Wrist/Hand

Question 1

Describe Intersection Syndrome

Answer 1

-inflammation where the tendons 1st and 2nd dorsal metacarpal compartment cross.
- It is most common in sports requiring wrist flexion/extension and firm gripping.

Question 2

Describe Scapholunate ligament injury

Answer 2

most commonly injured ligament in wrist
usually 2/2 FOOSH or repetitive grasp
Limits wrist ext (wrist pain with pushup)
typically NO swelling or clicking present

Question 3

FCU tendinitis

Answer 3

-inflammation of the FCU tendon along the ulnopalmar region
- happens with sports with repetitive wrist flexion and ulnar deviation

Question 4

Cheralgia paresthetica

Answer 4

(handcuff palsy)-
Paresthesia and burning pain on the dorsal hand and wrist.
The fingertips are spared.

Question 5

Anterior Interosseus syndrome:

Answer 5

weakness of pronator quadratus mm
no sensory changes
unable to do OK sign

Question 6

Scaphoid fractures

Answer 6

MOI: FOOSH
-tenderness to the anatomical snuff box.
- Initial radiographs are often negative.
**undiagnosed fracture of the scaphoid can lead to avascular necrosis.
Example Presentation:
-Wrist AROM WNL’s but painful -Resisted motions are painful but strong.
-radial side of wrist is very tender to palpation, particularly at the hook of the hamate and the anatomical snuff box.
- Finkelstein’s test and ulnar deviation are particularly painful

If concerned re scaphoid fracture- splint in thumb spica and refer to ortho physician
- best imaging is MRI, CT scan

Question 7

Game Keepers Thumb

Answer 7

Also Skier’s Thumb
Torn Ulnar collateral ligament of thumb MCP joint
-distal phalanx will deviate radially
-can be traumatic (sudden/forcefull ABD of thumb) or repetitive
-sx’s: Pain, swelling, weakness, instability of the thumb, and ifficulty gripping or pinching objects

Question 8

Stener lesions

Answer 8

Seen in context of Gamekeepers thumb
-interposition of the adductor pollicis aponeurosis between the ulnar collateral ligament and the MCP joint
-proximal retraction of the ligament fibers which looks like a small mass displaced superficial to the adductor aponeurosis; this gives the yo-yo on a string appearance both on ultrasound and MR

Question 9

Overuse Injuries of wrist

Answer 9

De Quervain’s syndrome
Dorsal impingment syndrome

Question 10

De Quervain’s syndrome

Answer 10

Inflammation at the site where the first dorsal compartment (APL, EPB) crosses the wrist extensors (ECRL, ECRB) is commonly associated with repeated wrist extension. It is an overuse injury. 
-causes: repetitive lifting of a baby, repetitive twisting (screwdriver), knitting

Question 11

Dorsal impingement syndrome

Answer 11

the capsule (joint lining) becomes thickened and gets pinched in the back of the joint when the wrist is extended. Specifically, the capsule is pinched between the extensor carpi radialis brevis tendon and the scaphoid bone.

Question 12

Terry Thomas sign

Answer 12

The wide space between the scaphoid and lunate In X-ray of scapolunate dislocation

Question 13

. Scapholunate injuries

Answer 13

Most common wrist injury
excessive wrist extension and ulnar deviation with intercarpal supination, such as a fall on a pronated hand
-Can be partial or complete
-common in collision and contact sports or any activity where a fall may occur
-After scapholunate ligament disruption, the scaphoid assumes a flexed position and the lunate and triquetrum extend, producing a dorsal intercalated segment instability pattern.

Question 14

Froment’s Sign

Answer 14

-tests for palsy of ulnar nerve causes weak pincer grip
-tests adductor pollicus
-pinch thumb to radial side of index finger on paper
-if distal phalanx flexes- froment sign

Question 15

Scaphoid Shift Test/ Watson’s Test

Answer 15

forefinger on dorm of wrist, thumb on distal pole of scaphoid, position into extension and radially deviate
+ test; pain with subluxation/ shift

Question 16

Volkmann’s contracture

Answer 16

-when there is a lack of blood flow (ischemia) to the forearm.
caused by increased pressure due to swelling, a condition called compartment syndrome.
frequent site of compression is in the proximal forearm in the area of the supinator muscle and involves the posterior interosseous branch
-presents as of increasing pain in his forearm, numbness in his fingers, and a cold sensation over his hand

Question 17

Volkmann’s Contracture in forearm symptoms

Answer 17

increasing pain in his forearm, numbness in his fingers, and a cold sensation over his hand

Question 18

Bennett’s fracture

Answer 18

most common thumb fracture
-fracture-dislocation of the base of the metacarpal
a proximal metacarpal fragment maintains its ulnar aspect attachment to the trapezium via the volar ligament. The distal aspect of the metacarpal is supinated and dislocated radially by the adductor pollicis. The proximal aspect of this fragment is pulled proximally by the abductor pollicis brevis and abductor pollicis longus.

