPB adherence
differentials for radial sided wrist pain
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
common fingers involving in trigger finger
ring, middle, thumb of dominant hand
risk factors for trigger finger
1) overuse
2) trauma
3) DM
4) RA
5) gout
classification for trigger finger (stenosing tenovaginitis)
green’s classification
stages in green’s classification
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
differential diagnosis for trigger finger
- RA
- septic arthritis
- suppurative tenosynovitis
- tumor of tendon sheath
- dislocation
- dupuytrens contracture
management of trigger finger
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)
clinical sign of infectious tenosynovitis of flexor tendon sheath in hand
kanavel’s sign
describe kanavel’s sign
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
most common organism implicated in infection of the hand
s. aureus
management of hand infections
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
management of suppurative tenosynovitis
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
commonest complication of hand fracture
tendon adhesion
complications of wrist fracture
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
cause of deformity post hand fracture
malunion
most commonly fractured carpal bone
scaphoid (75%)
scaphoid fracture extra/intra articular
ALWAYS INTRAarticular
investigations for scaphoid fracture
1) XR
- 5 views: AP, lateral, scaphoid, 2 oblique (semipronated + semisupinated)
2) MRI
- diagnosis of occult scaphoid fracture + AVN
management of scaphoid fracture
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
complications of scaphoid fracture
1) AVN of proximal pole > secondary radiocarpal OA
- blood supply of proximal pole: radial artery
2) non union
3) OA
management of AVN of proximal pole of scaphoid
1) removal entire proximal row of carpal bones (carpectomy)
2) remove scaphoid + fuse proximal to distal row (4 corner fusion)
MOI of mallet finger
rupture of extensor tendon of terminal phalanx as fingertip forcibly bend during active extension
management of mallet finger
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
management of displaced metacarpal shaft fracture
ORIF with plates/K wire
complications of lunate/perilunate dislocation
1) difficulty in reduction > AVN > secondary OA
2) CTS
3) improper periunate reduction > secondary lunate dislocation
management of lunate/perilunate dislocation
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
XR finding of lunate dislocation
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
