Hand/Wrist PE General The patient is in no acute ______, mood and affect are a_____, a____ and o______ times three. Note HAND D_______\ (true for any upper extremity examination) Inspection Both hands/wrists appear sy_______. S_____ is intact about both hands/wrists without erythema. Generally very _____ soft tissue envelope; can use your x-ray vision!

General The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three. Note HAND DOMINANCE (true for any upper extremity examination) Inspection Both hands/wrists appear symmetric. Skin is intact about both hands/wrists without erythema. Generally very minimal soft tissue envelope; can use your x-ray vision!

ROM Look fo ______try ____ion/______ion ____ation/____ination Radial/Ulnar D______ Symmetric Finger Ex_______ Fi__ / Finger Cas______ / Rotational or Angular Deformities

Look for symmetry Flexion/Extension Pronation/Supination Radial/Ulnar Deviation Symmetric Finger Extension Fist / Finger Cascade / Rotational or Angular Deformities

Common Conditions _______ Tunnel Syndrome Tr______ Finger De Q_____'s Tenosynovitis _____ Joint Arthritis G_____ Cyst D_______’s Disease Some acute injuries / conditions appropriate to review here: Infectious flexor teno_____ S_____ Fracture B______’s fracture ______ radius fracture (Colles, Smith) ______keeper’s thumb M_______ finger

Carpal Tunnel Syndrome Trigger Finger De Quervain's Tenosynovitis Basal Joint Arthritis Ganglion Cyst Dupuytren’s Disease Some acute injuries / conditions appropriate to review here: Infectious flexor tenosynovitis Scaphoid Fracture Boxer’s fracture Distal radius fracture (Colles, Smith) Gamekeeper’s thumb Mallet finger

Carpal Tunnel Syndrome History/Symptoms _____ness and t_____ in radial (1) digits C______ness Pain and paresthesias that awaken patient at ______

Numbness and tingling in radial 3-1/2 digits Clumsiness Pain and paresthesias that awaken patient at night

Carpal Tunnel Syndrome When to Refer Symptoms not responsive to N_____, sp______, ______modification (1)/weakness (although results of surgery are less favorable in these advanced stages)

Symptoms not responsive to NSAIDs, splints, activity modification Thenar atrophy / weakness (although results of surgery are less favorable in these advanced stages)

Trigger Finger History and Symptoms Usually pro_____ P_____ at the level of the _ _ pulley Cl_____/ Ca______ Finger becomes "_____" in ______ position at the _ _ _ joint May have referred pain to ________ _ _ P/_ _ P region

Usually progressive Pain at the level of the A1 pulley Clicking / Catching Finger becomes "locked" in flexed position at the proximal interphalangeal (PIP) joint May have referred pain to dorsal MCP/PIP region

De Quervain's Tenosynovitis Prevalence Very common ~1 per 1000 people annually Women _ Men __ - __ years old More commonly ________ wrist

Very common ~1 per 1000 people annually Women \> Men 30 - 50 years old More commonly dominant wrist

De Quervain's Tenosynovitis Diagnosis is made cl_______ with ______ sided _____ pain made worse with the _______ maneuver. Treatment is generally conservative with thumb spica _____, in_____ and in refractory cases, 1st dorsal compartment surgical ______.

Diagnosis is made clinically with radial sided wrist pain made worse with the Finkelstein maneuver. Treatment is generally conservative with thumb spica braces, injections and in refractory cases, 1st dorsal compartment surgical release.

Orthopedics Hand/Wrist Flashcards by Felita Salim

Normal Anatomy Hand/Wrist

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Compartments of the Hand

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Hand/Wrist PE

General
- The patient is in no acute ______, mood and affect are a_____, a____ and o______ times three.
- Note HAND D_______* (true for any upper extremity examination)
Inspection
- Both hands/wrists appear sy_______.
- S_____ is intact about both hands/wrists without erythema.
- Generally very _____ soft tissue envelope; can use your x-ray vision!

General
- The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
- Note HAND DOMINANCE (true for any upper extremity examination)
Inspection
- Both hands/wrists appear symmetric.
- Skin is intact about both hands/wrists without erythema.
- Generally very minimal soft tissue envelope; can use your x-ray vision!

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Tenderness to Palpation

_____ joint? where the metacarpal bone of the thumb meets the trapezium bone in the wrist.
______ dorsal compartment?
Sc_____?