Question 19

The role of the central slip of the dorsal extensor tendon is to

Answer 19

Extend the PIP joint

Question 20

triangular fibrocartilage complex (TFCC) Injury

Answer 20

Ulnar wrist pain and weakness
-TFCC is primary stabilizer of the distal radioulnar joint
-FOOSH
-common in gymnasts and in racquetball, tennis, and hockey players.
-Pain +/- snapping localized to the radioulnar joint exacerbated by forearm rotation
-Positive piano key sign, as well as a positive shuck test
-Pt has pain with palpation between FCU and ulna styloid

Question 21

Mallet finger

Answer 21

AKA “drop finger”, or “baseball finger
-after injury to extensor mechanism at DIP
-“droop” of the finger into flexion at the DIP. The end of the finger is tipped down.

Question 22

Keinbock’s disease

Answer 22

AVN of lunate

Question 23

Boutonniere deformity

Answer 23

DIP is hyperextended and PIP is flexed. The extensor tendons moved volarly

Question 24

Swan neck deformity

Answer 24

DIP is flexed and PIP is hyperextended.

Question 25

Jersey finger.

Answer 25

Injury to an FDP tendon at its point of attachment to the distal phalanx. “jersey finger” (flexor digitorum profundus injury)
Unable to flex distal joint_ DIP

Question 26

Wartenburgs SYNDROME

Answer 26

entrapment of superficial radial N- -only sensory deficits no motor
-pain over the distal radial forearm associated with paresthesia over the dorsal radial hand.

Question 27

Terry Thomas sign

Answer 27

-large gap btwn scaphoid and lunate
- can see on xray and MRI
-Means scaphoid/lunate lig torn
- instability

Question 28

Keinbach’s disease

Answer 28

AVN of lunate
see on MRI

Question 29

Treatment for triceps tendinitis

Answer 29

She needs to train her triceps and pronator concentrically
This problem often occurs at the acceleration and deceleration phases, which require triceps and pronator to be working concentrically to extend the elbow extension and pronate.

Question 30

For return to throwing after med condyle tendinitis:

Answer 30

-Increase the arc of deceleration from the throwing arm to dissipate forces.
-Increase the throwing arm movement across the body to
dissipate forces.
-Increase forward flexion of the trunk to allow forces to be absorbed by the larger musculature of the trunk and legs.

Question 31

You are analyzing your athlete’s golf swing. He reports wrist pain at the top of the backswing. Which is a likely diagnosis that may be contributing his wrist pain?

Answer 31

De Quervain’s syndrome is tenosynovitis of the first dorsal compartment. It is the most common tendinitis of the wrist developed from activities that require gripping and wrist extension (such as the backswing in golf).

Question 32

FCU tendinitis is:

Answer 32

inflammation of the FCU tendon along the ulnopalmar region in sporting activities with repetitive wrist flexion and ulnar deviation.

Question 33

Median nerve compression is more frequently seen with carpal tunnel syndrome (ie more distally)

Question 34

In general, what is the best (or ‘safe’) position for splinting of the hand after injury for prevention of ligamentous and muscular shortening?

Answer 34

Wrist extended,
MCP partially flexed,
IP joint extended,
thumb palmarly abducted.

Question 35

What is a bennets fractuere?

Answer 35

Bennett’s fracture is the most common of all thumb fractures. It is a fracture-dislocation of the base of the metacarpal. In this injury, a proximal metacarpal fragment maintains its ulnar aspect attachment to the trapezium via the volar ligament. The distal aspect of the metacarpal is supinated and dislocated radially by the adductor pollicis. The proximal aspect of this fragment is pulled proximally by the abductor pollicis brevis and abductor pollicis longus.

