9. Wrist Hand Peripheral Nerves Flashcards
(104 cards)
1
Q
Posterior Compartment of the Forearm Muscles
2 layers
A
Superficial
Deep
2
Q
Superficial Layer: Brachioradialis
A
- Forms lateral border of cubital fossa
- Superficial on anterolateral forearm
• Posterior compartment muscle that flexes elbow (Does not cross wrist) - insert just before wrist
- P: Lateral Supracondylar ridge of humerus
- D: Lateral surface of distal radius, proximal to styloid process
- I: Radial nerve (C5,6,7)
- A: Weak flexion of forearm (esp midpronated)
Beer drinking muscle – action of holding and drinking beer
3
Q
Superficial Layer: Extensor Carpi Radialis Longus
A
Inferior to brachioradialis
- P: Lateral Supracondylar ridge
- D: Dorsum of base of 2nd metacarpal
- I: Radial nerve (C6,7)
• A: Extend and abduct hand at wrist joint (radially deviates)
4
Q
Superficial Layer: Extensor Carpi Radialis Brevis
A
• Shorter than longus above – arises more distally
- P: lateral epicondyle (common extensor origin)
- D: Dorsum of base of 3rd metacarpal
- I: Deep branch of radial nerve (C7, C8)
- A: Extend and abduct hand at wrist joint
- Important (esp ECRL) for clenching fist/ tight grip finger flexion – gripping something tightly you extend your wrist
- ECRL and ECRB can act synergistically with FCR to produce pure abduction
5
Q
Superficial Layer: Extensor Digitorum
A
• Occupies much of posterior surface of forearm
- P: lateral epicondyle (common extensor origin)
- D: Extensor apparatus of fingers
- I: Deep branch of radial nerve (C7, C8)
• A: Extends fingers, primarily at MCPJs (also extends other joints) meta carpal pharyngeal joints
6
Q
Superficial Layer: Extensor Digiti Minimi
A
- P: lateral epicondyle (common extensor origin)
- D: Extensor apparatus of little finger
- Usually divides into 2 slips – radial one joined by tendon from extensor digitorum to little finger
- (EDM is ulnar to ED)
- I: Deep branch of radial nerve (C7, C8)
• A: Extends little finger, primarily at MCPJs (also extends other joints)
Distilly it splints into 2 tendons in little finger
7
Q
Superficial Layer: Extensor Carpi Ulnaris
A
- P: 2 heads – humeral head from lateral epicondyle (common extensor origin) – & ulnar head from posterior border of ulna
- D: Dorsal base of 5th Metacarpal. Runs in groove between ulnar head and styloid process
- I: Deep branch of radial nerve (C7, C8)
- A: Extend and adduct hand at wrist joint
- Important (like ECRL) clenching fist/ tight grip finger flexion
- ECU can act synergistically with FCU- flexor carpi ulnaris to produce pure adduction
8
Q
Superficial layer muscles
A
Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorium Extensor digit minimi Extensor carpi ulnaris
9
Q
Deep layer: Supinator
A
• P: osseofibrous origin = lateral epicondyle of humerus, radial collateral and anular ligament, supinator fossa and crest of ulna
Arises from humerus ulna and radius and ligaments around it
• D: Lateral (posterior and anterior) surfaces of proximal 1/3 of radius
• I: Deep branch of radial nerve (C7, C8) - passes between two heads
• A: Supinates forearm
• Deep branch of radial nerve passes between superficial and deep parts
10
Q
Deep layer: Abductor Pollicis Longus
A
- P: Ulna, radius and interosseous membrane (distal to supinator)
- D: Base of 1st metacarpal (Nb commonly split into 2 – one may attach to trapezium)
- I: Posterior interosseous nerve (C7,8) - continuation of radial nerve
- A: Abducts thumb and extends CMC (? wrist abductor)
11
Q
Deep layer: Extensor Pollicis Brevis
A
- P: Distal third radius and interosseous membrane
- D: Dorsal base of thumb proximal phalanx
