Wrist/Hand Flashcards
1
Q
of metacarpals and phalanges
A
5 metacarpals
14 phalanges (each finger with 3, thumb with 2)
-base of each met is concave and head is convex
2
Q
Thumb joint
A
-metacarpal has saddle shaped articular surface to accommodate trapezium
3
Q
8 carpal bones
A
Distal: trapezium, trapezoid, capitate, hamate
Proximal row: scaphoid, lunate, triquetrum
4
Q
Scaphoid
A
- bridges the mid-carpal joint and is susceptible to fracture
- receive it’s blood supply from a distal to proximal direction making proximal portions susceptible to avascular necrosis
- long with a narrowed waist - “boat shaped” appearance
- PA view
- lateral radiograph shows normal resting alignment is flexed position compared to lunate
5
Q
Lunate
A
- PA view - quadrangular appearance
- lateral view - more crescent shaped
- Kienbock’s disease- avascular necrosis of the lunate
6
Q
Triquetrum
A
- large triangular shaped bone on ulnar side of proximal row
- pisiform is superimposed on the triquetrum
7
Q
Hamate
A
- unique hook extending volarly
- hook is attachment point for flexor retinaculum on ulnar side
- painful fractures
8
Q
capitate
A
- largest of the carpal bones
- keystone of transverse arch of wrist
9
Q
Trapezoid
A
-very stable articulation with 2nd MC (2nd CMC joint), the capitate, and trapezium = most stable articulation of the carpus
10
Q
Trapezium
A
- found at base of thumb - location of mobile 1st CMC joint
- distal surface is saddle joint matching the base of the MC
- most mobile bone in the distal row
11
Q
Ulnar variance
A
- negative ulnar variance associated with Kienbock’s disease
- positive ulnar variance may lead to degenerative changes of TFCC
12
Q
Triangular fibrocartilage
A
- meniscus
- susceptible to degenerative changes and acute tears
- attaches medially to base of ulna styloid
13
Q
DIP and PIP joint supports
A
- articular capsule
- fibrous collateral ligaments
- thinner fan-like accessory ligaments
- volar plate
14
Q
Volar plate
A
- thick and broad at the base of the distal bone of each joint, but form thinner long extensions onto proximal bone (“check reins”)
- volar plate of PIP joints can avulse with hyperextension injuries or dislocations
15
Q
Collateral ligaments
A
- taut in flexion and extension for DIP
- taut only in extension for PIP
16
Q
Hberden’s nodes and Bouchard’s nodes
A
Heberden’s nodes = DIP joint
- Bouchard’s nodes = PIP joints
- OA
17
Q
MP joints
A
- biaxial joints with flexion/extension as well as abd/add
- collateral ligaments attach dorsolaterally on MC head and travel distally to volar lateral surface of proximal phalanx
- collateral ligament is taut in flexion, but relaxed in ext
18
Q
Normative values - pronation/supination
A
80-90*
19
Q
Normative values - wrist flex/ext
A
Flex - 90*
Ext - 80*
20
Q
Normative values - radial/ulnar deviation
A
Radial - 15-20*
Ulnar - 20-30*
21
Q
Normative values - MC joint flex/ext
A
Flex - 85-90*
Ext - 30-45*
22
Q
Normative values - MC abd/add
A
Abd - 20-30*
Add - 0*
23
Q
Normative values - PIP Flex/ext
A
Flex - 100-110*
Ext - 0*
24
Q
Normative values - DIP Flexion
A
70-80*
25
Normative values - Thumb CMC joint flex/abd
Flex - 20*
| Abd 50-55*
26
Normative values - thumb MCP joint flex/ext
Flex - 50-55*
| Ext - 0*
27
Normative values - Thumb IP Joint flex/ext
Flex - 80-85*
| Ext - 0*
28
1st CMC joint
- 1st MC and trapezium
| - biaxial motion of palmar abduction
29
Dorsoradial ligament
- strongest ligament for the 1st CMC joint
| - major stabilizer to prevent dorsal subluxation of 1st MC
30
50% of wrist flex/ext occurs at which joints
inter-carpal or mid-carpal joint and radiocarpal joint
31
Weak link of the wrist
proximal carpal row
32
Extrinsic extensor compartments mneumonic
221211
of extensors within each of 6 compartments
33
1st compartment
- APL
- EPB
- dequervain's
34
2nd compartment
- ECRL
| - ECRB
35
3rd compartment
EPL
36
4th compartment
ED
| -EI
37
5th compartment
-extensor digiti minimi (or quinti)
38
6th compartment
- ulnar most tendon
| - ECU
39
Extrinsic flexors of the wrist
- FCU
- FCR
- FDP
- FDS
FDS tendons stack on top of FDP tendons in 2 rows of 2
40
FDS tendons
- split into 2 slip with seach attaching to a ridge on the edges of the volar middle phalanx