Basal joint?
First dorsal compartment?
Scaphoid?

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ROM

Look fo ______try
____ion/______ion
____ation/____ination
Radial/Ulnar D______
Symmetric Finger Ex_______
Fi__ / Finger Cas______ / Rotational or Angular Deformities

Look for symmetry
Flexion/Extension
Pronation/Supination
Radial/Ulnar Deviation
Symmetric Finger Extension
Fist / Finger Cascade / Rotational or Angular Deformities

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Strength, Sensation, Stability

Strength
- Finger Extension (______)
- Finger Abduction/Adduction (______)
- Thumb IP flexion (______)
Sensation
- Medial / Radial / Ulnar
Stability
- Hand / Wrist / DRUJ Instability = (1)?

Strength
- Finger Extension (Radial)
- Finger Abduction/Adduction (Ulnar)
- Thumb IP flexion (Median)
Sensation
- Medial / Radial / Ulnar
Stability
- Hand / Wrist / DRUJ Instability = Distal radioulnar joint instability is the abnormal orientation or movement of the radius and ulna bones at the wrist in relation to one another

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Common Conditions

_______ Tunnel Syndrome
Tr______ Finger
De Q_____’s Tenosynovitis
_____ Joint Arthritis
G_____ Cyst
D_______’s Disease
Some acute injuries / conditions appropriate to review here:
- Infectious flexor teno_____
- S_____ Fracture
- B______’s fracture
- ______ radius fracture (Colles, Smith)
- ______keeper’s thumb
- M_______ finger

Carpal Tunnel Syndrome
Trigger Finger
De Quervain’s Tenosynovitis
Basal Joint Arthritis
Ganglion Cyst
Dupuytren’s Disease
Some acute injuries / conditions appropriate to review here:
- Infectious flexor tenosynovitis
- Scaphoid Fracture
- Boxer’s fracture
- Distal radius fracture (Colles, Smith)
- Gamekeeper’s thumb
- Mallet finger

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Carpul Tunnel Syndrome

Co_______ neuropathy of the _____ nerve at the wrist (the carpal tunnel)
Very common
- Up to 10% of general population
Pain, numbness, tingling
Causes
- R______ motion / vi_______
- Certain athletic activities (e.g. cycling, tennis, throwing)
Associated conditions (4)

Compressive neuropathy of the median nerve at the wrist (the carpal tunnel)
Very common
- Up to 10% of general population
Pain, numbness, tingling
Causes
- Repetitive motion / vibration
- Certain athletic activities (e.g. cycling, tennis, throwing)
Associated conditions
- DM, hypothyroid, RA, pregnancy

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Carpal Tunnel Syndrome History/Symptoms

_____ness and t_____ in radial (1) digits
C______ness
Pain and paresthesias that awaken patient at ______

Numbness and tingling in radial 3-1/2 digits
Clumsiness
Pain and paresthesias that awaken patient at night

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Carpel Tunnel Syndrome PE

_____ness in median distribution
- Loss of __-point discrimination
Thenar ______
Special Tests (3)

Numbness in median distribution
- Loss of 2-point discrimination
Thenar atrophy
Special Tests
- Durkan
  - Carpal compression test - paresthesia
- Phalen
- Tinel - tapping and getting paresthesia

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Carpal Tunnel Syndrome Studies

(1)/Imaging:
- Not necessary or helpful
(1)/(1)
- Provides objective evidence of a compressive neuropathy
- Not needed to establish diagnosis
- NCV
  - ______ conduction
(1)
- Tests the electrical activity of individual muscle fibers and motor units
Severe NCV/EMG findings tend to improve less than patients with moderate findings

XR/Imaging:
- Not necessary or helpful
EMG/NCV
- Provides objective evidence of a compressive neuropathy
- Not needed to establish diagnosis
- NCV
  - Slowed conduction
EMG
- Tests the electrical activity of individual muscle fibers and motor units
Severe NCV/EMG findings tend to improve less than patients with moderate findings

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Carpal Tunnel Syndrome Non-Operative Treatment

NSAIDs
Night _______
- We tend to sleep with wrists flexed
Activity Modification
- Avoid / modify agg_______ activities
S______ injections
- If initial treatments are not helping
- Sometimes useful (diagnostic utility) in clinically and EMG/NCV-equivocal cases
- Failure to improve with an injection is a poor prognostic indicator for ______