- I: Posterior interosseous nerve (C7,8)
- A: Extends proximal phalanx at MCPJ metacarpal pharyngeal joint (extend CMC and abduct wrist)- extesnor for the thumb
12
Q
Deep layer: Extensor Pollicis Longus
A
- P: Middle third ulna & interosseous membrane
- D: Dorsal base of thumb distal phalanx. [change its line of pull on radial tubercle = a pulley]
- I: Posterior interosseous nerve (C7,8)
- A: extends distal phalanx at IPJ intralaryngeal joint (extend MCPJ & CMC)
• Tendons of APL and EPB anteriorly and EPL posteriorly form the anatomical snuff box
13
Q
Deep layer: Extensor Indicis
A
- P: Distal third ulna and interosseous membrane
- D: Extensor apparatus of index finger
- I: Posterior interosseous nerve (C7,8)
- A: Extends index finger, allows independent extension – extend index finger alone
14
Q
Extensor Retinaculum
A
• Tunnels formed by attachment of retinaculum to the distal radius and ulna
• Tendons have synovial sheaths as they pass in tunnels
Keep tendons close to bone
15
Q
• Wrist compartments
A
– 1: APL & EPB – abductor pollucis longus and extenser pollucis brevis
– 2: ECRL & ECRB –extensor carpiradiallis longus and brevis
– 3: EPL – extensor pollucis longus
– 4: EDC & EI - extensor digiti and indicies
– 5: EDM exteonsor digiti minimi
– 6: ECU extenosir carpi ulnaris
16
Q
• Oblique inter-tendinous connections (Juncturae tendinum)
A
• Oblique inter-tendinous connections (Juncturae tendinum) [stabilize, support, limit individual movement of individual fingers]
17
Q
Radial Nerve in Forearm
A
- Enters cubital fossa anterior to lateral epicondyle
- Between brachioradialis and brachialis
Branches
• Divides into a superficial branch and deep branches
18
Q
Radial nerve Deep branch
A
- Posterior interossus nerve / Deep Branch passes under proximal edge of the supinator (arcade of Frohse)
- passes Between 2 superficial and deep layers of supinator
- Runs in plane between superficial and deep extensor muscles (close to posterior interosseous artery)
19
Q
Radial nerve Superficial branch
A
- Superficial Branch travels with radial artery, deep to brachioradialis
- Emerges into subcutaneous plane (approximately 9 cm proximal to radial styloid) by passing between BR and ECRL
- NB. Posterior cutaneous nerve of forearm comes off in radial groove and runs independently
20
Q
Bones of Hand
A
‘• 8 carpal bones, arranged into 2 rows – distal row and proximal row
- Metacarpals & phalanges similar to feet
- Each has base, shaft, head
21
Q
Proximal row:
A
- Scaphoid (Gk Boat) – articulates proximally with radius. Largest bone in proximal row. Prominent tubercle = bridges both rows in wrist joint
- Lunate (L Moon) - articulates proximally with radius
- Triquetrum (L 3 cornered) – pyramidal bone. Articulates proximally with disc of DRUJ
- Pisiform (L pea) –lies anterior to triquetrum. A sesamoid, increases leverage of FCU flexor carpi ulnaris
22
Q
Distal row
A
- Trapezium (G – table) – 4 sided bone. Articulates with 1st & 2nd Metacarpals and scaphoid and trapezoid. Prominent tubercle – articukatr wuth thumn
- Trapezoid – wedge shaped. Articulates with 2nd metacarpal, trapezium, capitate and scaphoid
- Capitate (L head) – largest bone. Articulates with 3rd metacarpal. With trapezoid, scaphoid, lunate and hamate
- Hamate (L little hook) – wedge shaped. Articulates with 4th & 5th metacarpals, capitate and triquetral bones. Hook of hamate anteriorly
23
Q
Metacarpals & phalanges of hund
A
- 1st metacarpal is shortest and thickest
- Thumb has 2 phalanges, others 3
- Thumb phalanges are stouter
- Proximal, middle distal phalanges – reduce in size
- Distal phalanges flattened and expanded at end, under nailbed.
