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pt momints ver 2.0 > MS1: Affectations of the Wrist and Hand > Flashcards

MS1: Affectations of the Wrist and Hand Flashcards

1
Q

describe the distal radioulnar joint

A

uniaxial - pivot jint

formed by distal radius, articulating disc and ulna

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2
Q

what is the articulating disc of the DRUJ

A

TFCC - triangular fibrocartilage complex

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3
Q

where is the TFCC located

A

betw medial and proximal carpal row and distal ulna

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4
Q

what is the composition of TFCC

A

articular disc - for cushion or shock absorber so ulna will not hit carpals

meniscus homologue

origin of ligaments

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5
Q

which ligaments originate from the TFCC

A

ulnocarpal - unlolunate and unlotriquetral

ulnar collateral and ECU tendon sheath

radioulnar - dorsal and palmar

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6
Q

what is the function of TFCC

A

covers nd protects ulnar head

load transmission across ulnocarpal joint and cushion against compression

allows forearm rotation

supports ulnar portion of carpus

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7
Q

how does injury on TFCC typically occur

A

falling on supinated outstretched wrist

chronic repetitive rotational loading

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8
Q

what are the 2 types of TFCC injury

A

type 1 - traumatic

type 2 - degenerative

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9
Q

signs and symptoms of TFCC injury

A

medial wrist pain distal to ulna increased by pronation-supination and gripping

painful click during wrist motions

tenderness on posterior distal to ulnar head

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10
Q

how to test for TFCC injury

A

mcmurrays test - passive or active ulnar deviation causes pain or snap = +

passive supination w/ ulnar deviation can reproduce pain

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11
Q

sports related to TFCC injury

A

GOLF, boxing, tennis, waterskiing, gymnastics, pole vaulting, hockey

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12
Q

diagnosis of TFCC injury

A

imaging

radiograph - usually negative; done to rule out fractures

triple injection arthrography - low specificity; might see tear

MRI - high specificity; identify tear

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13
Q

treatment of TFCC injury

A

conservative
- modification of lifestyle to remove inciting force
- ice-heat and immobilization for 3-6 weeks then PT

surgical - if may pain after 6 wks
- type 1
- immobilized for 1 wk post op then ROM exercises
- light activity at 3 wks
- normal sports activity at 4-6 wks

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14
Q

management of TFCC injury

A

conservative
- NSAID
- steroid injections
- physical therapy
- exercises

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15
Q

discuss the differential diagnosis for TFCC injury

A

TFCC tear - pain on ulnar deviation - negative on xray

ulnar styloid fracture - pain over styloid - fx on xray

ulnar nerve trap at guyons - numbness nd weakness of grip

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16
Q

what makes up the wrsit

A

distal radius and ulna, 8 carpal bones, 5 base of metacarpals

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17
Q

describe the radiocarpal joint

A

betw distal raduis and scaphoid, lunate, triquetrum and TFCC

condyloid - main wrist joiny

listers tubercle - dorsal at center of radius

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18
Q

what is the significance of listers tubercle

A

EPL tendon passes that causes friction

common site of microtears

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19
Q

what are the carpal bones lateral to medial

A

proximal
- scaphoid, lunate, triquetrum, pisiform

distal
- trapezium, trapezoid, capitate, hamate

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20
Q

what is colle’s fracture

A

fracture of distal radius with dorsal displacement

due to fall from outstretched hand

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21
Q

what is the epidemiology of colle’s fracture

A

high in women over 50 - menopausal nd osteoporotic
- bc predictor of other fractures - high chance na osteoporotic

high impact - skiing nd horseback riding

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22
Q

signs and symtoms of colle’s fracture

A

dinner fork deformity - posterior displacement of distal radial fragment

  • dorsal wrist pain
  • swelling
  • increased angulation of distal radius
  • inability to grasp
  • numbness
  • tenderness
  • bruising
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23
Q

management of colle’s fracture

A

operative - ORIF to normal length of radius
- Fx displaced intra-articular
- volar/dorsal comminution
- severe osteoporosis
- more than 5mm of radial shortening
- dorsal angulation more than 5 degrees
- progression after closed reduction nd casting
- w/ ulnar styloid fracture

non operative - closed reduction and cast immobilization
- less than 5mm of radial shortening
- dorsal angulation less than 5 degrees

