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Flashcards in Wrist and Hand Deck (63):

usual age group affected by CTS?



CTS clinical features?

pain and paraesthesia in median nerve distribution in hand= radial 3 and a half digits
night pain- burning, tingling and numbness, ptnt awoken and has to shake their hands or hand arm over side of bed=relieves pain, result of sleeping with a flexed wrist- position which elicits pain in phalens test.
wasting of thenar eminence in late cases, wkness of thumb abduction, sensory dulling in medial nerve territory.


2 tests for CTS?

Tinel's sign= sensory symtpoms reproduced by percussing over median nerve
Phalen's test= holding wrist fully flexed for 1 min reproduces sensory symptoms.


how is CTS treated?

treat underlying cause e.g. oral thyroxine (levothyroxine) if hypothyroidism
light splints- can be worn at night to stop wrist flexion if night pain or pregnancy related symptoms.
steroid injection into carpal tunnel can provide temporary relief if mild symptoms- but as can mask symptoms, don't use if severe as nerve deterioration may go unoticed with ongoing compression
surgery- open surgical division of transverse carpal ligament (flexor retinaculum) under LA, or endoscopic carpal tunnel release- slightly quicker post-op rehabilitation.


where should incision be kept to in open surgery for CTS?

ulnar side of thenar crease to avoid damage to palmar cutaneous and thenar motor branches of median nerve.


only work-related syndrome proven to cause CTS?

hand-arm vibration syndrome- sympathetics damaged to blood vessels, disturbing blood supply and leading to nerve ischaemia.


location of Guyon's canal (site of ulnar nerve compression in 10% of cases)?

between pisiform and hook of hamate


muscle tested to determine ulnar nerve function in hand?

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.


tests for CTS?

Tinel's sign= sensory symtpoms reproduced by percussing over median nerve
Phalen's test= holding wrist fully flexed for 1 min reproduces sensory symptoms.
electrophysiology- NCSs- slowing of nerve conduction across wrist, performed if atypical symptoms.


RFs for CTS?

tenosynovitis, occupational trauma, wrist fractures
acromegaly, amyloidosis
myxoedema, hypothyroidism
pregnancy- fluid retention- raised oestrogen and progesterone

diabetes, idiopathic


muscle tested to determine ulnar nerve function in hand?

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.


how are ulnar nerve symptoms produced in hand?

compression in cubital tunnel
compression in guyon's canal
iatrogenic- nick in nerve


muscles tested to determine ulnar nerve function in hand?

abductor digiti minimi- with fingers abducted, little fingers are pushed against 1 another.
adductor pollicis- Froment's sign= ptnt asked to hold an object between thumb and index finger and examiner tries to pull object away, sign elicited with ulnar nerve palsy where thumb flexes via FPL to compensate for not being able to maintain hold with AP, causing a pinching effect.


how are ulnar nerve symptoms produced in hand?

compression in cubital tunnel
compression in guyon's canal
iatrogenic- nick in nerve


how can ulnar nerve symtpoms in hand be treated?



what is 'saturday night palsy'?

radial nerve compressed resulting in wrist drop, due to falling asleep in awkward position e.g. with arm stretched over the back of a chair.


most common cause of radial nerve symptoms in hand?

humeral fracture- mid-shaft where radial nerve runs relatively superficial in radial groove on poster. humerus.


where is sensory supply of hand via radial nerve tested?

1st web space between thumb and index finger


how can ulnar nerve symtpoms in hand be treated?

transposition e.g. moving ulnar nerve anterior to medial epicondyle of humerus so it isn't stretched against this when elbow flexed.


tment of radial nerve symptoms in hand?

therapy- don't want stiffness
nerve graft
tendon transfers


how is motor function of radial nerve tested in hand?

no motor innervation to intrinsic hand msucles

wrist extensors
finger extensors
EPL, these are all muscles originating outside of the hand which control hand movements


other considerations in ptnts presenting with nerve problem symtoms?

cervical spine
brachial plexus e.g. cervical rib- extra rib which reduces space of brachial plexus
nerve disorders


why is there are high recurrence rate with Dupuytren's disease?

disease has a genetic link


what can worsen a Dupuytren's contracture?



assoc. disorders with Dupuytren's disease?

Plantar fibromatosis, nodules on soles= Ledderhose's disease
Peyronie’s disease- fibrous plaques along penile shaft (fibrosis of corpus cavernosum)


when to operate in Dupuytren's disease?

?threshold 30 degrees
op when hand unable to function properly and can't put hand completely flat on a table


op for Dupuytren's affecting MCPJs?

easy to correct
Segmental fasciectomy
Full Fasciectomy


problem with Dupuytren's affecting PIPJs?

more difficult to correct than if affects MCPJs
Full fasciectomy
Additional releases
– Collaterals
– Volar plate
Skin graft (FT)
Garrod’s pads= lumps on dorsum of finger joints


what is trigger finger?

finger 'jumps', 'clicks' or gets stuck in flexion, further effort allows snapping into full extension
pain on movement, and tenderness over 'nodule'
occurs with thickening of flexor tendon which becomes temporarily trapped at entrance to its sheath, and then passes constriction with a snap on forced extension
classified as a stenosing tenosynovitis
can be passively straightened
location of A1 pulley= the 1st annular ligament of the finger
more common in diabetics
may be assoc. with joint OA and RA


tment of trigger finger?

steroid injection at entrance of tendon sheath-can inject into nodule of tissue, and just above the nodule, should work within hours to days
surgical release- fibrous sheath incised to allow tendon to move freely
must avoid injuring digital nerve in case of thumb, which runs close to sheath


name given to disease in which irritation of tendons around base of thumb occurs?