24
Q
The Wrist Joint (radiocarpal joint)
A
• Formed proximally by concave distal end of radius and articular disk and distally by convex proximal row of carpal bones (not pisiform)
- Ulna not part of wrist joint (articulates with radius at DRUJ distal radial ulna joint)
- Fibrocartilaginous, triangular articular disc (part of Triangular FibroCartilage Complex (TFCC)
- Attachments ulnar notch of radius and (lateral side of base of) styloid process of ulna
25
Radio carpal joint ligaments
* Palmar radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during supination
* Dorsal radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during pronation
* Ulnar collateral –from ulnar styloid process to triquetrum and pisiform
* Radial collateral –from radial styloid to scaphoid and trapezium
* Collateral ligaments prevent excessive lateral joint displacement
26
Flexion muscles - forearm
Flexor carpi radialis
Flexor carpi ulnaris
(assistance from finger flexors and Palmaris longus)
27
Extension muscles - forearm
• Extension – ECRL, ECRB, ECU (assistance from finger and thumb extensors)
28
Addiction muscles
• Adduction – ECU, FCU
29
Abduction muscles
• Abduction – APL, FCR, ECRL, ECRB
30
Intercarpal joints -
• Intercarpal joints - between carpal bones
31
Midcarpal joint
• Midcarpal joint - between prox and distal row
32
Joints of hand
* Intercarpal joints - between carpal bones
* Midcarpal joint - between prox and distal row
* Pisotriquetral joint
* Carpometacarpal and Intermetacarpal joints
33
Carpometacarpal joints
– plane type, except 1st CMC = saddle
| – 2/3 CMC almost no movement, 4 slightly, 5 moderately mobile increasing movemenet as you move more medially
34
Palmar Fascia
• Fascia of palm is continuous with antebrachial (forearm fascia)
* Thenar and hypothenar fascia is thin Palmar aponeurosis = thick, triangular, central fascia
* Over thenar muscle
• Proximally (apex) continuous with flexor retinaculum & palmaris longus tendon
• Distally forms 4 longitudinal digital bands (rays) attach to
– bases of proximal phalanges
– become continuous with fibrous digital sheaths (= tubes that enclose synovial sheath and flexor tendons)
35
Palmar aponeurosis
* Thick triangular fascia
| * Test for palmaris longus – feel it when press pinky finger with thumb
36
Hypothenar (medial) compartment
• Medial fibrous septum from medial border of palmar aponeurosis to 5th metacarpal
– Medial to septum = Hypothenar (medial) compartment
37
Thenar (Lateral) compartment
• Lateral fibrous septum from Lateral border of palmar aponeurosis to 3th metacarpal
– Lateral to septum is Thenar (Lateral) compartment
38
Central compartment
– Contain flexor tendons and their sheaths, lumbricals, superficial palmar arch, digital vessels and nerves
• Adductor and interossei compartments, contain adductor pollicis and interossei
• Adcuctor myscles
39
Spaces - in the forearm
* Potential deep spaces – deep to thenar and central compartment = thenar and midpalmar spaces
* (Between spaces is fibrous septum)
* Midpalmar space is continuous with anterior compartment of forearm (via carpal tunnel) - infecrion in arm can spread to forearm
40
Thenar Muscles - Abductor Pollicis Brevis
• Forms anterolateral part of thenar eminence
* P: Flexor retinaculum and tubercle of scaphoid (and trapezium)
* D: Lateral side of base of proximal phalanx of thumb
* I: Recurrent branch of median nerve (C8,T1)
* A: Abducts thumb, helps oppose it
41
Thenar Muscles - Flexor Pollicis Brevis
• Medial to APB abductor pollucis brevis
• P: 2 muscle bellies
– superficial head from flexor retinaculum & trapezium
– deep head from trapezoid & capitate
• D: Lateral side of base of proximal phalanx of thumb
–with APB via a sesamoid containing common tendon
• I: Superficial head: recurrent branch of median nerve (C8,T1)