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24
Q

what is smith’s fracture

A

fracture on distal radius with palmar displacement due to falling on the back of flexed hand

reverse colle’s

majority treated with conservatice

surgery same as colle’s

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25
Q

what is barton fracture

A

intra-articular fracture of distal radius with dislocation of radiocarpal joint

volar - more common
dorsal - less common

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26
Q

causes of barton fracture

A

joint involved - direct blow to forearm

sudden pronation on fixed wrist

70% common in young men

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27
Q

what is the treatment of barton fracture

A

conservative
- closed reduction and casting on full supination, mid extension and ulnar deviation

surgical
- ORIF with 16 wks healing time

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28
Q

what is madelung’s deformity

A

uncommon, congenital

retardation of growth of ulna and volar distal radius = tilting of distal radius

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29
Q

what is epidiemiology of madelung’s disease

A

common in female

usually bilateral

congenital and slowly progressive

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30
Q

signs and symptoms of madelung’s deformity

A

wrist is enlarged and unstable radioulnar joint upon palpation

end of radius is displaced anteriorly

dorsal prominence on lower end of ulna and limitation of wrist DF

wrist weakness

supination lessened nd pronation can be decreased

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31
Q

treatment of madelung’s deformity

A

unnecessary - person can adapt

mild pain - temporary splinting

severe cases - resection of distal ulna to allign bones

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32
Q

describe the scaphoid

A

palpated distal to radial styloid in anatomic snuffbox

most common fractured carpal bone

avascular necrosis - preiser’s disease

biggest in proximal row

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33
Q

describe the lunate

A

distal and ulnar to lister’s tubercle

most commonly dislocated carpal and scapholunate most common area for carpal instability

osteonecrosis follows after single severe trauma to wrist

spontanenous osteonecrosis - keinblock’s disease due to repetitive trauma

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34
Q

describe osteonecrosis or avascular necrosis

A

common in 20-40 yo
pain nd swelling for several days to wks
localize swelling nd tenderness nd DF is limited

radiographic - initially negative but later flattening = abnormally dense

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35
Q

treatment of osteonecrosis or avascular necrosis

A

conservative - immobilization bc bone is soft

surgery - excision the replace with metal prosthetic implant

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36
Q

what is the extensor retinaculum

A

from lateral border of distal radius to posterior surface of distal ulna and ulnar styloid, pisiform and triquetrum

prevents bow stringing of tendons nd enhances efficiency

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37
Q

what is the anatomic snuffbox

A

triangular depression at lateral of the wrist at compartment 1

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38
Q

what are the compartments of extensor retinaculum

A

1 - APL and EPB

2 - ECRL and ECRB

lister’s tubercle

3 - EPL

4 - extensor digitorum and extensor indicis

5 - EDM

6 - ECU

38
Q

what are the compartments of extensor retinaculum

A

1 - APL and EPB

2 - ECRL and ECRB

lister’s tubercle

3 - EPL

4 - extensor digitorum and extensor indicis

5 - EDM

6 - ECU

39
Q

what is de quervain’s syndrome

A

stenosing tenosynovial inflammation of the 1st dorsal compartment - APL nd EPB

40
Q

what is the epidemiology of de quervain’s syndrome

A

more common in women
30 - 50 yo
more common in dominant hand but can be bilateral

risk factors
overuse
repetitive wringing, grasping clenching or pinching
post-traumatic
postpartum

