Flashcards in Orthopaedics - Hand, wrist and elbow Deck (70)
What causes De Quervain's disease?
The cause is unknown, but symptoms can be exacerbated by overuse of the tendons.
How is De Quervain's disease treated?
First try rest (thumb spica splint), ice and NSAIDs. Hydrocortisone injection at tend side during the 1st 6 months of symptoms is effective in 90% of patients. If injection and rest fail to relieve, decompression of the tendons is provided by splitting the tendon sheaths, >80% do well post op.
What is trigger finger? Which fingers are most
Trigger finger (or tendon nodules) is probably caused by a swelling of the flexor tendon, or tightening of the flexor tendon sheath. Ring and middle fingers are most commonly affected, and the thumb especially in babies and children. Swelling of the tendon sheath along with nodule formation on the tendon, proximal to the A1 pulley prevents smooth gliding of the tendon. As a result, the tendon "catches" causing the finger to lock in flexion. As extension occurs the nodule moves with the flexor tendon, but then becomes jammed on the proximal side of the pulley, and has to be flicked straight so producing triggering.
How is trigger finger treated?
Simple immobilisation is the initial treatment of choice. If severe, steroid injection into the region of the nodule may be tried (not if the patient is a child, has renal failure or diabetes). Risk of recurrence is high, so surgery may be needed.
What is Volkmann's ischaemic contracture?
This follows compartment syndrome or interruption of the brachial artery near the elbow (e.g. after supracondylar fracture of the humerus). Muscle necrosis (especially flexor pollicis longus and flexor digitorum profundus) result in contraction and fibrosis causing a flexion deformity at wrist and elbow with forearm pronation, wrist flexion, thumb flexion and adduction, digital MCP joint extension and interphalangeal joint flexion.
Suspect compartment syndrome if a damaged arm has no radial pulse, and passive finger extension is painful (a crucial sign).
How is Volkmann's contracture treated?
Firstly, remove any constricting splints, and warm other limbs (promotes vasodilation). If pulse doesn't return within 30 mins, exploration of the artery is needed.
To treat the contracture, release of any compressed nerves and tendon lengthening usually restores lost function.
What is the function of the flexor tendon pulley mechanism?
In order to stop the long flexor tendons of the hand bowing when the fingers are flexed, the fingers have a number of pulleys attached to the bones and volar plates beneath. Named as either A for annular or C for cruciate, there are 5 A pulleys and 3 C pulleys. The most important are A2 (which is at the proximal end of the proximal phalanx) and A4 (at the middle of the middle phalanx) both of which NEED to be preserved during any surgery to prevent bowing of the flexor tendons.
What is a Colles fracture?
This is a distal radius fracture.
It occurs following a fall onto an outstretched hand.
Most common in elderly females with OA.
Physical signs include the dinner fork deformity.
How should a Colles' fracture be managed?
Examine for neurovascular injury as the median and radial nerves are close.
If there is considerable displacement then reduce the fracture:
- under haematoma block, IV regional anaesthesia (Bier's) or GA
- Disimpact and correct angulation
- Position: ulnar deviation + some wrist flexion
- Apply dorsal backslab: provide 3 point pressure
Re-X ray, satisfactory position?
- No: ortho review and consider MUA +/- K wires
- Yes: home with fracture clinic review, and follow up fowithin 48 hours