• Deep head: Deep branch of the ulnar nerve (C8, T1)
• A: Flexes thumb (CMCJ and MCPJ) and aids in opposition
42
Thenar Muscles - Opponens Pollicis
• Deep to APB and lateral to FPB
* P: Flexor retinaculum and tubercle of trapezium (& scaphoid)
* D: Lateral side of 1st metacarpal
* I: Recurrent branch of median nerve (C8,T1)
* A: Oppose thumb = draws 1st metacarpal medially and rotates it at CMCJ
43
Adductor Pollicis (adductor compartment)
• P: 2 heads (Radial artery see later)
– Oblique: Bases 2nd & 3rd metacarpals, capitate
– Transverse: Shaft of 3rd metacarpal
• D: Medial side of base of proximal phalanx of thumb – via a sesamoid containing tendon
• I: Deep branch of ulnar nerve (C8, T1)
• A: adducts thumb
44
Hypothenar Muscles – Abductor digiti minimi
• Most superficial
* P: Pisiform
* D: Medial side of base of proximal phalanx of little finger
* I: Deep branch of ulnar nerve (C8, T1)
* A: Abducts little finger (assists in flexion of proximal phalanx)
45
Hypothenar Muscles – Flexor digiti minimi brevis
• Lies lateral to ADM
* P: Hook of hamate and flexor retinaculum
* D: Medial side of base of proximal phalanx of little finger
* I: Deep branch of ulnar nerve (C8, T1)
* A: Flexes proximal phalanx of little finger (at MCPJ)
46
Hypothenar Muscles – Opponens digiti minimi
* Deep to other 2
* P: Hook of hamate and flexor retinaculum
* D: Medial border of 5th metacarpal
* I: Deep branch of ulnar nerve (C8, T1)
* A: Draws 5th metacarpal anteriorly and rotates it laterally (at CMCJ) for opposition with thumb- make a cup in your hand
47
lumbricals
Arise from tnedon and isnert into tendon
4 of them
1st & 2nd
• P: lateral 2 tendons of FDP (unipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: Median nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers
3rd & 4th
• P: medial 3 tendons of FDP (bipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: deep branch of ulnar nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers
48
Short Muscles - Interossei
• 4 Dorsal Interossei (1st – 4th)
* Between metacarpals
* P: Adjacent sides of 2 metacarpals (bipennate)
* D: Bases of proximal phalanges and extensor expansions of fingers
* I: Deep branch of ulnar nerve (C8,T1)
* A: Abducts index and ring fingers from axial line; acts with lumbricals as above
49
Extensor Mechanism
* Tendons flatten at distal ends of metacarpals
* Extensor expansions (“hood”) hold tendon in middle
• Tendon divides into
– central slip, inserts into base of middle phalanx
– 2 lateral bands, insert into base of distal phalanx (unite over middle phalanx)
* Deep transverse metacarpal ligament connects (heads of) metacarpal bones
* Lumbrical tendon is anterior passes volar to ligament, on radial side of digit, attaches to radial lateral band flexes mcp joint but extends others
* Interossei tendons are posterior pass dorsal to ligament, to join lateral bands near the extensor expansion
* Note interossei and lumbricals anterior to MCPJ centre of axis => cause flexion
50
Finger Flexor Tendons
• Pass deep to flexor retinaculum, common flexor sheath
* Enter central compartment
* Fan out to individual digital synovial sheaths individual fingers
• FPL has own synovial sheath
– Passes between two sesamoid bones at head of 1st metacarpal
• Over proximal phalanx, FDS splits to allow passage of FDP (tendinous chiasm)
• FDS attached to margins of anterior aspect of base of middle phalanx
• FDP attaches to anterior aspect of base of distal phalanx
51
Finger Flexor Tendons Fibrous digital sheaths
* Strong ligamentous tunnels (contain tendons and synovial sheaths), prevent bowstringing
* Anular and Cruciform parts (pulleys) are thickened reinforcements
* Small blood vessels pass within synovial folds called vincula, from perisoteum to flexors
52