41
Q

what are the symptoms of de quervain’s syndrome

A

pain on lateral wrist when moving wrist and thumb that shoots into thumb and wrist and forearm

localized swelling

thickening of tendon sheath and hard nodule on styloid process of radius

42
Q

how to test for de quervain’s syndrome

A

finklestein’s test - pt will grasp thum and ulnar deviate if pain over styloid = +

43
Q

what is treatment for de quervain’s syndrome

A

conservative
- wrist brace/cast
- anti-inflammatory medication
- restricted movement of wrist and thumb
- ice-heat
- cortisone injections
- PT nd OT
- avoid movement that cause pain

surgical
- release of constriction or partial resection of sheath

44
Q

what is the flexor retinaculum

A

from tubercle of scaphoid and pisiform and hook of hamate and tubercle of trapezium

aka transverse carpal ligament

45
Q

functions of flexor retinaculum

A

attachment for thenar and hypothenar muscles

help maintain transverse carpal arch

restrain against bowstringing of extrinsic flexors

protects median nerve

46
Q

what are the structures that pass deep to the flexor retinaculum

A

4 FDS tendons
4 FDP tendons
FPL
median nerve

47
Q

what are the structures that pass superficial to the flexor retinaculum

A

ulnar nerve and artery
palmaris longus tendon
sensory branch of medial nerve

48
Q

describe the carpal tunnel

A

conduit for the medial nerve and 9 flexor tendons

common location for nerve impingement

49
Q

what are the boundaries of the carpal tunnel

A

roof - flexor retinaculum
ulnar border - hook of hamate
radial border - trapezium
floor - radiocarpal ligaments and palmar ligament complex

50
Q

describe the median nerve

A

sensory - palmar cutaneous passes superficial to flexor retinaculum or outside carpal tunnel
- innervates central palm over thenar eminence

enters carpal tunnel
- motor: APB, OP and FPB and 1st nd 2nd lumbricals
- sensory - thumb, index, middle

51
Q

what are the causes of carpal tunnel syndrome

A
  • synovitis or inflammation
  • trauma: colle’s
  • edema: pregnancy
  • metabolic: diabetes, thyroid
  • repeated stress in hands
52
Q

signs and symptoms of carpal tunnel syndrome

A

numbness or tingling in hand: thumb, index and middle

paint in wrist or hand that may extend to shoulder

weakness and clumsiness with grip and pinch

worse at night or at driving or when holding objects, gripping

severe - atrophy of thenar muscles

53
Q

how is carpal tunnel syndrome tested

A

tinel test - are over median nerve is tapped an palmar surface of wrist; if produces tingling = +

flick’s manuever - pt sitting and shakes hand vigorously; resolution of paresthesia = +

prayer’s test - full wrist and finger extension; if psi on carpal tunnel inc = +

phalen’s test - reverse prayer’s
- better test

54
Q

what is the treatment of CTS

A

conservative
- lifestyle modifications
- splinting
- medication
- NSAID
- steroids
- PT
- cortisone injections

surgical - carpal tunnel release

55
Q

describe the tunnel of guyon

A

depression superficial to flexor retinaculum betw hook of hamate and pisiform

passage of ulnar nerve and artery into hands to supply intrinsic muscles

56
Q

boundaries of tunnel of guyon

A

roof - flexor retinaculum, palmaris brevis and palmar aponeurosis

floor - pisohamate ligament and pisometacarpal ligament

57
Q

describe the ulnar nerve

A

from inferior roots of brachial plexus (C8-T1) and branches out at forearm
- palmar cutaneous: skin over hypothenar eminence
- dorsal cutaneous: dorsal aspect of fingers

motor branch passes cubital tunnel to supply FCU and FDP to 4th and 5th digits

58
Q

describe the ulnar nerve as it passes the tunnel of guyon

A

deep motor branch - FDM, ADM, ODM, AP, palmaris brevis, 3rd and 4th lumbricals, deep head of FPB and interossei

superficial sensory branch - 4ht and 5th palmary, tips dorsally

59
Q

describe canal of guyon syndrome

A

distal impingement of ulnar nerve at canal of guyon

60
Q

causes of canal of guyon syndrome

A

ganglion cyst
hook of hamate fracture/displacement
tumors
repetitive trauma
abberant tunnel or excess fat tissue w/in canal
ulnar artery thrombosis or aneurysm