- FDP tendon passes through the middle of these 2 slips to attach to the distal phalanx base
41
Pulleys
- arranged in an X - "cruciate pulleys"
- or arranged in a circle - "annular pulleys"
- 3 cruciate pulleys: C1, C2, C3
- 5 annular pulleys - A1-A5
MOST IMPORTANT: A2 and A4 - these maintain integrity of system
42
Dorsal interrossei
- group of 4 bipennate muscles arising from metacarpals and inserting on proximal phalanges
- abduct index and ring finers away from long finger
43
Palmar interossei
- group of 3 unipennate muscles arising from MC of index, ring, and small fingers
- attach to base of each proximal phalanx
- 1st palmar interossei is found on ulnar side of 2nd MC and acts to adduct index finger
- 2nd and 3rd arise from radial sides of ring and small MCs and adduct fingers towards long finger
44
Hypothenar intrinsic muscles
- abductor digit minimi
- flexor digiti minimi
- opponens digiti minimi
45
Thenar eminence
4 muscle groups:
- APB
- opponens pollicis
- FPB
- AP
46
Anterior interosseous nerve
- from median nerve
| - innervates FPL, FDP to index and long fingers, and pronator quadratus
47
Ulnar nerve
- travels through cubital tunnel an dinnervates FCU and FDP to ring and small fingers
- divides into superficial and deep branch when it enters guyon's canal
48
Radial nerve
- ECRL
| - posterior interosseous nerve innervates all other dorsal extrinsic muscles
49
TTP radial styloid
- fracture
- de quervain's
- arthritis
- radial nerve neuritis
50
TTP scaphoid
- fracture
- AVN
- scapholunate ligament injury
51
TTP thumb
- fracture
- sprain/tendon injury
- gamekeeper thumb (ulnar aspect of thumb MP joint)
52
TTP 1st CMC joint
-OA
53
TTP scaphoid-trapezium-trapezoid joint
-scaphoid-trapeziium-trapezoid synovitis or arthritis
54
TTP 1st dorsal compartment (APL, EPB)
- de quervain
| - tendon rupture
55
TTP 3rd dorsal compartment (EPL)
-EPL tendon rupture or tendonitis
56
PROM > AROM more than 10*
-weakness or tendon adhesions
57
AROM = PROM
-similar and accompanied by capsular end feel = joint or capsular restriction
58
Grip dynamometer - 5 handle positions
-when using all 5 positions, a graph of grip measurements should form a bell shaped curve if patient exerts maximal effort and has no median or ulnar nerve injury
59
Finkelstein test
-De Quervain's
+ = produes pain
-perform in stages
-sn 100%, sp 100%
60
Differentiating de quervain's from intersection syndrome
- by noting location of patient's symptoms
- in intersection syndrome, patient will c/o pain 4 cm from wrist, more proiximal than dorsal and then 1st dorsal compartment
- also test for intersection syndrome by resisting wrist extension
61
1st CMC grind test
- compress 1st MC into trapezium using axial load and rotate
| - sn 42-53%, sp 80-93%
62
Scaphoid shift test
- palpate scaphoid tubercle and passively ulnar deviate and extend patient's wrist
- while applying pressure, move into radial deviation and flexion
- relief of pressure causes scpahoid to reduce with palpable clunk
- + = clunk and recreates patient's symptoms
- sn 69%,, sp 66%
63
Scapholunate ballottement test
-patient's forearm pronated
-stabilize lunate with thumb and index finger, with other hand grasp scaphoid and move scaphoid on lunate dosrally and volarly
+ = recreates patient's pain, laxity, crepitus
64
Finger extension test
-patient's wrist and MP joints flexed, resist long finger extension at MP joint
+ = pain in 3rd and 4th dorsal compartments indicates an occult dorsal wrist ganglion
-sn 100%
65
Scaphotrapeziototrapezoid joint instability/arthritis
-patient's wrist and forearm in neutral
-apply pressure to scaphoid tubercle while radially and ulnar deviating the wrist
+ = pain
66
Lunotriquetral ballottement test
-forearm pronated, palpate lunate with 1 hand and pisotriquetral complex with other - move pisotriquetral complex dorsally and volarly while stabilizing lunate
+ = pain or laxity/clicking/crepitus
-sn 64%, sp 44%
67
Ulnar fovea sign
-disruptions of DRUJ ligaments
-patient's wrist and forearm in neutral, palpate "soft spot" bw ulnar styloid, FCU tendon, volar surface of ulnar head and pisiform
+ = pain
-Sn 95%, sp 87%
68
TFCC load
- ulnarly deviate wrist and apply an axial load through wrist and ulna, move carpals on ulna volarly and dorsally