NSAIDs
Night Splints
- We tend to sleep with wrists flexed
Activity Modification
- Avoid / modify aggravating activities
Steroid injections
- If initial treatments are not helping
- Sometimes useful (diagnostic utility) in clinically and EMG/NCV-equivocal cases
- Failure to improve with an injection is a poor prognostic indicator for surgery

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Carpal Tunnel Syndrome Operative Treatment

(1)

Carpal tunnel release (open or endoscopic; no difference) - just making room for the nerve

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Carpal Tunnel Syndrome When to Refer

Symptoms not responsive to N_____, sp______, ______modification
(1)/weakness (although results of surgery are less favorable in these advanced stages)

Symptoms not responsive to NSAIDs, splints, activity modification
Thenar atrophy / weakness (although results of surgery are less favorable in these advanced stages)

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Trigger Finger

The inhibition of smooth tendon ______ due to mechanical _______ at the level of the _ _ p_____that causes progressive p____, cl____, ca____, and lo______ of the digit.
Trigger Finger = St_______ Ten______
Very common
- 2-3% of general population
- 10% of d______ population
- (3) fingers are most commonly affected
Sw______, and sometimes a n______ on the flexor tendon

The inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking, catching, and locking of the digit.
Trigger Finger = Stenosing Tenosynovitis
Very common
- 2-3% of general population
- 10% of diabetic population
- Ring Finger, Middle Finger, and Thumb are most commonly affected
Swelling, and sometimes a nodule on the flexor tendon

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Trigger Finger History and Symptoms

Usually pro_____
P_____ at the level of the _ _ pulley
Cl_____/ Ca______
Finger becomes “_____” in ______ position at the _ _ _ joint
May have referred pain to ________ _ _ P/_ _ P region

Usually progressive
Pain at the level of the A1 pulley
Clicking / Catching
Finger becomes “locked” in flexed position at the proximal interphalangeal (PIP) joint
May have referred pain to dorsal MCP/PIP region

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Trigger Finger PE

Palpation
- T____ness at level of A1 _____
- Palpable n______ of the flexor tendon
Motion
- Triggering with digit _____ and _____
- Fixed ______ of _IP joint
Provocative test
- Flexion and extension of the digit may reproduce symptoms

Palpation
- Tenderness at level of A1 pulley
- Palpable nodule of the flexor tendon
Motion
- Triggering with digit flexion and extension
- Fixed flexion of PIP joint
Provocative test
- Flexion and extension of the digit may reproduce symptoms

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Trigger Finger Imaging

No X-rays or other studies needed

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Trigger Finger Non-Op Treatment

(1)
- (1) the hand and avoiding activities that make it worse may be enough to resolve the problem.
NSAIDs
(1)
- Wearing one at night to keep the affected finger or thumb in a straight position
Exercises
- Gentle st______ exercises can help decrease _____ness and improve range of motion in the involved digit.
Steroid injections
- If ____ injections do not help the problem, surgery may be considered.

Rest
- Resting the hand and avoiding activities that make it worse may be enough to resolve the problem.
NSAIDs
Splints
- Wearing a splint at night to keep the affected finger or thumb in a straight position
Exercises
- Gentle stretching exercises can help decrease stiffness and improve range of motion in the involved digit.
Steroid injections
- If two injections do not help the problem, surgery may be considered.

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Trigger Finger Operative Treatment

(1)

Trigger Finger Release (release A1 pulley)

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Trigger Finger When to Refer?

Symptoms not responsive to (3)

Symptoms not responsive to NSAIDs, splints, activity modification

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De Quervain’s Tenosynovitis

De Quervain’s Tenosynovitis is a st_______ tenosynovial inflammation of the (1) compartment.
Risk Factors
- _____use (esp. Golfers and racquet sports)
- After hand in_______
- Post______
Etiology
- Th______ and sw______ of the (1) causing increased tendon friction

De Quervain’s Tenosynovitis is a stenosing tenosynovial inflammation of the 1st dorsal compartment.
Risk Factors
- Overuse (esp. Golfers and racquet sports)
- After hand injuries
- Postpartum
Etiology
- Thickening and swelling of the extensor retinaculum causing increased tendon friction

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De Quervain’s Tenosynovitis Prevalence

Very common
- ~1 per 1000 people annually
- Women _ Men
- __ - __ years old
- More commonly ________ wrist

Very common
- ~1 per 1000 people annually
- Women > Men
- 30 - 50 years old
- More commonly dominant wrist

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De Quervain’s Tenosynovitis

Diagnosis is made cl_______ with ______ sided _____ pain made worse with the _______ maneuver.
Treatment is generally conservative with thumb spica _____, in_____ and in refractory cases, 1st dorsal compartment surgical ______.

