Wrist/Hand Flashcards
(84 cards)
1
Q
A
2
Q
Joints of the wrist.
A
- Distal radioulnar
- Radiocarpal*
- Midcarpal*
- Carpometacarpal
3
Q
Which carpal row is viewed as a single bone?
A
- Distal carpal row is viewed as a single bone as carpal ligaments are stout,
providing stability
4
Q
What muscles attach to the proximal carpal row?
A
- FCR and FCU muscles attach to the proximal carpal row.
5
Q
What is the most commonly injuried ligament of the wrist/hand?
A
Instrinsic - Scapholunate mc followed by the lunotriquetral
6
Q
How does Instability usually occur?
A
Followed by a FOOSH injury, affecting the interosseous ligament, proximal row motion abnormality, stretching the extriniscs, carpal collapse and more.
7
Q
The wrist is a Double joint system between
A
- Radiocarpal
- Midcarpal
8
Q
Movement at the wrist between the double joint system
A
- F/E are evenly distrubted between the radiocarpal and midcarpal joints.
- Abd/Add occur through the MC
Functional motion arcs for ADL’s
– 5-10 to 30-35 F/E
– 10-15 Abd/Add
9
Q
Why is ulnar deviation greater than radial deviation?
A
- Bone anatomy of the ulna extends farther
- Ligament/soft tissue: ulna side is more flexible
- Articular surfaces: carpal bones allow for it. Trapezium and hamate have diffferent shapes providing more space.
10
Q
Closed packed position of the wrist
A
- Hyperextended position
11
Q
Why is the scaphoid more suspectable to injury in the closed packed position?
A
- The scaphoid position makes it more suceptable to injury during a fall in this position. Radial flexion the wrist of the MC joints and metacarpal joints influence the position of the IP joints. Complete flexion of the fingers is better with slight wrist extension (synergistic)
12
Q
Triangular Fibrocartilage
complex
A
- Articular disc
- Distal radial ulnar joint ligs
- Palmer ulnocarpal lig
- Ulna collateral
- Fascial sheath
13
Q
Triangular Fibrocartilage
complex location and function
A
5 interconnected tissues in the ulnocarpal space
- The disc originates from the medial border of the radius and inserts onto the base of the ulnar styloid.
- TFC is a main stabiliser for the distal radioulnar joint
- Axial loading radius carries more load, and excision of the TFFC increases its load
14
Q
Ulnar Deviation Axial load transmission
A
- Hand
- Head of capitate
- scapholunar ligament
- distal radius
15
Q
Paitent history for hand
A
- Age
- Occupation
- MOI: important for DDx
( FOOSH, Fall/trauma with R deviation and extension = scaphoid or colles - Dominant hand
- Past Hx
- Medial Hx
16
Q
Carpal Tunnel Syndrome (median n): Highly associated with
A
- Poor wrist ergonomics [extension/compression]
- Edema
- Construction worker [repetive or vibration tools]
17
Q
CTS aetiological factors
A
- Space occupying lesion
- Traumatic or overuse
- Hormonal/endocrine
- Third trimester pregancy
- Idiopathic
- Occupational
- Local anatomic [acute, malunion, stenosis, anomalous, lesions]
- Systemic [fluid disorders, endocrinopathy, collagen/autoimmune etc]
18
Q
CTS signs and symptoms
A
- Numbness, paraesthesia, pain along n. distrubtion
- Loss of grip strength, hand weakness (dropping things)
- Pain ventral wrist and hand + burning sensation
- ANS: Temperture or colour changes, dry skin, swelling
- Night pain worse
- Flick sign (shaking hand when awake)
- Severe cases thenar atrophy
- Sensory deficit is RARE; if suspected, entrapement likely more proximal
19
Q
DDX of CTS
A
- Neuromuscular and vascular [higher lesion, cervical, peripheral [tendon, myofasical, OA or inflammatory]
- Neurological: brachial plexopathy, peripheral entrapement [pronator teres]
- Vascular- raynaud phenomenon [white/redness]
- Prox median n. compression,
- Ulna n. compression
20
Q
Orthopaedic evaluation of CTS
A
Best clinical performance for detection (DT, PT and TT)
- Tinels
- CT compression test
- Wrist flexion test
- Prayer Test [reverse WF test
- Hand elevation
- Pronator Teres test
21
Q
Prognosis factors for CTS
A
- Poor outcome for diabetes,
- workers compensation,
- fail to respond to steroids or orthotics,
- prolonged symptoms
22
Q
Ulnar nerve pathway to the wrist
A
- Originates C8-T1 enters anterior forearm. through 2 heads of FCU
- Runs with ulna A. and branches proximal to the wrist
- Dorsal ulnar cutaneous sensory
- At the level of the ulnar styloid, palmer cutaneous sensory branch
- At wrist, ulna n entes Guyon’s canal
-> Superfical branch [mixed
-> Deep branch [motor only; most hand muscles]
23
Q
Ulnar nerve entrapment
A
Entrapement of the ulnar nerve, which may cause motor, sensory or mixed deficits depending on site. Common in cyclists due to prolonged pressure; leaning/pressure on the hand/wrist
vibrations, hand position etc
24
Q
Clinical presentation of Ulna n. Entrapement
A
- Muscle atrophy: Primarily hypothenar and interossei muscles
-
Sensory loss and pain: Palmer surface and 5th digit and medial aspect of 4th.