DeQuervain's tenosynovitis


what test can be used to diagnose DeQuervain's tenosynovitis?

Finkelstein's test= examining physician grasps the thumb, keeping it tucked close to palm, and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (stab of pain over radial styloid) de Quervain's syndrome/disease is likely.


location of bouchard's nodes?

hard outgrowths on PIPJs in OA


name given to a ganglion located in the finger?

mucous cyst
may be long history, pain if caught


how does a giant cell tumour of the tendon sheath in the hand present?

long history of a slowly increasing in size painless solid lump
rapid increase in size-suspect malignancy
solid in contrast to cystic with a ganglion


what happens with an enchondroma?

bone is replaced by cartilage


what do we look for on a hand and wrist examination?

scars, swelling, alignment, muscle wasting
symmetrical or asymmetrical abnormalities?
nails- psoriasitic changes- pitting, onchyolysis
nailfold vasculitis
joint affected?
rashes, LT steroid use- skin thinning, bruising?
palms- finger pulp, palmar erythema, scars from carpal tunnel release


what is ulnar impaction/abutment syndrome?

degenerative wrist condition caused by the ulnar head impacting upon the ulnar-sided carpus with injury to the triangular fibrocartilage complex (TFCC)
ulna typically impacts on the lunate


presentation of ulnar impaction syndrome?

chronic or subacute ulnar-sided wrist pain exacerbated by activity. There is often associated swelling and limitation of forearm and wrist movement. Anything that results in relative increase in ulnar variance such as firm grip, pronation and ulnar deviation of the wrist, can exacerbate the symptoms.


predisposing factors to ulnar impaction syndrome?

+ve ulnar variance/increased dorsal tilt of distal radius- may be congenital or due to previous fracture
premature physis closure
radial head resection


what is the radial height measurement?

normally around 11 mm
measured on PA radiograph as distance between 2 perpendicular lines, 1 drawn through radial styloid process and 1 through distal articular surface of head of ulna


what is the radial inclination?

usually 22 degrees
is equal to the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius
loss will increase load across lunate


what is radial tilt?

measured on lateral radiograph
angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin.
averages 11 degrees volar tilt

? what is acceptable in fracture** no more than 15 degrees dorsal tilt?


what is dexterity in the hands?

ability to coordinate small movements of the hands


people in which there is a higher than usual incidence of Dupuytren's?

ptnts with epilepsy receiving phenytoin therapy


what is Dupuytren's?

thickening of the palmar fascia, nodular hypertrophy, producing contractures of commonly the ring and little fingers
more common in males, familial
pain unusual


what must Dupuytren's be distinguished from?

skin contracture- where a previous laceration is usually obvious
tendon contracture- where 'cord' moves on passive flexion of finger


how is Dupuytren's treated if extensive hand involvement?

Z -shaped incision that does not cross directly over a skin crease *surgical incisions should never cross flexor creases. Thickened part of fascia is excised.
Hand then splinted for a few days and active movement then encouraged, night splinting for a few months may reduce recurrence.


alternative to surgery for significant Dupuytren's?

injection of collagenase to dissolve cord


what is an intrinsic-plus deformity?

flexion of MCPJs with extension of IPJs and thumb adduction
occurs with intrinsic muscle shortening after trauma or infection

can release intrinsic muscle where cross MCPJs


what is mallet finger and how is it treated?

flexion deformity of distal IPJ, ptnt cannot straighten terminal joint but passive movement is normal
due to injury at attachement of extensor tendon to terminal phalanx
DIPJ should be splinted with proximal joint free- splint in extension for 6 weeks.
May then after 6-8 wks wear a night splint


why might long thumb extensor (EPL) rupture?

after fraying where it crosses the wrist e.g. after a Colle's fracture- distal radial fragment displaced radially, dorsally and dorsal tilt
or in RA

treat with tendon transfer using EI


how can dropped fingers be treated?

can directly repair extensor tendon if only 1 finger affected, or distal portion of tendon can be attached to an adjacent finger extensor


what is a Boutonniere deformity?

flexion deformity of PIPJ due to interruption of central slip of extensor tendon. lateral slips separate and head of prox phalanx pops through the gap
seen after trauma or in RA


what is a swan-neck deformity?

PIPJ hyperextended and DIPJ flexed
due to imbalance of extensor versus flexor action in finger


name for infection under the nail fold?



how should hand be positioned for splintage after draining fascial space or tendon sheath infections, in order for ligaments to be at their longest and splintage therefore least likely to result in stiffness?

wrist slightly extended
MCPJs in 70 degrees of flexion
IPJs extended
thumb abducted


tment for dislocated proximal IP joint of ring finger?

manipulative reduction
and buddy strapping splintage


what is De Quervain's disease?

tenosynovitis of the 1st dorsal compartment of the extensor retinaculum at the wrist. there is synovial inflammation causing secondary thickening of the sheath and compartment stenosis
usually seen in women aged between 30 and 50


presentation of De Quervain's disease?

may be history of unaccustomed activity e.g. cutting with scissors, quite common shortly after childbirth
pain, sometimes swelling, localised to radial side of wrist
tendon sheath feels thick and hard
tenderness most acute at very tip of radial styloid


clinical indications of scaphoid fracture?*

tenderness over AS
painful dorsiflexion
pain on rotation of thumb
difficulty with wrist plantarflexion?


tment of de quervain's disease?

US therapy or corticosteroid injection into tendon sheath, may splint wrist
may need to operate to cut the thickened tendon sheath- must be careful not to injure dorsal sensory branches of radial nerve- can cause intractable dysaesthesia


main stabiliser of distal radio-ulnar joint?

triangular fibrocartilage complex (TFCC)