Diagnosis is made clinically with radial sided wrist pain made worse with the Finkelstein maneuver.
Treatment is generally conservative with thumb spica braces, injections and in refractory cases, 1st dorsal compartment surgical release.

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De Quervain's Tenosynovitis History and Symptoms ## Footnote * Pain over (1) compartment * Usually gradual * Worse pain with g\_\_\_\_ing, r\_\_\_\_\_ objects with wrist in _____ position

* Pain over first dorsal compartment * Usually gradual * Worse pain with gripping, raising objects with wrist in neutral position

De Quervain's Tenosynovitis PE ## Footnote * T\_\_\_\_\_\_\_ness over first dorsal compartment * Especially at level of radial st\_\_\_\_\_ * Usually normal wrist ROM but pain with re\_\_\_\_\_\_ radial de\_\_\_\_\_ * _____ neurovascular examination

* Tenderness over first dorsal compartment * Especially at level of radial styloid * Usually normal wrist ROM but pain with resisted radial deviation * Normal neurovascular examination

De Quervain's Tenosynovitis Finkelstein’s Test ## Footnote * On grasping the _____ and quickly \_\_\_ducting the hand towards the \_\_\_\_\_, the pain over the styloid tip is painful * More indicative of ___ \> ___ tendon pathology

* On grasping the thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is painful * More indicative of EPB (extensor pollicis brevis) \> APL (abductor pollicis longus) tendon pathology

De Quervain's Tenosynovitis Imaging (1)

Usually not necessary BUT can be useful to rule out basal joint arthritis of the tumb

De Quervain's Tenosynovitis Non-Op Treatment ## Footnote * Non-operative * NSAIDs * Thumb Spica \_\_\_\_\_\_ * R\_\_\_\_/ A\_\_\_\_\_\_ Modification * ______ injections * If initial treatments are not helping

* Non-operative * NSAIDs * Thumb Spica Splints * Rest / Activity Modification * Steroid injections * If initial treatments are not helping

De Quervain's Tenosynovitis Operative Treatment (1) Usually considered how long after non-op managment?

Release of first dorsal compartment Usually considered only after 6-months of failed non-op management

De Quervain's Tenosynovitis When to Refer Symptoms not responsive to (3)

Not responsive to NSAIDs, splints, activity modification

Basal Joint Arthritis ## Footnote * Basal Joint = Base of Thumb * **(1) Joint** * Pain at the _____ of the thumb and difficulty with pi\_\_\_\_ and gr\_\_\_\_\_ * Diagnosis is made clinically with a painful CMC _____ test and radiographs of the hand showing \_\_\_\_\_\_\_\_of the 1st CMC joint. * Treatment can be conservative (bracing, injections) or operative depending on the severity of symptoms and the stage of disease.

* Basal Joint = Base of Thumb * CMC joint * Pain at the base of the thumb and difficulty with pinching and grasping * Diagnosis is made clinically with a painful CMC grind test and radiographs of the hand showing osteoarthritis of the 1st CMC joint. * Treatment can be conservative (bracing, injections) or operative depending on the severity of symptoms and the stage of disease.

Basal Joint Arthritis ## Footnote * Common * 2nd most common hand arthritis * __ IP \> Thumb CMC \> \_IP \> _ \_P * Seen in \_\_% of men and \_\_% of women aged \> __ years old * Risk Factors * _____ gender * E\_\_\_\_-D\_\_\_\_\_ syndrome * ______ BMI * Etiology * Thought to be related to inst\_\_\_\_/sub\_\_\_\_\_ of the CMC joint

* Common * 2nd most common hand arthritis * DIP \> Thumb CMC \> PIP \> MCP * Seen in 25% of men and 40% of women aged \> 75 years old * Risk Factors * Female gender * Ehler-Danlos syndrome * Increased BMI * Etiology * Thought to be related to instability/subluxation of the CMC joint