The dorsum of the digits have no sensory loss. - Ulnar Claw: loss of intrinsic muscles flexing the MCP’s and extending the IP joints
- Allen test to diagnose artery thrombsis or palpable mass
25
Special test for Ulna n. Entrapement
- Clinical diagnosis
- Special studies used to determine cause
- Plain film may show hook of hamate fracture; & helps look for RA
- MRI usefull for ganglion cysts or other structures compressing n.
- MR angiograph reveal any aneurysms / or thrombosis
26
Treatment for Ulna n. Entrapement
- Non operative for mild cases, activity modifcation NSAIDs and splints
- Operative for obvious disabilites ie Claw fingers, loss of power in pinch and grasp
- Usually for severe cases or failed conservative
27
De Quervain’s epidemiology
- F>M 40’s-50s
- Correlate with repetitve, forceful or ergonomically stressful manual work
- Prolonged smart phone users or gaming increases prevalance
28
De Quervain’s
- Inflammation of the common tendon sheath of the first dorsal compartment
29
De Quervain’s Clinical presentation
- Several weeks/months of pain from thumb/wrist motions
- Tenderness and thickening of the radial styloid
- Pain often over dorso-radial aspect of the wrist and radial aspect of the forearm along extensor tendons
- Daycare workers or others involved in repetitve lifting
- Direct blows can cause
30
De Quervain’s Special investigations
- Plain is not useful; only for ruling out
- Ultrasonography; helps estabilish the tendon thickening and narrowing of the fibro-osseous canal
31
De Quervain’s Clinical assessment
- Finkelstein Test
32
De Quervain’s Management
- Education/activity modification
- Soft tissue massage
- Taping
- Graded pain free active exercise
- Eccentric and isometric exercise
33
Intersection Syndrome
- Painful condition of forearm, often mistaken for De Quervain [same pain presentation]
- Less prevalent, likely under-reported as its self-limiting and responds quickly to conservative care.
- First extensor compartment tendons [APL EPB] intersect the 2nd extensor comparement [ECRL + B]
34
Intersection Syndrome Theories
1. Friction between muscle bellies of the APL and EPB with the tendon sheath housing the ECRL and ECRB
2. Entrapment of the muscles in the second dorsal compartment due to stenosis
35
Intersection Syndrome Clinical presentation
- Thumb and wrist movement [extension] pain + crepitus
- Sweling distal dorso-radial forearm approx 5cm to wrist joint
- Common with rowers and weight lifters; anything with repetitive wrist extension
36
Intersection Syndrome Management
- Cross friction massage,
* injection,
* activity modification and.
* night splint
37
Trigger finger [Stenosing tenosynovitis]
- Sheet issue where the tendon cannot glide correctly
- Finger gets stuck in flexion then straightens with associated snap [release]
- Severe cases remains locked
38
Trigger finger [Stenosing tenosynovitis] Epidemiology
- Common with Diabetes paitents with CTS
- Biomodal incidence;
[Young gender Older common with females dominant hand]
- Ring finger and thumb at MCP joint
39
Trigger finger [Stenosing tenosynovitis] causes
* Inflammation of the tendon [hard to glide]
* Palpable nodule often present due to telescoping of sheath
* High concordance with CTS
40
Trigger finger [Stenosing tenosynovitis] causes
* Conservative initially with rest and splinting, NSAIDS and steroid injections
* Needs to be treated when affects ADL’s
41
Wrist Sprain
- Common injury, often in work and or athletes
- Acute sprain = injury to ligament either from acute traumatic event or chronic repetition
42
When wrist sprains, due to their locations and the mechanisms of common injuries, what two non-bony structures more prone to injury?