- + = reproduces pain or leads to crepitus
69
Ulnocarpal instability
- suspennt's forearm in pronation away from exam table - observe position of carpals in relation to ulnar styloid
- + = ulnar aspect of carpals "sag" volarly and a prominent ulnar head
70
Pisiform boost test
- forearm in a vertical position and neutral rotation - push pisiform dorsally while translating ulnar head volarly
- + = reproduces patient's symptoms or excess laxity
- Sn 66%, sp 64%
71
Piano key sign (DRUJ instability)
- patient's forearm in neutral, stabilize radius and press ulnar styloid in a volar direction
- when pressure is released, + = ulna will "spring" back up to its original position
72
Piano key test (DRUJ balottement)
- stabilize radius and apply volar and dorsal overpressure to the ulna in pronation, supination, and with forearm in a neutral position
- compare bilaterally and compare for pain/laxity
- + = pain or laxity
73
(B) test for subluxation of DRUJ
- forearm in pronation, palpate dorsal DRUJ with index finger and place long fingers on ulnar head - rotate patient's forearms
- compare movement between raidus and ulna between the 2 sides
- sn 90-100%
74
Ulnar compression test (DRUJ inflammation or arthritis)
- comperss ulnar head into sigmoid notch of radius
- combine compression with pronation and supination
- + = patient's symptoms
75
Extensor carpi ulnaris sublux
-palpate ECU tendon with wrist in slight ulnar deviation, have patient slowly rotate forearm
+ = ECU tendon snaps or pain
76
Midcarpal instability
-patient's wrist in neutral and forearm in pronation, apply volar directed force at capitate and simaltaneously load the wrist axially and ulnarly deviate
+ = painful clunk
77
Pisotriquetral grind test
- palpate pisiform and apply a dorsal pressure - apply a volar counter pressure to triquetrum
- + = pain
78
Ulnar collateral ligament stress test (skier thumb or gamekeeper thumb)
-apply a valgus stress to MP joint of thumb at 0* and 30* flexion, laxity of greater than 30-40* with valgus stress or more than 15* greater than CL side = positive for rupture
79
Collateral ligament stress test
- most often used to test integrity of collateral ligament of PIP joints
- examine UCL - apply valgus force to joint
- examine radial collaeral ligament - apply varus force
- perform with joint in 0* ext and 30* PIP flexion
- + = pain or laxity
80
bunnel - littler test (intrinsic muscle tightness or contracture)
-hold patient's wrist in extension an dMP joint of test finger in hyperextension
-measure passive PIP joint flexion
-flex MP joint and reassess PIP joint flexion
+ = PIP joint motion increases with MP joint flexion
81
Allen test (vascular disorder)
- ask patient to open and close fist several times while compression radial and ulnar arteries at the wrist
- ask patient to open hand - should be white and blanched
- release one of the arteries and observe bblood flow back into the hand
- repeat entire process for other artery
- + = sluggish revascularization or does not revascularize
82
Tinel sign for CTS
- tap over median nerve at carpal tunnel
- + = reproduction of paresthesia
- sn 50%, sp 77%
83
Tinel sign for cubital tunnel syndrome
- tap over cubital tunnel between medial condyle of humerus and olecrenon
- + = paresthesia in ulnar nerve distribution
- sn 54%, sp 99%
84
Tinel sign for compression at superficial sensory branch of radial nerve
- tap at the radial styloid
| - + = paresthesia in corresponding nerve distribution
85
Phalen test (CTS)
- extension patient's elbow and allow the wrist to flex and fingers to extend for 60 seconds
- result in (+) if paresthesia develops
- sn 68%, sp 73%
86
OK sign (AIN lesion)
-patient makes OK sign
-look for IP joint flexion of thumb and DIP joint flexion of index finger
+ = patient brings
87
Froment sign
- ulnar nerve lesoin
- have patient hold index card using key pinch and try to pull card away
- positive = ip joint of thumb flexes indicating use of FPL muscle due to weakness or loss of aP and FPB (deep head) muscles
88
Scratch collapse test
-nerve lesion
-scratch patient's skin over the area supplied by the nerve with suspected compression, while patient performs resisted shoulder ER bilaterally.
