Hand and Wrist

Question 1

Examples of hand and wrist injury

Answer 1

-Trauma: distal radius fractures, scaphoid fractures
-Elective: carpal tunnel syndrome, ulnar nerve entrapment, Dupuytren’s contracture, de Quervain’s tenosynovitis

Question 2

General principles of hand and wrist injury

Answer 2

-The radius and ulna function together as a ‘joint’, permitting supination and pronation of the forearm.
=These movements are very disabling if lost

-Like the foot, the bony and ligamentous anatomy of the wrist /carpus is complex, where disruption of one bone can have significant consequences for the wrist as a whole

Question 3

Describe Distal radius fractures

Answer 3

-Very common
-Many associated with fragility
-Several different fracture patterns
=Colles vs Smith vs Bartons
-Avoid eponyms if you’re not sure….just describe what you see!

Question 4

Colle’s vs Smith’s vs Barton’s

Answer 4

-Colle’s: result of fall onto an outstretched hand= dinner fork deformity (dorsally displaced, distal radius fracture) (more common)
-Smith’s fall onto flexed wrist
-Barton’s intra-articular compared to the other two (extra-articular)

Question 5

Management of Colle’s distal radius fracture

Answer 5

-Extra-articular
-Dorsally displaced (dinner fork)

-Management
=Reduce, backslab, XR in 1-2/52
=ORIF if re-displacement

Question 6

Management of Smith’s distal radius fracture

Answer 6

-Extra-articular
-Volarly displaced
-Caused by falling backwards onto palm of outstretched hand or falling with wrists flexed

-Management
=Inherently unstable - ORIF

Question 7

Management of Barton’s distal radius fracture

Answer 7

-Intra-articular
-Displacement – dorsally or volarly
-Radiocarpal dislocation, fall onto extended pronated wrist

-Management
=Inherently unstable - ORIF
=If displaced Volarly, may be referred to as ‘volar Barton’ or ‘reverse Barton’

Reduce fracture if displaced
-Cast 6 weeks/ ORIF with plate and screws for Smith, Barton’s, open fracture etc

Question 8

Describe forearm fractures

Answer 8

-Forearm fractures are also common, especially in children.
-Usually both radius and ulna # in the diaphysis (shaft)
-Some variants to be aware of: MUGGER
=Monteggia – Ulna # with dislocation of the radial head (PROXIMAL)
=Galeazzi – Radius # with dislocation of the DRUJ (distal radioulnar joint) (DISTAL). Bruising, swelling, tenderness lower end of forearm

Question 9

Management of forearm fractures

Answer 9

-Reduce in ED
-Above elbow backslab
-Most adults will require surgery
=This is not necessarily true in children, due to their remodelling potential

Question 10

Describe scaphoid fractures

Answer 10

-Has a retrograde blood supply from dorsal carpal branch (radial) -> union rate reduces as the fracture moves proximally so risk of avascular necrosis
-Acts as a link between the proximal and distal carpal row -> rapid degeneration of the entire wrist follows if the scaphoid is non functional.
-Fall onto outstretched hand: axial compression of scaphoid
-Typically:
=2 : 1♂ ♀
=20 – 30 y/o
=High energy injury

Question 11

Presentation of scaphoid fractures

Answer 11

-Pain (base of wrist) radial aspect of wrist at base of thumb
-+/- swelling (variable)

-+/- swelling (hyperacute or delayed less)
-Snuff box tenderness, scaphoid tubercle tenderness
-Pain worse with wrist movement (ulnar deviation)
-Loss of grip/ pinch strength
-Tenderness of scaphoid tubercle
-Special tests: scaphoid compression test (telescoping thumb so pain on longitudinal compression)

Question 12

Investigation of scaphoid fractures

Answer 12

-X/R – you need specific scaphoid views; if you do not specify, the radiographers will do a AP /lateral only
-CT if ongoing suspicion, planning operative management
-MRI definitive

It is common for the fracture line to be absent initially (~25%)

Question 13

Management of scaphoid fractures

Answer 13

-Cast only (often >12 weeks) undisplaced waist /distal pole # / high clinical suspicion (but no X/R changes)
=Immobilisation with Futuro splint or standard below-elbow backslab
=Referral to ortho

-Surgical fixation for:
=Proximal 1/3rd #
=Displaced # >1mm
=Scaphoid pole

Complications: non-union (pain and early OA), avascular necrosis

Question 14

Risk factors for carpal tunnel syndrome

Answer 14

Compression of the median nerve within the carpal tunnel
=Females 40-60

-Risk factors: TRAPT DM
=Trauma (repetitive motion or vibrations)
=RA (rheumatoid arthritis)
=Pregnancy
=Thyroid disease
=DM
=Oedema (heart failure), obesity
=Lunate fracture

Question 15

Presentation of carpal tunnel syndrome

Answer 15

-Paraesthesia in radial 3.5 digits
=Often initially worse at night
=Shake to obtain relief
=Unusually the symptoms may ascend proximally
=Aching wrist, clumsiness

-Thenar eminence muscle wasting
-Weak thumb abduction (APM weakness in severe cases)- abductor pollicis brevis
-Special tests: Phalen (flexion of wrist), Tinel (tapping causes paraesthesia), Durkan

