Wrist/Hand Complaints Flashcards
Anatomy & Biomechanics
1—Stability is primarily ____________
2—Carpal bones divided into distal and proximal rows
ligamentous
Anatomy & Biomechanics
3–Extrinsic and intrinsic connections
4–________ does most of the axial weight bearing
Radius
Anatomy & Biomechanics
5–2nd and 3rd metacarpals: ________ joints of the hand
stabilizing
Conditions that Need Immediate Referral
1) SCAPHOID fx
2) _________ forearm fx
3) Carpal instability
4) Avascular necrosis = AVN
5) _________ ___________ tear
Distal
Triangular fibrocartilage
Evaluation of Pain
ANTERIOR? 1) \_\_\_\_\_\_\_\_\_\_\_ dislocation 2) Carpal instability 3) \_\_\_\_\_\_\_\_\_\_\_\_ fx 4) Nerve entrapment: A) Median- = \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ B) Ulnar = \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_
Lunate
Hamate
carpal tunnel syndrome
Tunnel of Guyon
Evaluation of Pain
POSTERIOR?
1) ___________ fx
2) Carpal instability
(yes, I’m aware it is listed under both—I’m not doing any more pushups)
3) _______________ syndrome
4) Tendonitis (non-specific)
5) Radial nerve entrapment (Wartenberg’s)
Scaphoid
de Quervain’s
History of Trauma?
A) Fall on an outstretched hand
1) Consider ___________ fracture
(especially if pain in “anatomical snuff box”)
2) Triangular fibrocartilage damage at ________ side
3) Other fractures may occur
scaphoid
ulnar
Weakness upon Presentation?
1—Often reported as “difficulty gripping”
—Check power (_________ nerve)
and precision (________ nerve) grip ability
2—Pain will often cause weakness
ulnar
median
Instability?
1—-Associated with a sense of __________, or simply the misinterpretation of a sense of clumsiness
2—Usually the result of trauma, but can be seen in patients with generalized ________
weakness
laxity
Restricted Motion?
1—Decreased AROM & PROM indicates joint effusion
2—No trauma = Inflammatory arthritis
3—YES!!! TRAUMA!!! = Consider _______ or dislocation
fracture
Superficial Complaints?
1–Painful nodules on the dorsal wrist
If a history of chronic repetitive motion →_______ likely
2—Multiple nodules & swelling over the dorsum with pain and stiffness → _________ ___________
3—Skin lesions?
Usually systemic conditions (rheumatic fever or RA)
Ganglions
Rheumatoid arthritis
History & Evaluation
A--Pain, swelling, restricted motion, weakness B--VIPPPIRONE C--Nodules? 1) Ganglion cysts 2) RA nodules 3) Lipomas D--Power grip (assess integrity of \_\_\_\_\_\_\_\_ nerve) E--Precision grip (\_\_\_\_\_\_\_\_ nerve) F--2-point discrimination
ulnar
median
Ulnar Variance
Negative ULNA IS LOWER THAN RADIUS
&
Positive ULNA IS HIGHER THAN RADIUS
KNOW
Distal Motor Function Testing
A—Radial N.- Finger _____________
Hand Postures:
1) Median nerve- “_______ _______”
(extensor muscles draw thumb parallel with fingers; patient loses ability to flex or oppose the thumb)
2) Mixed Ulnar/Median- “Bishop/Benediction” hand (predominantly median pathology)
3) Ulnar nerve- “Ulnar claw”
(the posture of the finger is FLEXED PIP and DIP joints being more pronounced in the 4th and 5th digits)
extensors
Ape hand
Carpal Instability-Scapholunate
1—_____________ is the #1 instability in the wrist (Lunotriquetral #2, Triquetrohamate #3)
2–Usually from __________
3—Tearing of the interosseous ligaments and radiocarpal ligaments (palpable instability
4—Watson’s test will be positive
Scapholunate
FOOSH
Carpal Instability-Scapholunate (cont.)
- –For scapholunate: Terry Thomas sign will be present (>=___mm space)
- –_______&____________ if significant widening
- –Don’t be afraid to re-x-ray in 2 weeks if x-ray normal and no improvement
3
Casted and surgical
Triangular Fibrocartilage Injury
1—_____ side wrist pain (increased with ____ deviation)
2—Associated with a + ulnar variance
3—Tear or degeneration within meniscus
4–+ TFC test
5–+ MRI
6–Able to treat this (surgical if not improved)
Ulnar
ulnar
SLIDE 22
DeQuervain’s Disease/Stenosing Tenosynovitis
1–Radial wrist pain increased with ______ deviation or repetitive THUMB use
2–Overuse microtrauma or forceful grip
3–May radiate into thumb or up forearm a little
4–Abductor Pollicus Longus (APL) & Extensor Pollicus Brevis (EPB)
5–Tenderness to palpation
ulnar
DeQuervain’s Tenosynovitis
1—-+ Finkelstein’s test
2—-Pain on resisted thumb _________/_________
3—Tx w/ CMT thumb distraction, PT, cortisone, thumb spike
extension/abduction
Intersection Syndrome
1—____________ distal forearm pain and crepitus
2–Inflammatory response to 2 muscles intersecting- APL & EPB mm
3–From repetitive flexion/extension
4–Tender 4-6 cm proximal to Lister’s tubercle
5–Tx as ___________
Dorsoradial
tendonitis
Peripheral Nerve Entrapments Near the Wrist
1---\_\_\_\_\_\_\_\_ N. Carpal tunnel syndrome 2---\_\_\_\_\_\_ N. Tunnel of Guyon syndrome 3---\_\_\_\_\_\_\_ N. Wartenberg syndrome (Cheiralgia Paresthetica, “handcuff neuropathy”, etc.)
Median
Ulnar
ULNAR
Carpal Tunnel Syndrome
1–Most common upper extremity neuropathy
2–Increase in FEMALE > 40 y.o.
3–50% are _____________
4–Pain/numbness/tingling in the PALMAR surface of the thumb, plus 2½ fingers
5–Secondary to direct pressure on ________ nerve from repetitive flexion/extension, transverse carpal ligament, ganglion, inflammation
6–Also seen in pregnancy, RA, connective tissue diseases, diabetes
bilateral
median
History & Evaluation of CTS
–With pain & paresthesia there is a complaint of clumsiness with precision grip
–Worse at NIGHT
+ Phalen’s/reverse Phalen’s
+ Tinel’s?
–Weak pinch test
–Weak opposition/precision grip
–Weak Jamar
–_________ atrophy if chronic
Thenar
Management of CTS
- -Splint in rest position of wrist
- -Vitamin C, Bs
- -Adjust _________ A-P (to induce distal radioulnar approximation) and C/S
- -Ergonomic advice (mouse, keyboard, chair, etc.)
- -Surgical usually only if + EMG findings
lunate