+ = brief loss of muscle resistance
89
Tendon injury - surgery
read about this
90
most commonly fractured bone in the body
- distal phalanx of digits
91
Tuft fractures
- distal phalanx fractures
| - often comminuted
92
Mallet finger deformity
- terminal tendon of extensor mechanism is disrupted
| - could be just soft tissue or could be bone avulsed
93
Jersey finger injury
- volar surface of distal phalanx
- tear of the insertion of FDP
- commonly occurs on ring finger
- MOI: active fisting action of the fingers (grabbing a jersey) following by an agressive force into finger ext
94
Phalangeal fractures
- 50% of hand fractures
| - stable fractures can be buddy taped
95
Angle of proximal phalanx shaft fractures
volar direction in part due to tension from intrinsic motors
96
Boxer fracture
- most common metacarpal fracture
- metacarpal neck fracture (most commonly small finger)
- MOI: punch with clinched fist into a solid object
- flexion of distal fragment
97
Metacarpal shaft fractures
-typically displaced with the apex-dorsal due to pull of intrinsic muscles
98
Bennett fracture
-fracture dislocation of thumb metacarpal - intraarticular CMC joint
99
Rolando fracture
- base of thumb MC
- 2 or more fragments on the articular surface
- comminuted
100
Scaphoid fracture
- 70% occur at waist of bone
- most frequently fractured carpal bone
- can result in SNAC wrist deformity
101
SNAC
scaphononunion advanced collapse wrist deformity
102
Hamate fracture
- occur at the hook most often due to compressive force transmitted through the base of the palm or shear during forceful torque of the wrist
- conventional radiographs don't show the fracture
- carpal tunnel view (wrist and fingers in full extension and beam angled through carpal tunnel) is required
103
Colles fracture
- extraarticular fracture occurring 1.5-2 inches proximal to articular surface of distal radius
- dorsal angulation with traction injury to volar surface of bone
104
4 basic stages of ligament tears leading to lunate instability
1. minor sprain to palmar aspect of SL ligament without total disruption
2. continuing force, causing dissociation of the SL ligament
3. continuing hyperextension causes additional force through the wrist
4. radioscaphocapitate ligament forces the capitate to collapse into radiocarpal space and push lunate in palmar direction
Lunate frequently spontaneously reduces leaving little evidence of dislocation other than recurring pain
105
S/S associated with most common patterns of the SL dissociation
1. TTP over scaphoid tuberosity, waist, or scapholunate joint line
2. laxity of the scapholunate joint during a ballotment test
3. significant scaphoid shift exam
4. radiographic evidence
Symptoms:
1. pain on radial side of wrist at rest or w/ activity
2. complaints of decreased grip strength
106
UCL sprain of thumb
- hyperextension with radial deviation
- "skier's thumb" = acute version
- "gamekeepers thumb" also used to refer to this
107
PIP joint sprain grades
I - produce tensile stress in a collateral ligament, but do not disrupt the coninuity of the ligament
II - more unstable and involve a complete ligament tear or avulsion, but still stable during AROM
III - complete ligament rupture as well as an injury to the volar plate or dorsal capsule
108
Ganglion cysts
- most common soft tissue mass in wrist and hand
- 10-15% associated with predisposing traumatic event
- begin small and gradually increase in size
- most common develops at the SL joint
109
Dupuytren disease
- fibropoliferative disease of digital and palmar fascia
- cords form and extend distally and proximally
- cords shorten and thicken causing flexion contractures
- painful and self limiting
- genetic and environmental factors
- male, northern European descent
110
de Quervain's
- APL and ePB
- thickening of tendon sheaths and accumulation of mucopolysaccharides
- clinical presentation includes c/o pain, tenderness, finkelstein's, resisted thumb extension
111
Trigger finger
-stenosiing tendovaginitis that includes snapping or locking of finger or thumb during flexion w/ or w/o pain
112
Nerve injuries
-review