Ulnar Artery in the Hand
Runs on ulnar side superficial to flexor retinaculum
• Anterior to flexor retinaculum (TCL)
• Deep to palmar (volar) carpal ligament
• Between pisiform and hook of hamate via ulnar canal (Guyon’s)
• Artery lies lateral to nerve
• Divides into superficial and deep palmar arches - Superficial palmar arch is completed by branch from radial = give common digital artery
53
• 3 common (palmar) digital arteries
– anastomose with palmar metacarpal arteries from deep palmar arch
– divide into a pair of (proper palmar) digital arteries
– run along adjacent sides of each finger
• (sometimes) anastomoses with superficial palmar branch of the radial artery
54
Radial Artery in the Hand
• After branch, curves dorsally and crosses floor of anatomical snuff box
• Enters palm by passing between heads of
– 1st dorsal interosseous
– Adductor pollicis
Ends by anastomosing with deep branch of ulnar artery to form deep palmar arch
• Arch lies just distal to metacarpal bases
• 3 palmar metacarpal arteries
• Princeps pollicis artery – artery to thumb split into 2 branches
• Radialis indicis - usually from radial artery but may arise from princeps pollicis- supply radial side of index finger
55
Median nerve in the Hand
* median nerve passes Through carpal tunnel (with 9 tendons under flexor retinaculum, TCL)
* attachments - Tubercles of scaphoid & trapezium and pisiform & hook of hamate
Supplies
• 2 ½ thenar muscles
• 1st & 2nd lumbricals
Sensory to
• Palmar surface & sides of radial 3 digits, lateral half of ring finger and dorsum of distal halves of these digits
• Palmar cutaneous branch supplies central palm (arises proximal to flexor retinaculum)
56
Ulnar nerve in the Hand
2 branches
• Palmar cutaneous branch proximal to wrist
• Dorsal cutaneous branch – approx. medial half of dorsum of hand and little & ring fingers
Divides into
• superficial branch – (PB &) cutaneous branches to anterior surfaces of the medial and half digits
• deep branch – hypothenar muscles, medial 2 lumbricals, adductor pollicis, deep head of FPB and all interossei
57
Radial nerve in the Hand
* Superficial branch of radial nerve pierces deep fascia near dorsum of wrist
* Supplies skin and fascia over approx. lateral half of dorsum of hand, dorsum of thumb, index and middle fingers
58
Taking a history - what to include
* Age, handedness, occupation hobbies – right or left handed
* Presenting complaint
* Symptoms – probing qs
* Functional problems – what they can't do due to problem
* Past medical history
* Drugs
* Allergies
* Social history
59
Examination
* Neck
* Nerves in upper limb are connected to neck, so pathology in neck can impact hand
* Check for pain and movement
* Shoulder
* Elbow – flex and extend
* Wrist
* Hand
60
Special investigations
* Blood tests
* Useful if it is an infection e.g. infection in tendon sheeth or RA (elevation of rheumatory factors)
* Imaging
* Neurophysiology
* Test of nerve and muscle action using electricity
Not always needed
61
4 types of Imaging in Hand surgery
* X-Rays
* Ultrasound
* CT scan
* MRI
62
X-Rays -views
• Minimum three views
• AP, Lateral, Oblique
Important ot have alll 3 vies as some may not spot abnormaliteis
63
Ultrasound
• Operator dependent
• Real time
Probe over area for suspected pathology
• Tendons and ligaments
64
CT scan
* Uses radiation
| * Visualises bones and joints
65
MRI
* Uses magnetic field
| * Visualises bones and soft tissues
66
Common Elective Hand conditions
* Arthritis
* Tendinopathies
* Nerve compressions
* Lumps – ganglia
* Dupuytren’s contracture
67
Arthritis
* Degeneration of the joints
* Several types
* Osteoarthritis
* Rheumatoid arthritis
* Psoriatic arthritis
* Gouty arthritis
* Post-traumatic arthritis
68
Osteoarthritis
* Autosomal dominant - Maternally inherited
