Hand + Wrist Pathology Flashcards
(29 cards)
What do scaphoid fractures result from?
- Common + easily missed on X-ray
- Results from a fall on the hand (FOOSH)
- Contact sports (football + rugby)
How does scaphoid fracture present clinically?
- Tender in ANATOMICAL SNUFFBOX
- Pain along radial aspect of wrist + at base of thumb
- Loss of grip/pinch strength
- Wrist joint effusion
- Pain elicted by telescoping of thumb
- Pain on ulnar deviation of wrist
Which investigations for scaphoid fracture?
- Plain film radiographs → sensitivity in first week only 80%
- CT scan superior to radiograph
- MRI is definitive investigation to confirm/exclude diagnosis → NICE says to use first-line, but it is actually commonly used second-line when radiographs are inconclusive
What is the initial management of suspected or confirmed scaphoid fracture?
- Immobilisation → Futuro splint or standard below-elbow backslab
- Referral to orthopaedics
- Clinical review w/ further imaging should be arranged for 7-10d later when initial radiographs are inconclusive
What is the orthopaedic management of scaphoid fractures?
Dependent on pt and type of fracture:
-
Undisplaced of scaphoid waist →
- cast for 6-8 wks
- union is achieved in > 95%
- certain groups eg. professional sports people may benefit from early surgical intervention
- Displaced fractures → requires surgical fixation
- Proximal pole fractures → require surgical fixation
What is the main complication to worry about from scaphoid fracture?
Avascular necrosis
What is a boxer’s fracture?
- Fracture of the 5th metacarpal neck
- Caused by clenched fist striking hard object
What is Bennett’s fracture?
- Fracture of 1st metacarpal base
- Caused by forced hyperabduction of thumb
- Defined as intra-articular two-part fracture
- Extends to first carpometacarpal joint → instability + subluxation of joint
- Often needs surgical repair
- Rolando fracture is similar but completely intra-articular
What are different types of phalangeal fractures?
- Proximal phalanx → spiral or oblique fractures lead to rotation deformity; corrected with open reduction and fixation
- Middle phalanx → manipulate; splint in flexion over a malleable metal splint strapping finger to neighbour; aim is to control rotation, which interferes with lateral finger flexion
- Distal phalanx → caused by crush injuries; often open; if closed, symptoms may be relieved by trephining the nail
Which tendons may be injured in the hand?
- Flexor digitorum profundus → finger flexion (MCP + IP joints)
- Flexor digitorum supeficialis → finger flexion (PIP joints)
- Flexor pollicis longus → flexes IP joint of thumb
What is the treatment for flexor tendon injuries?
- Primary repair (most are open injuries)
- If loss of tendon substance or delayed presentation → staged repair with silastic implant to keep tendon sheath open, followed by tendon graft
- Intensive hand physio with supervision is essential
Fractures of the distal radius (and/or ulnar) are commonly seen in A+E. Wrist fractures are mostly caused by FOOSH.
What is a Colles’ fracture?
- Extra-articular fracture of distal radius w/ dorsal displacement of distal radius
- Common in females over 50yrs (osteoporosis) following a FOOSH
- Classic dinner fork deformity visible
What is the management of Colles’ fracture?
- Reduction of fracture under regional anaesthesia (Bier’s block) or LA (haematoma block) to reverse deformities
- Area is held in plaster backslab from elbow to metatarsophalangeal joints for 6wks
- Intra-articular involvement, failed reduction or malunion require surgical intervention
What are complications of Colles’ fractures?
- Carpel tunnel syndrome
- Malunion
- Stiffness
- Rupture of extensor pllicis longus
What is a Smith’s fracture?
- Reverse of Colles’ fracture with anterior angulation and tilt
- Uncommon
Tx → manipulation under anaesthesia and a plaster cast above elbow for 6wks
What is Barton’s fracture?
- Intra-articular fracture of wrist
- Causes hand and part of distal raidus to displace proximally
Tx → ORIF
What is a chauffeur’s fracture?
Fracture of radial styloid
What is the commonest cause of hand pain at night?
- Carpal tunnel syndrome
- Due to compression of median nerve as it passes under flexor retinaculum
What are clinical features of carpal tunnel syndrome?
- Tingling or pain felt in thumb, index and middle finger
- When pain at worst, pt flicks or shakes wrist to bring relief
- Pain especially common at night and after repetitive actions
- Wasted thenar eminence + reduced sensation over lateral 3.5 digits
- Lateral palmar sensation is spared as its supply (palmar cutaneous branch of median nerve) does not pass through tunnel
- Phalen’s test → holding the wrist hyperflexed for 1min reproduces the symptoms
Which investigations for carpal tunnel syndrome?
- Usually a clinical diagnosis
- Nerve conduction studies can be helpful in complex or mixed symptoms as well as monitoring responses to surgery
- USS + MRI can help identify lesions
What are associations of carpal tunnel syndrome?
- Hypothyroidism
- Pregnancy / the pill
- Gout + pseudogout
- Diabetes + obesity
- Acromegaly
- Rheumatoid arthritis
- Amyloidosis
What is the management of carpal tunnel syndrome?
- Treat any association
- 1st line → rest, weight reduction, wrist splints
- Splinting in a neutral position alone was sufficient to relieve symptoms + avoid surgery in 37% pts
- Medical → corticosteroid injections (for short-term 10wk pain relief)
- Surgical → carpal tunnel decompression (release of flexor retinaculum)
What are wrist ganglions and their treatment?
- Smooth, multilocular cysts containing jelly-like fluid in communication w/ joint capsules or tendon sheaths
- Treatment not needed unless pain or pressure
- They may appear spontaneously
- Aspiration may work, but surgical dissection gives less recurrence
What is DeQuervain’s tenosynovitis?
Refers to stenosing tenosynovitis (thickening + tightening) of the 1st extensor compartment, abductor pollicis longus and extensor pollicis brevis tendons (at the anterior border of anatomical snuffbox) as they cross distal radial styloid