Question 16

Investigation of carpal tunnel syndrome with differentials

Answer 16

-Clinical
+/- nerve conduction studies (motor and sensory prolongation of action potential in electrophysiology)- atypical history
=EMG (focal slowing of conduction velocity in the median sensory nerves across the carpal tunnel; prolongation of the median distal motor latency; possible decreased amplitude of median sensory and/or motor nerves)

-OA (associated with CTS, painful stiff thumb and wrist worse in evening with tenderness and crepitus: EMG normal)
-Stroke (sensory and motor loss, EMG normal peripheral NS)
-ALS (muscle weakness and atrophy, fasciculations, EMG)

Question 17

Management of carpal tunnel syndrome

Answer 17

-Conservative (first line) 6 week trial
=Treat the cause
=Nocturnal wrist splinting
=Activity modification
-+/- steroid injection
-+/- Carpal tunnel decompression (CTD) if all the above fails (flexor retinaculum division)

Question 18

Epidemiology of OA hand

Answer 18

-There may be a positive family history
-More commonly affects women (M:F 1:3)
-Rare to present before 55 years of age
-Radiologic signs are more common than symptoms
-The presence of hand OA increases the risk of future hip and knee OA (higher for hip OA than for knee OA)

Question 19

Describe nodal arthritis

Answer 19

-Osteoarthritis (OA) of the hands is sometimes referred to as nodal arthritis.
-It results from the loss of cartilage at synovial joints and is often accompanied by the degeneration of underlying bone

Question 20

Risk factors for nodal arthritis/ OA

Answer 20

-Previous trauma of a joint increases the risk of having OA in that joint
-Obesity
-Hypermobility of a joint increases the risk of -OA in that joint
-Occupation e.g. cotton workers and farmers are more susceptible to hand OA
-Osteoporosis reduces the risk of OA

Question 21

Features of nodal arthitis

Answer 21

-Usually bilateral: Usually one joint at a time is affected over a period of several years. The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs).
-Episodic joint pain: An intermittent ache. Provoked by movement and relieved by resting the joint.
-Stiffness
=worse after long periods of inactivity e.g. waking up in the morning
=stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis.
-Painless nodes (bony swellings)
=Heberden’s nodes at the DIP joints
=Bouchard’s Nodes at the PIP joints
=these nodes are the result of osteophyte formation.
-Squaring of the thumbs: Deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb.
-Functionally patients do not usually have any problems. If there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy.

Question 22

Investigations of nodal arthritis

Answer 22

-X-ray: radiologically there are osteophytes and joint space narrowing. Often signs may be visible on X-ray, before symptoms develop

Question 23

OA vs RA

Answer 23

OA
-Mechanical wear and tear: localised loss of cartilage, remodelling of adjacent bone, associated inflammation
-Similar incidence men and women, common elderly
-Large weight baring joints: hip and knee, CMJ, DIP, PIP
-Pain following use, improves with rest, unilateral symptoms, no systemic upset
-LOSS x-ray

RA
-Autoimmune
-More common in women, all ages
-MCP, PIP
-Morning stiffness, improves with use, bilateral symptoms, systemic upset-X-ray: loss of joint space, juxta-articular osteoporosis, periarticular erosions, subluxation

Question 24

Overview of Dupuytren’s contracture

Answer 24

-Prevalence of about 5%.
-It is more common in older male patients and around 60-70% have a positive family history, men on northern EU >40 smoking and diabetes
-Inherited disease of progressive fibrous tissue contracture of palmar fascia

-Specific causes include:
=manual labour
=phenytoin treatment
=alcoholic liver disease
=diabetes mellitus
=trauma to the hand

-Features
=the ring finger and little finger are the fingers most commonly affected

-Management
=consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table (percutaneous fasciotomy/ aponeurotomy)
=Corticosteroid injections

Question 25

Overview of de Quervain’s tenosynovitis

Answer 25

-Common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
-It typically affects females aged 30 - 50/60 years old, typically involves dominant hand, pregnancy, lactation, diabetes

-Features
=pain on the radial side of the wrist, increased with motion
=tenderness over the radial styloid process
=abduction of the thumb against resistance is painful
=Locking
=Swelling and tenderness to radial side
=Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollicis brevis and abductor pollicis longus

Differentials: OA, flexor carpi radialis tenosynovitis, occult fracture, RA

High-resolution USS (effusion, tendon sheath thickening, hyperaemia)

-Management
=analgesia
=steroid injection
=immobilisation with a thumb splint (spica) may be effective
=surgical treatment is sometimes required

Question 26

Complications of Colle’s fracture

Answer 26

-Early
=median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
=compartment syndrome
=vascular compromise
=malunion
=rupture of the extensor pollicis longus =tendon
-late
=osteoarthritis
=complex regional pain syndrome

Question 27

C6 radiculopathy presentation

Answer 27

Sudden onset of severe unilateral neck pain radiating to shoulder/arm/scapula. Associated with weakness (mainly shoulder movements and elbow flexion) and numbness predominantly of the dorsal aspect of first and second fingers and lateral aspect of forearm. Decreased or absent biceps and brachioradialis reflexes.

Question 28

C7 radiculopathy

Answer 28

Sudden onset of severe unilateral neck pain radiating to shoulder/arm/scapula. Associated with weakness (mainly elbow, wrist, and finger extensors) and numbness predominantly of dorsal aspect of third finger. Decreased or absent triceps reflex.