Basal Joint Arthritis History ## Footnote * History / Symptoms * _____ at base of thumb * Difficulty \_\_\_\_\_\_/\_\_\_\_\_\_ * Differentiate from (1)

* History / Symptoms * Pain at base of thumb * Difficulty pinching/grasping * Differentiate from De Quervain's

Basal Joint Arthritis Physical Exam ## Footnote * Sw\_\_\_\_\_ / Cr\_\_\_\_\_ basal joint * Tenderness over ____ joint, not over course of ____ dorsal \_\_\_\_\_\_\_ * Metacarpal \_\_duction / MCP fixed hy\_\_\_\_extension (later findings)

* Swelling / Crepitus basal joint * Tenderness over CMC joint, not over course of first dorsal compartment * Metacarpal adduction / MCP fixed hyperextension (later findings) * Special Test

CMC Grind Test ## Footnote Combined axial com\_\_\_\_\_ and cir\_\_\_duction Positive test =

Combined exial compression and circumduction Positive if pain and crepitus is elicited

Basal Joint Arthritis Imaging ## Footnote * XR/Imaging: * **(2) Views +** * **(1) View** * X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb hyperpronated

* XR/Imaging: * AP * Lateral * Roberts view * X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb hyperpronated

Basal Joint Arthritis Non Op Treatment ## Footnote * N\_\_\_\_\_s * Thumb Spica \_\_\_\_\_ * R\_\_\_ / A\_\_\_\_\_\_ Modification * ______ injections * If initial treatments are not helping

* NSAIDs * Thumb Spica Splints * Rest / Activity Modification * Steroid injections * If initial treatments are not helping

Basal Joint Arthritis Operative Tx ## Footnote * CMC arthro\_\_\_\_\_, fu\_\_\_\_ * Many different techniques...

* CMC arthroplasty, fusion * Many different techniques...

Basal Joint Arthritis When to Refer ## Footnote Symptoms not responsive to (3)

Symptoms not responsive to NSAIDs, splints, activity modification

Ganglion Cyst ## Footnote * Most common mass or lump in the hand * **\_\_\_\_\_-filled synovial \_\_\_\_\_** * ______ to do with nerve ganglion... * Not dangerous, usually \_\_\_\_less * Only reason to address is pain/discomfort, sometimes cos\_\_\_\_\_\_

* Most common mass or lump in the hand * **Mucin-filled synovial cysts** * Nothing to do with nerve ganglion... * Not dangerous, usually harmless * Only reason to address is pain/discomfort, sometimes cosmesis

Ganglion Cyst ## Footnote * Most frequently develop on the back of the wrist (d\_\_\_\_\_ carpal ganglion) * Causes * Tr\_\_\_\_\_ * De\_\_\_\_\_\_ changes * Rises out of a joint, like a “ba\_\_\_\_\_ on a stalk" * Note: Called a mucous cyst if it affects DIP joint * Not only hand (feet too...rare)

* Most frequently develop on the back of the wrist (dorsal carpal ganglion) * Causes * Trauma * Degenerative changes * Rises out of a joint, like a “balloon on a stalk” * Note: Called a mucous cyst if it affects DIP joint * Not only hand (feet too...rare)

Ganglion Cyst History and Symptoms ## Footnote * Usually \_\_symptomatic? * Can cause p\_\_\_\_/dis\_\_\_\_\_ (e.g. push-ups) * Can cause compressive neur\_\_\_\_\_\_ * \_\_\_\_mesis issues

* Usually asymptomatic * Can cause pain / discomfort (e.g. push-ups) * Can cause compressive neuropathies * Cosmesis issues

Ganglion Cyst Physical Exam ## Footnote * Trans\_\_\_\_\_\_\_! (Special Test) * F\_\_\_\_ and well cir\_\_\_\_\_\_\_\_ * Often fi\_\_\_ to deep tissue but not to overlying skin

* Transilluminates! * Firm and well circumscribed * Often fixed to deep tissue but not to overlying skin

Ganglion Cyst Imaging ## Footnote * XR/Imaging ? * MRI/Ultrasound? * Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not \_\_\_\_, or to distinguish the cyst from other tu\_\_\_\_\_.

