Wrist/Hand Flashcards
Describe Intersection Syndrome
-inflammation where the tendons 1st and 2nd dorsal metacarpal compartment cross.
- It is most common in sports requiring wrist flexion/extension and firm gripping.
Describe Scapholunate ligament injury
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
FCU tendinitis
-inflammation of the FCU tendon along the ulnopalmar region
- happens with sports with repetitive wrist flexion and ulnar deviation
Cheralgia paresthetica
(handcuff palsy)-
Paresthesia and burning pain on the dorsal hand and wrist.
The fingertips are spared.
Anterior Interosseus syndrome:
weakness of pronator quadratus mm
no sensory changes
unable to do OK sign
Scaphoid fractures
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
Game Keepers Thumb
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
Stener lesions
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
Overuse Injuries of wrist
De Quervain’s syndrome
Dorsal impingment syndrome
De Quervain’s syndrome
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
Dorsal impingement syndrome
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.
Terry Thomas sign
The wide space between the scaphoid and lunate In X-ray of scapolunate dislocation
. Scapholunate injuries
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.
Froment’s Sign
-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
Scaphoid Shift Test/ Watson’s Test
forefinger on dorm of wrist, thumb on distal pole of scaphoid, position into extension and radially deviate
+ test; pain with subluxation/ shift
Volkmann’s contracture
-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
Volkmann’s Contracture in forearm symptoms
increasing pain in his forearm, numbness in his fingers, and a cold sensation over his hand
Bennett’s fracture
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.
The role of the central slip of the dorsal extensor tendon is to
Extend the PIP joint
triangular fibrocartilage complex (TFCC) Injury
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
Mallet finger
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.
Keinbock’s disease
AVN of lunate
Boutonniere deformity
DIP is hyperextended and PIP is flexed. The extensor tendons moved volarly
Swan neck deformity
DIP is flexed and PIP is hyperextended.
Jersey finger.
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
Wartenburgs SYNDROME
entrapment of superficial radial N- -only sensory deficits no motor
-pain over the distal radial forearm associated with paresthesia over the dorsal radial hand.
Terry Thomas sign
-large gap btwn scaphoid and lunate
- can see on xray and MRI
-Means scaphoid/lunate lig torn
- instability
Keinbach’s disease
AVN of lunate
see on MRI
Treatment for triceps tendinitis
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.
For return to throwing after med condyle tendinitis:
-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.
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?
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).
FCU tendinitis is:
inflammation of the FCU tendon along the ulnopalmar region in sporting activities with repetitive wrist flexion and ulnar deviation.
Median nerve compression is more frequently seen with carpal tunnel syndrome (ie more distally)
In general, what is the best (or ‘safe’) position for splinting of the hand after injury for prevention of ligamentous and muscular shortening?
Wrist extended,
MCP partially flexed,
IP joint extended,
thumb palmarly abducted.
What is a bennets fractuere?
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.
The role of the central slip of the dorsal extensor tendon is to:
Extend the PIP joint
Claw Hand
Ulnar Nerve injury causing 1sst and 2nd fingers to flex
-paralysis of lumbricals
Ape Hand
limited use of hallux
-damage to median N
-
wrist drop
Radial N injury
Discuss prognosis and healing for TFCC tears
-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.
What is the best (of poor tests) test for a scaphoid fracture?
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.
Describe gymnasts wrist
-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.
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?
mallet finger- Splint the DIP in slight hyperextension with either a custom splint or a commercially available splint for 6 weeks
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.
The role of the central slip of the dorsal extensor tendon is to:
Extend the PIP joint
What is the primary stabilizer of the distal radioulnar joint.
TFCC
FCU tendinitis
inflammation of the FCU tendon along the ulnopalmar region in sporting activities with repetitive wrist flexion and ulnar deviation.
Volkmann’s Contracture presentation once occurs
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
Describe what is found in anatomical snuff box?
radial nerve, scaphoid (and a little bit of trapezium)
can check for radial pulse and scaphoid fracture
Kienbach’s Disease
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
Triangular Fibrocartilage Complex Injury
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
Fracture to what part of scaphoid has highest incidence of AVN
proximal
2/2 path of artery - gets less blood flow
If an athlete has a DIP ext injury but no fracture, is she allowed to play?
Mallet finger injury- can play but must be splinted at all times and stay in extension
FDP avulsion
Jersey finger
Central Slip Extensor Tendon Injury (possible boutonniere deformity)
PIP
forcibly flexed while actively extended
-cannot extend actively
-tender at dorsal middle phalanx
-splint in full ext 6 weeks