61
Q

signs and symptoms of canal of guyon syndrome

A

purely motor/sensory or mixed depending on the zone of nerve lesion

motor
- weakness or paralysis of intrinsic muscles
- weakening of grip
- clawing of 4th and 5th digit: benedict sign
- advanced: hypothenar atrophy

62
Q

how to test for tunnel of guyon syndrome

A

froment’s test - grip sheet of paper using thumb; thump IP joint flexion = +

wartenberg’s sign - 5th digit is over-abducted
- seen in ulnar nerve palsy
- sensory: pain/paresthesia of medial palm and ulnar half of 4th digit and anterior of 5th digit

63
Q

differential diagnosis for canal of guyon syndrome

A
  1. test for strength of muscles
    - intrinsic: guyon
    - extrinsic: ulnar
  2. sparing of dorsal surface of hand and 4th and th fingers = guyon
  3. tinel’s - tap the nerve to identify and localiz e
63
Q

differential diagnosis for canal of guyon syndrome and cubital fossa syndrome

A
  1. test for strength of muscles
    - intrinsic: guyon
    - extrinsic: ulnar
  2. sparing of dorsal surface of hand and 4th and th fingers = guyon
  3. tinel’s - tap the nerve to identify and localiz e
64
Q

treatment for canal of guyon syndrome

A

conservative
- avoidance of stress at guyon’s canal
- ergonomical handle bar
- minimize wrist extension
- splint wrist at neutral position at night for 12 wks
- PT

surgical
- for high intensity trauma

65
Q

describe the radial nerve

A

splits into superficial and deep as enters cubital fossa

superficial: lateral border of forearm
- at wrist divides into 4-5 digital branches = sensory to lateral 2/3 of dorsal hand and lateral 2 1/2 of fingers

deep: motor to muscles of posterior compartment of forearm

66
Q

what is the palmar aponeurosis

A

deep to subcutaneous tissue from palmaris longus tendon to fascia of thenar and hypothenar up to transverse carpal ligament

continues to fingers and splits and wraps the 4 tendons around MCP

protects ulnar artery and nerve and digital nerves and vessels

67
Q

describe dupuytren’s contracture

A

fibrotic condition of palmar aponeurosis; nodule or scarring

finger flexion contracture

often in men 55-75

common in ring or 5th finger or both

common bilateral; if uni affects R

68
Q

clinical appearance of dupuytren’s contracture

A

small nodular in palmar fascia at MCP joint
flexion of MCP and PIP; DIP sparred

less or no pain - splints and stretching

non-functional or non-correctable - surgery then splint

69
Q

what is the differential diagnosis for dupuytren’s contracture

A

rule out flexion from:
- congenital malformation
- spasticity
- trauma and infection

70
Q

describe the extensor hood and extensor expansion

A

distal part of the hood receives tendons from lumbricals and distal phalanx

central band - band inserts in proximal dorsal edge of middle phalanx and insert at extensor hood on lateral slide and splits going to distal

lateral bands - rejoins over middle phalanx into terminal tendon and inserts at distal phalanx

71
Q

what are the flexor tendon zones

A

1 - tip of finger to middle phalanx; FDP

2 - middle of middle phalanx to distal palmar crease; flexor tendon superficialis and flexor tendon profundus
- no man’s land bc repair is difficult

3 - distal palmar crease to distal edge of flexor carpal ligament; lumbrical zone

4 - under carpal tunnel ligament and carpal tunnel

5 - proximal to wrist joint from origin of flexor tendons to muscle bellies to proximal carpal tunnel
- vv small in thum