* XR/Imaging: * Not necessary or helpful * MRI/Ultrasound * Very rarely done/needed * Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

Ganglion Cyst Non-Op Treatment ## Footnote * Non-operative * Observation (most \_\_\_\_\_\_, especially in kids) * “Closed Rupture” * Hit it with a bible (!) - *?* * _____ recurrence * As\_\_\_\_\_ / In\_\_\_\_\_ * _____ recurrence * Avoid on the volar side (radial artery)

* Non-operative * Observation (most resolve, especially in kids) * “Closed Rupture” * Hit it with a bible (!) - *old method, to rupture it, dont’ do it, high recurrence* * High recurrence * Aspiration / Injection * High recurrence * Avoid on the volar side (radial artery)

Ganglion Cyst Operative Treatment ## Footnote * Need to resect st\_\_\_\_ as well as adjacent cap\_\_\_\_\_ to reduce recurrence risk * For mucous cysts (DIP), need to resect associated osteophyte

* Need to resect stalk as well as adjacent capsule to reduce recurrence risk * For mucous cysts (DIP), need to resect associated osteophyte

Ganglion Cyst When to Refer ## Footnote Symptoms not responsive to obs\_\_\_\_/reass\_\_\_\_\_\_ (surgery is not \_\_\_\_)

Symptoms not responsive to observation / reassurance (not urgent)

Dupuytren's Disease ## Footnote * **B\_\_\_\_\_ proliferative disorder characterized by decreased hand f\_\_\_\_\_\_\_ caused by hand con\_\_\_\_\_\_ and painful fascial n\_\_\_\_\_.** *Th\_\_\_\_\_ of the fascia* * Diagnosis can be made by physical examination which shows painful n\_\_\_\_\_\_ in the palm with associated digital con\_\_\_\_\_\_. * Treatment ranges from nonoperative passive str\_\_\_\_\_\_ to in\_\_\_\_\_\_, needle \_\_\_\_neurotomy, and operative open f\_\_\_\_\_tomy if the disease progresses or affects a patient's daily living.

* **Benign proliferative disorder characterized by decreased hand function caused by hand contractures and painful fascial nodules.** *Thickening of the fascia* * Diagnosis can be made by physical examination which shows painful nodules in the palm with associated digital contracture. * Treatment ranges from nonoperative passive stretching to injections, needle aponeurotomy, and operative open fasciectomy if the disease progresses or affects a patient's daily living.

Dupuytren’s Disease ## Footnote * Epidemiology * \_\_:\_\_ male to female ratio * \_\_th to \_\_th decade of life * Most commonly in ______ (ethnicity) males of northern European descent * ______ in South America, Africa, China * \_\_\_\_\_\> small \> middle \> index * Myo\_\_\_\_\_\_\_ is the dominant cell type * Associated conditions: H _ \_, al\_\_\_\_\_\_ism, di\_\_\_\_\_\_, anti s\_\_\_\_\_\_ medications

* Epidemiology * 2:1 male to female ratio * 5th to 7th decade of life * Most commonly in caucasian males of northern European descent * Rare in South America, Africa, China * Ring \> small \> middle \> index * Myofibroblast is the dominant cell type * Associated conditions: HIV, alcoholism, diabetes, anti seizure medications

Dupuytren's Disease History and Symptoms ## Footnote * Decreased _ \_ _ affecting _ \_ \_ * \_\_\_\_ful N\_\_\_\_\_\_

* Decreased ROM affecting ADL * Painful Nodules

Dupuytren's Disease PE ## Footnote * \_\_\_\_ful no\_\_\_\_\_ and co\_\_\_ * Usually r\_\_\_\_ or small fingers * Look for \_\_lateral involvement and ask about other possible locations (rare, but can indicate a more ______ form of Dupuytren’s) * Plantar Fascia: Ledderhose's disease * Penis: Peyronie’s disease

* Painful nodules and cords * Usually ring or small fingers * Look for bilateral involvement and ask about other possible locations (rare, but can indicate a more aggressive form of Dupuytren’s) * Plantar Fascia: Ledderhose's disease * Penis: Peyronie’s disease

Hueston's Tabletop Test ## Footnote Ask patient to place palm? Look for (2)

Ask patient to place palm flat on table Look for MCP or PIP contracture

Dupuytren's Disease Imaging ## Footnote \_\_\_\_\_\_ Diagnosis, Imaging?