-> Triangular fibrocartilage complex (TFCC)
-> Scapholunate ligament complex
43
Scapholunate Ligament complex Function
- Support/maintain scaphoid and lunate connections, which serve as the proximal foundation of the wrist.
44
Scapholunate Ligament Instability is also referred to as?
Ulna deviation
45
Scapholunate Ligament MOI
- FOOSH with wrist extension and ulnar deviation, or overuse type of injury
46
Who are more prone to Scapholunate ligament injury?
Athletes are more prone with hx of sprain and failure to seek treatment
47
Scapholunate ligament injury is often assocated with what other injury?
- Often associated with radial styloid fractures [colle’s]
48
A Compromised
SCL
- Deformity [dorsal intercalated segement instability : DISI ]
- If untreated = Scapholunate advanced collapse
- Result in a predictable degenerative change [wrist arthritis]
49
Biomechanical implications of SCL injury
- Scaphoid tends to move into volar flexion
- Carpal kinematics, the lunate which is fixed to the triquetrum, is forced to follow it into dorsal extension
- Not to be confused with lunate or perilunate dislocation
[lunate dislocated towards the palmer side or maintains alignment while the rest of the wrist dislocates posteriorly]
50
Clinical presentation of SCL injury
- Swelling of snuffbox and dorsal radiocarpal joint
- Weakness/pain, esp. in extension and loading
- Unstable feeling, or giving way, clicking/popping with activity
- Chronic cases CTS may be present due to synovitis
51
Following a FOOSH injury, where should palpation be?
Direct palpation distal [1cm] to the tubercle of lester
52
Imaging for SCL injury - stages
- Stage 1: Radiographs appear normal.
-> Partial rupture = abnormal movement between scaphoid and lunate creating wrist synovitis.
- Stage 2: Identified with closed fist by widening the scapholunate interval
-> dynamic instability: volar or dorsal disruption
- Stage 3: DISI on non-stress x-rays
-> static instability corresponds to involvement of secondary stabilisers [volar carpal lig and dorsal capsule]
- Stage 4: SLAC wrist leading to degenerative changes
53
Differing features form RA and SCL injury
Evidence of erosive arthitis on radiographs.
Hand and finger deformity such as MCP dislocations or swan neck
54
Differing features form De Quevain and SCL injury
Positie Finkelstein sign
55
Differing features for CTS and SCL injury
- Hx of numbess/tingling/pain in median n distribution
- psotive provocative maneuvers for CTS
- normal radiographs
- evidence of CTS on electromyography and nerve studies
56
Differing features for Triangular fibrocartilage complex injury and SCL injury
- Tender on palpation over the complex
- normal radiographs if isoloated injury
- MRI may help identfiy tear in complex
57
Differing features for acute fracture or wrist sprain and SCL injury
- hx of recent fall or trauma
- no evidence of chronic degeneration changes on radiographs
58
Differing features tendonitis of common extensors and SCL injury
- Tender on palpation over the affected tendon
- Normal radiographs
59
common wrist extensors
- ECU
- ERCB
- ECRL
- FCU
- FCR
60
Conservative managment of SCL injury at diagnosis
Predynamic instability
- NSAIDS
- splint or short cast immobilisation for 4-6 wks
Dynamic instability
- splint immobilsation and refer to specialist with 7-10 days
SLAC wrist
- NSAID
- Splint/cast immobilsation
- Avoid provocative activity
- radiocarpal steroid injection
61
Conservative managment of SCL injury at later stage
Predynamic instability
- repeat radiographs
- If asymptomatic, begin ROM
- If symptomatic, refer
SLAC wrist
- if conservative fails, refer to specialist
62
SCL injury prognosis
- If untreated it can lead to complete disruptions in the SL ligament, leading to degenerative changes [SLAC wrist]
- Early treatment allows for repair and better outcome
- Late treatment or if there is degenerative changes, its more difficult and has suboptimal outcomes
63
If the TFCC is injured, what is a likely presentation
The ulnar will present, with possible clicking, point tenderness between the ulnar head and pisiform.