* Affects multiple joints
* No effective medical treatments
* Diagnosed based on history and X-Rays
• In hands commonly first CMC joint of thumb joint and DIP most distl on fingers joints
Osteophytes, narroewing of joint space, sclerosis of bones
69
Osteoarthritis base of thumb
* Pain base of thumb
* Base of thumb subluxed, causes ‘squaring of thumb’ - more rectangle than square
* Grind test positive – hold aptient thumb, push it = pain
* patient struggles to use thumb so Compensates using MCP joint = hyperextension
* Results in ‘z- deformity’
70
Osteoarthritis base of thumb
Treatment
* Analgesics
* Splint
* Steroid injection
Surgical treatment
• Joint fusion – fuse 1st metacarpal to trapezium
• Trapeziectomy - remove trapeziuma nd reconstruct ligaments using piece of tendon
• Joint replacement – can fade overtime
71
Trapeziectomy
• Trapezium is removed
Maintain sapce between thumb metacarpal and scaphoid
• Ligament reconstruction may be added
* Good pain relief
* Risk of instability – MCP joint hyperextension
72
CMC joint fusion
---> fusion of first carpal metacarpal joint
* Gives stability
* Good for manual workers
* Unable to make a flat hand
73
Joint replacement
* Give relative stability
* Expensive
* Risk of failure
74
DIP joint arthritis – distal interphalangeal joints
* Seen as Heberden’s nodes – nodules
* Pain, loss of movements
* Mucous cysts may be seen – osteophytes corrdoe joint capsule fill with fluid
* Treated with NSAIDs, splints or joint fusion
75
Other hand joints
* Can affect STT joint, scaphoid, trapexium, trapzoid MCP joints or PIP joints
* Treated with NSAIDs, steroid injections, joint
* fusions or replacements
76
Rheumatoid Arthritis
* Autoimmune disease
* Can affect young people
* Affects multiple joints and other body systems
* Progressive
77
Pathology of RA
1. IgMs against Fc portion of IgG
2. AntigenAntibody complexes
3. Inflammatory cells
4. Phagocytosis of immune complexes
5. release Lysozymes Free radicals Leukotrienes
6. Joint destruction
78
Joint pathology in Rheumatoid arthritis
* Fluid in joint
* Inflamamtion of joint
* Stretch joint capusle and ligaments
* Bone erosisn
79
Wrist involvement
* Subluxation of the carpus
* Prominent ulna
* ‘Piano key sign’
* Pain
* Limitation of movements
* Tendon ruptures over prominent ulna or synovitis
80
Wrist involvement - treatment
* Wrist fusion - with minimal effort due to inflammation- but limits movement
* Wrist replacement
* Excision of distal ulna(Darrach’s procedure)
* Tendon reconstruction(EIP extensor indices propius tendon may be used) if rupture of tendons
81
Other joints affected
* Thumb
* MCP joints
* PIP joints
* DIP joints rarely affected
82
Thumb
* Can cause CMC and MCP joint
* Boutonniere or Swan neck deformity
* Treatment based on disability
* Splints, NSAIDs, joint fusion
83
MCP joints
* Ulnar drift of fingers
* Subluxation of the joints
* Treatment using splint, fusion or joint
* replacement
* Silicone joints - hinge to move joint , pyrocarbon joints or metal – no problem with subluxation
84
PIP joints
Flexion DIP
Hyperextension of PIP
* Swan neck deformity
* Boutonniere deformity
* Treatment using splints, steroid injections or surgery
* Surgery mainly joint replacement or fusion – silicone or metal
85
4 Tendinopathies
* Tennis elbow
* Golfer’s elbow
* De Quervain’s tenosynovitis
* Trigger fingers
86
Tendinopathies
Treatment principles
* Rest, splint
* NSAIDs
* Steroid injections
* Physiotherapy
* Release of tendon sheath, muscle origin – help tendon glide or reduce pain
87
Tennis and golfer’s elbow
---> either side of elbow joint
* Often middle aged (35 - 50)
* Pain can commence after minor trauma.
* May be recent history of excessive activity involving that elbow (rarely tennis ! Dusting,
* sweeping, heavy gardening etc).