Clinical Diagnosis, No imaging

Dupuytren’s Disease Non-Operative Treatment ## Footnote * R _ \_ exercises * C\_\_\_\_\_\_\_\_ Injection (Xiaflex) * Causes lysis and _______ of cords * Low activity against type IV collagen (in basement membrane of blood vessels and nerves) explaining the ___ neurovascular complication rate * Works best for _______ contractures (MCP more than PIP) * Needle \_\_\_\_\_\_\_\_ * Percutaneous needle technique; mostly for _____ contractures

* Range of motion exercises * Collagenase Injection (Xiaflex) * Causes lysis and rupture of cords * Low activity against type IV collagen (in basement membrane of blood vessels and nerves) explaining the low neurovascular complication rate * Works best for smaller contractures (MCP more than PIP) * Needle aponeurotomy * Percutaneous needle technique; mostly for smaller contractures

Dupuytren's Disease Operative Treatment ## Footnote * Surgical resection / \_\_\_\_\_\_tomy * MCP flexion contractures \> \_\_\_-degrees * _____ PIP flexion contracture * Note: painful nodules are ____ an indication for surgery

* Surgical resection / fasciectomy * MCP flexion contractures \> 30-degrees * ANY PIP flexion contracture * Note: painful nodules are not an indication for surgery

Acute hand injuries / conditions...1 slide each! (6)

**Infectious flexor tenosynovitis** **Scaphoid Fracture** **Boxer’s fracture** **Distal radius fracture (Colles, Smith)** **Gamekeeper’s thumb** **Mallet finger**

Infectious flexor tenosynovitis ## Footnote * Py\_\_\_\_\_ flexor tenosynovitis is an infection of the synovial sh\_\_\_\_ that surrounds the flexor tendon. * Diagnosis is made clinically with the presence of the **4 K\_\_\_\_\_ signs**. * Treatment is urgent irr\_\_\_\_\_ and de\_\_\_\_\_\_ of the flexor tendon sheath with **(1)\***

* Pyogenic flexor tenosynovitis is an infection of the synovial sheath that surrounds the flexor tendon. * Diagnosis is made clinically with the presence of the **4 Kanavel signs.** * Treatment is urgent irrigation and debridement of the flexor tendon sheath with **IV antibiotics.**

Kanavel signs (4 total) ## Footnote 1. f\_\_\_\_\_ posturing of the involved digit 2. _______ to palpation over the tendon sheath 3. marked pain with passive ______ of the digit 4. \_\_\_\_form sw\_\_\_\_\_\_ of the digit (“\_\_\_\_\_ digit”)

1. flexed posturing of the involved digit 2. tenderness to palpation over the tendon sheath 3. marked pain with passive extension of the digit 4. fusiform swelling of the digit (“sausage digit”) *Note: fusiform = spindle shaped, tapering at both ends*

Scaphoid Fracture ## Footnote * Scaphoid Fractures are the ______ common carpal bone fracture, often occurring after a ____ onto an \_\_\_\_stretched hand. * Diagnosis can generally be made by dedicated radiographs but (1) or (1) may be needed for confirmation. * Treatment may require a prolonged period of ____ immobilization, per\_\_\_\_\_\_ surgical fixation, or o\_\_\_ reduction and in\_\_\_\_\_ fixation

* Scaphoid Fractures are the most common carpal bone fracture, often occurring after a fall onto an outstretched hand. * Diagnosis can generally be made by dedicated radiographs but CT or MRI may be needed for confirmation. * Treatment may require a prolonged period of cast immobilization, percutaneous surgical fixation, or open reduction and internal fixation

Scaphoid Fracture ## Footnote * Can be ______ on plain x-rays * \_\_\_\_mobilize and refer if snuff box T _ \_ * Thumb spica * _____ healing due to tenuous retrograde blood flow * Non-un\_\_\_\_ can lead to future _____ degenerative changes

* Can be missed on plain x-rays * Immobilize and refer if snuff box TTP * Thumb spica * Poor healing due to tenuous retrograde blood flow * Non-union can lead to future early degenerative changes

Boxer's Fracture ## Footnote * **\_\_\_\_\_\_\_\_ Fractures** are the **most common hand injury** and are divided into fractures of the head, neck, or shaft. * **Diagnosis** is made by orthogonal ______ the hand. * **Treatment** is based on which metacarpal is involved, lo\_\_\_\_\_\_ of the fracture, and the ro\_\_\_\_\_/ang\_\_\_\_\_ of the injury.