64
TFCC Clinical presentation
- Compressive load associated with ulnar deviation with forearm supinated
- Forced ulnar deviation [swing a bat]
- Associated with Ve+ ulnar variance [shortening]
- Ulnar-sided wrist pain with clicking/grinding and weakness
- Pain with passive pronation/supination [rotation]
- As well as ulnar deviation
65
TFCC epidemiology
- Prevalence increases with age
- Abnormalites are common with asymptomatic wrist
66
TFCC assessment
- Ulnar Fovea sign
- Compression test
- Shunk test: Assess lunotriquetral lig. injury
- ECU synergy test: distriminate between intra or extra articular pathology because the proximity of the ECU is part of the TFCC complex
67
Ulnar styloid impingment DDx with TFCC injury
The same, but the TFCC is intact
68
Why is it importment to differ Ulnar carpal impingement from TFCC?
Differentiate because this is commonly a result of ulnar shortening due to surgical resection from a prior injury
69
Ulnar extensor or flexor tendonitis and TFCC - DDx
Movement cause muscle to fire which causes pain.
It may radiate along muscle belly, depending on degree of inflammation
70
Managment of TFCC injury
At diagnosis and later stage
At Diagnosis
- Tear present, and no distal radioulnar joint instabilit, 4-6 weeks of wrist immobilsation and NSAIDs for pain
- Conservative = slow process
- Return to pain free state can take 3-6 months
- Modify work/avoid heavy lifting
Later:
- Once pain free, OT may help wean off splint
- Progressive ROM
- Strength program with gradual return to activities
71
Common surgey approaches for TFCC injury
- Arthroscopic repair
- Arthroscopic debridement
- Ulnar shortening
- Wafer procedure
Surgery has good outcomes but can be impacted if theres concurrent pathology
72
Ulnar Collateral Ligament
injury
[Game keepers]
- The ligament stabilises the first metacarpophalangeal joint and is vital for thumb stabilisation
- Most injuries are traumatic from FOOSH
- Fall with a thumb in abduction [radially deviated]
- May be associated with avulsion fracture at base of proximal phalanx
73
Ulnar Collateral Ligament
injury
[Game keepers] Clinical presentation
- Pain along ulnar side of thumb MCP joint
- Weakness in grasping or pinching objects; a complete tear = unable to do these
- Associated with Stenar lesion, the UCL come superficial to the adductor aponeurosis/adductor pllicis muscles
- The UCL will commonly be avulsed from its distal attachment [proximal phalanx]
74
Ulnar Collateral Ligament
injury
[Game keepers] Assessment
- Radially applied force to assess MCP stability
- Grade 1: spain with instability
- Grade 2: incomplete tear; laxity and firm endpoint
- Grade 3: complete tear; instability
75
Ulnar Collateral Ligament
injury Orthopaedic examination
- Scaphoid shift test
- Lunotriquetral Ballottement [kleinman shear test]
- Ulnomeniscotriquetral Dorsal glide test
- Press test
76
Why is the scaphoid susceptible to injury?
- More susceptible to injury because its unique position bridges the proximal and distal rows of carpal bones
77
How is the scaphoid commonly fractured?
- Usually FOOSH with extension and radial deviation
78
What condition should be looked for with a scaphoid fracture?
Avascular necrosis due to inadequate bloody supply, only one dorso-radial artery to proximal pole.
79
scaphoid fracture orthopaedic evaluation
- Scaphoid fracture test
- Anatomical snuff-box tenderness
- Wrist radial deviation
80
A part from scaphoid fractures, what are some other common locations for fractures in the wrist/hand?
- Colle's [distal radius] from FOOSH
- Boxer's 5th MC neck
81
# *
Ganglion of wrist
- Belived to arise from repetitve microtrauma
- Fluid filled mass, usually doesn’t create issues unless it’s attached to a highly used tendon
- Asymptomatic usually
- Pain, tenderness, weakness and unhappy with cosmetic appearance
82
Ganglion of wrist treatment
- Immobilisation
- Steroids if symptomatic
- Surgery [recurrence is likely]
83
Boston Carpal Tunnel Syndrome Questionnaire
Out of 55
High score = worse outcome
84
Patient specific wrist and hand evaluation
Out of 100
High score = worser function