* Golfer’s elbow similar history but medial pain less than Tennis elbow
88
• Tennis elbow:
• Lateral elbow pain reproduction on resisted wrist extension(Mills' Test)= pain
89
• Golfer’s elbow:
• Medial elbow pain reproduction on resisted = pain
90
Treatment of tennis and Golfer’s elbow
* Non operative
* Activity modification
* NSAIDS
* Clasp – support muscle and ease pain
* Physiotherapy – stretched inflammaed muscles in either extensors or flexors
* Ultrasound
* Steroid injections
• Surgery
91
Trigger finger / thumb
* Thickening of the flexor tendon such that it does not pass through the sheath.
* Local injection injected into tendon sheath to relax It
* Surgical release
Pain over MCP joint, inability to flex finger, need other hand to flex it, or it locks
92
De Quervain’s Tenosynovitis
---> first extensor compartment
* Inflammation affecting APL and EPB tendons and their sheaths
* Women more often affected
* 30-50yrs
* Finkelstein’s test = make fist with thumb causes pain
* Treatment
* Rest and NSAID’s
* Corticosteroid injection
* Surgical Decompression
93
Nerve compressions
• Can affect Median nerve and Ulnar nerve
* Radial nerve compression rare
* Median nerve commonly at wrist- Carpal tunnel syndrome
* Ulnar nerve at Elbow- Cubital tunnel syndrome
94
Carpal tunnel syndrome
* Compression of median nerve under flexor retinaculum
* Retinaculum is tight or contents of carpal tunnel increase
* Pain, tingling, pins and needles in hands
* Nocturnal symptoms – flex hands at night cause symptoms and fluid shift
* Later weakness or wasting of thenar muscles
95
Diagnosis of carpal tunnel syndrome
* Typical history
* Examination of median nerve
* Provocative tests
* Phalen’s - flex and hold wrist = symptoms
* Carpal compression test = presure over carpal tunnel with thumb = symptoms
* Tinel’s sign
• Nerve conduction studies – conduction velocity of medial nerve across carpal tunnele
96
Treatment of carpal tunnel syndrome
* Splint
* Steroid injection
* Carpal tunnel release = Open procedure, Endoscopic
97
Cubital tunnel syndrome
* Ulnar nerve compression at elbow
* Both compression and tension on the nerve as you flex elbow
* Symptoms along ulnar nerve
* Pain, numbness, tingling – over ring and little fingers
* Weakness of small muscles of hand – interossir and abductor pollucius
* Positive elbow flexion test
98
Cubital tunnel syndrome
Treatment
* Activity modification - limit elbow flexion
* Splint – keep elbow straight
* Nerve gliding exercises
* Cubital tunnel release
• May need a nerve transposition or medial epicondylectomy – reduce tension on nevre
99
Dupuytren’s disease
* Common in Northern Europe
* ‘Viking disease’
* Causes contractures of fingers
* Associated with feet fibromatosis(Ledderhosen’s disease) and penile fibromatosis(Peyronie’s disease
Affects multiple digits and joint MCP and pip
100
Dupuytren’s disease
Aetiology and pathogenesis
* Genetic
* Environmental-smoking, DM, epilepsy, alcoholism
* Microngiopathy - proliferation of Myofibroblasts – produce muscle fibres causing contraxtion
101
'Dupuytren’s disease
Treat ment
* Needle fasciotomy – needle brak cords and straighten finger
* Collagenase – inject enzymes into finger
* Limited fasciectomy – excise disease part
* Dermofasciectomy – excsise skin and disese
102
Lumps in the hand
* Ganglia – cystic swelling around tendon and joints
* Lipomas – fatty lumps
* Cysts – epithelieum lined fluid filled lumps
* Giant cell tumours of tendon sheath – solid benign
* Nerve sheath tumours
* Sarcomas- malignant tumours
103
Ganglia
* Usually occur spontaneously
* Contain gelatinous fluid due to mucoid degeneration of the synovium.
* Develop around joints or tendon sheaths, and usually communicates with the joint.
* Most common around the wrist.
* Dorso radial or volar radial
* Can be intermittently painful
• Treatment=aspiration or excision
Best to treat them by leaving them they will eventually go away
• Beware of recurrence!
104
Carpal tunnel bones
proximal to distal
Scaphoid
Lunate
Triquetrium
Pisiform
Distal row
Trapezoid
Trapezium
Capitate
Hamate