Question 36

The role of the central slip of the dorsal extensor tendon is to:

Answer 36

Extend the PIP joint

Question 37

Claw Hand

Answer 37

Ulnar Nerve injury causing 1sst and 2nd fingers to flex
-paralysis of lumbricals

Question 38

Ape Hand

Answer 38

limited use of hallux
-damage to median N
-

Question 39

wrist drop

Answer 39

Radial N injury

Question 40

Discuss prognosis and healing for TFCC tears

Answer 40

-MR arthogram bettter than nonarthrogram MRI DX of TFCC injuries.
-Peripheral TFCC tears have the highest likelihood of healing due to their proximity to the blood supply.
- radial and central tears have a low healing potential and are best treated with debridement.
-racquet sport athletes are often able to return to sports,
-but athletes who ‘WB on hands have a lower rate of return.
-Ulnar variance can play an important role in the success of TFCC treatment.

Question 41

What is the best (of poor tests) test for a scaphoid fracture?

Answer 41

No good test to rule out scaphoid fracture-
. There are no great tests for identifying a scaphoid fracture, but Thumb-and-index pinch test is the best of the selections provided. Has best NEG LR and Pos LR but still not great.

Question 42

Describe gymnasts wrist

Answer 42

-overuse injury that occurs in up to 40% of young gymnasts.
-It usually appears during a period of increased intensity of gymnastic activity, such as when a gymnast moves to a higher competitive level.
-Impact activities like tumbling and vaulting put a large amount of compressive force on the growth plate in the wrist. This repetitive stress leads to inflammation and irritation in the growth plate. If not treated properly, gymnast wrist can lead to premature closure of the radial growth plate, causing the radius to be shorter than the ulna. This resulting asymmetry in length of the two forearm bones results in uneven stress distribution at the wrist with impact activities, leading to chronic pain, stiffness, and difficulty competing in gymnastics.

Question 43

basketball player jammed his right middle finger on the rim during practice. He reports pain, swelling and tenderness over the dorsal aspect of the distal interphalangeal joint (DIP). Your manual muscle test is unremarkable, other than the inability to activity extend the DIP joint. How should this individual be initially managed?

Answer 43

mallet finger- Splint the DIP in slight hyperextension with either a custom splint or a commercially available splint for 6 weeks

Question 44

Sensation along the lateral side of the index finger and the medial side of the little finger is mediated by the median and ulnar nerves, respectively. These areas are reliable because they are unlikely to be altered by variation or by overlapping of adjacent nerves.

Question 45

The role of the central slip of the dorsal extensor tendon is to:

Answer 45

Extend the PIP joint

Question 46

What is the primary stabilizer of the distal radioulnar joint.

Answer 46

TFCC

Question 47

FCU tendinitis

Answer 47

inflammation of the FCU tendon along the ulnopalmar region in sporting activities with repetitive wrist flexion and ulnar deviation.

Question 48

Volkmann’s Contracture presentation once occurs

Answer 48

Paleness of the skin
Muscle weakness and loss (atrophy)
Deformity of the wrist, hand, and fingers that causes the hand to have a claw-like appearance

Question 49

Describe what is found in anatomical snuff box?

Answer 49

radial nerve, scaphoid (and a little bit of trapezium)
can check for radial pulse and scaphoid fracture

Question 50

Kienbach’s Disease

Answer 50

AVN of lunate
Cause: Unknown; thought to be from a fall
Exam: Pain similar to sprained wrist, stiffness, decreased grip strength, pain with turning hand upward
Treatment: Early intervention is immobilization in cast, in progressed cases may need fusion or removal

Question 51

Triangular Fibrocartilage Complex Injury

Answer 51

Cause: FOOSH, rotational injury, repetitive axial loading
Exam: Ulnar sided wrist pain, crepitus, pain with gripping and radial deviation, shuck test, shear test, TFCC grind
test, press test
Imaging: PA, lateral, oblique w/shoulder abduction
Treatment: Wrist braced 4-6 weeks, return to sport ~ 3 months

Question 52

Fracture to what part of scaphoid has highest incidence of AVN

Answer 52

proximal
2/2 path of artery - gets less blood flow

Question 53

If an athlete has a DIP ext injury but no fracture, is she allowed to play?

Answer 53

Mallet finger injury- can play but must be splinted at all times and stay in extension

Question 54

FDP avulsion

Answer 54

Jersey finger

Question 56

Central Slip Extensor Tendon Injury (possible boutonniere deformity)

Answer 56

PIP
forcibly flexed while actively extended
-cannot extend actively
-tender at dorsal middle phalanx
-splint in full ext 6 weeks