* **Metacarpal Fractures** are the **most common hand injury** and are divided into fractures of the head, neck, or shaft. * **Diagnosis** is made by orthogonal radiographs the hand. * **Treatment** is based on which metacarpal is involved, location of the fracture, and the rotation/angulation of the injury.

Boxer's Fracture Non-Operative Tx ## Footnote * Generally non-op if: * No ro\_\_\_\_\_\_\_ deformity * Shaft angulation * ____ finger: 40-degrees * _____ finger: 30-degrees * _____ finger: 20-degrees * _____ finger: 10-degrees

* Generally non-op if: * No rotational deformity * Shaft angulation * Little finger: 40-degrees * Ring finger: 30-degrees * Middle finger: 20-degrees * Index finger: 10-degrees

Distal radius fracture (Colles, Smith) ## Footnote * Distal radius fractures are one of the most common orthopaedic injuries and generally result from ___ on an _______ hand. * Diagnosis is made ______ and _______ with orthogonal radiographs of the wrist * Treatment can be nonoperative or operative depending on fracture st\_\_\_\_ and fracture dis\_\_\_\_\_ as well as patient a\_\_\_ and a\_\_\_\_\_\_demands * Appropriate to refer ____ fractures

* Distal radius fractures are one of the most common orthopaedic injuries and generally result from fall on an outstretched hand. * Diagnosis is made clinically and radiographically with orthogonal radiographs of the wrist * Treatment can be nonoperative or operative depending on fracture stability and fracture displacement as well as patient age and activity demands * Appropriate to refer all fractures

Gamekeeper's Thumb (AKA Skier's thumb) ## Footnote * Most thumb sprains involve the (1) ligament, which is located on the _____ of the knuckle joint. * Treatment for a sprained thumb usually involves wearing a sp\_\_\_\_or c\_\_\_ to keep the thumb from moving while the ligament heals. * For more severe sprains, _____ may be needed to restore stability to the joint. * Thumb _____ brace * Referral appropriate if s/p injury and there is any concern for ins\_\_\_\_\_\_

* Most thumb sprains involve the ulnar collateral ligament, which is located on the inside of the knuckle joint. * Treatment for a sprained thumb usually involves wearing a splint or cast to keep the thumb from moving while the ligament heals. * For more severe sprains, surgery may be needed to restore stability to the joint. * Thumb spica brace * Referral appropriate if s/p injury and there is any concern for instability

Mallet Finger (Baseball Finger) Definition ## Footnote * Deformity caused by disruption of the _______ extensor tendon _____ to the (1) joint * Usually caused by a traumatic imp\_\_\_\_\_\_ blow (i.e. sudden forced \_\_\_\_\_) to the tip of the finger in the ______ position

* Deformity caused by disruption of the terminal extensor tendon distal to DIP joint * Usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the finger in the extended position

Mallet Finger (Baseball Finger) ## Footnote * Diagnosis is made clinically with a presence of a distal phalanx that rests at ~\_\_\_° of _______ with lack of active DIP \_\_\_\_\_\_\_. * Treatment * Usually extension sp\_\_\_\_\_\_ of DIP joint for \_-\_ weeks. * Surgical management is indicated for volar sub\_\_\_\_\_\_ of the distal phalanx, ch\_\_\_\_\_ injuries, or with the presence of significant ar\_\_\_\_\_\_\_. * Bony Mallet: usually surgery if * \>\_\_\_% articular surface * \>\_\_ mm articular gap * FYI…”jersey finger” is flexor tendon \_\_\_\_\_\_\_...

* Diagnosis is made clinically with a presence of a distal phalanx that rests at ~45° of flexion with lack of active DIP extension. * Treatment * Usually extension splinting of DIP joint for 6-8 weeks. * Surgical management is indicated for volar subluxation of the distal phalanx, chronic injuries, or with the presence of significant arthritis. * Bony Mallet: usually surgery if * \>50% articular surface * \>2 mm articular gap * FYI…”jersey finger” is flexor tendon rupture...

Orthopedics Hand/Wrist Flashcards

(67 cards)