72
Q

what are the extensor tendon zones

A

1 - DIPJ
2 - middle phalanx
3 - PIPJ
4 - proximal phalanx
5 - MCPj
6 - metacarpals
7 - wrist joint
8 - distal 1/3 of forearm
9 - proximal 2/3 of forearm

73
Q

what are the extensor tendon injuries

A

1 - mallet finger
2 - disruption of EPL
3 - central slip; boutonniere’s deformity
5 - fight bite

74
Q

describe mallet finger

A

rupture or avulsion of terminal extensor tendon

DIP flex while PIP extended; baseball

75
Q

what is swan neck deformity

A

hyperextended PIP and flexed DIP

related to arthritis

injury to extensor tendon insetion

76
Q

describe boutonierre’s deformity

A

affectation of central slip tendon; nothing holds PIP

PIP flexed but DIP extended

central slip rupture

77
Q

what are the flexor pulleys from proximal to distal

A

A1
A2
C1
A3
C2
A4
C3
A5

78
Q

what is trigger finger

A

pain, stiffness or locking when you bend or straighten finger

ring and thumb are most affected

swelling of flexor tendon
- A1 pulley becomes inflamed = hard for tendon to glide
- FDP nodule = same effect

79
Q

what are the classifications of trigger finger

A

1 - pain on A1 pulley
2 - triggering on PE can extend PIP active
3A - PIP extended passively
3B - patient cannot flex
4 - rigid or stuck in flexion or extension

80
Q

etiology of trigger finger

A

2-3% of gen pop

10% of diabetic popu - common in diabetic

more common in females over 50

81
Q

treatment of trigger finger

A

non-operative:
- splinting
- modify activity
- NSAID
- corticosteroid injections
- PT

operative:
- percutaneous release of A1 pulley
- open surgical debridement and release of A1

82
Q

describe swan neck deformity

A

most frequent deformity in fingers
- if thumb = zigzag deformity

hyperextention of PIP and flexion of DIP

inability to grasp

82
Q

causes of swan neck deformity

A

lax volar plate

imbalance of extension > flexion force on PIP = passive flexion of DIP

rupture of FDS

83
Q

describe ulnar drift

A

ulnar shift and deviation at MCP w rheumatoid arthritis

more common than radial bc of opening bottles, doors

MCP capsule and ligaments are stretched = loosens collateral ligaments and dec joint stability

84
Q

describe intrinsic minus deformity

A

claw hand - strong extrinsic; no intrinsic

MCP hyperextension and PIP and DIP flexion

85
Q

causes of intrinsic minus deformity

A

ulnar nerve palsy - cubital or ulnar tunnel

median nerve palsy
- volkmann’s ischemic fracture
- leprosy: hansen’s
- failure to splint in intrinsic plus

charcot-marie-tooth disease - hereditry

compartment syndrome of hand

86
Q

describe intrinsic plus hand

A

spastic intrinsics and weak extrinsics

MCP flexion and PIP and DIP extension

87
Q

describe gamekeeper’s thumb

A

rupture of collateral ligament on ulnar side of thumb at MCPJ

overextended and abducted

skier’s thumb; deals w cards

88
Q

what are the causes of gamekeeper’s thumb

A

blow or fall on extended thumb

repeated abduction of thumb

89
Q

signs and symptoms of gamekeeper’s thumbs

A

pain at base of thumb
swelling at base
difficulty grabbing and throwing
unstable or wobbly thumb
brusing
weak thumb-index pinch

90
Q

what is the treatment of gamekeeper’s thumb

A

incomplete acute tears - immobilize for 4-6 wks

acute complete and chronic fracture - surgery

91
Q

decribe the piano key sign

A

floating ulnar styloid due to damage to radioulnar ligament

ulnar styloid moves when applying pressure to finger

causes:
arthtritic conditions
ligament laxity
trauma
overuse

pt momints ver 2.0 (14 decks)

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