Wrist Hand Surgeries - Dr. Worst

Question 1

7 common Surgeries of Wrist and hand

Answer 1

1. CTS (carpal tunnel syndrome)
2. Trigger fingers
3. Arthroscopy
4. TFCC
5. Fractures
6. DSTS
7. Tendon Repairs

Question 2

CTS

Answer 2

Carpal tunnel syndrome

Question 3

How common is Carpal tunnel syndrome (CTS)?

Answer 3

1% of population

Question 4

CTS symptoms (7)

Answer 4

1. Median nerve distribution
2. Pain
3. Paresthesias
4. Pinch Grip weakness
5. Thenar atrophy (chronic)
6. Night pain (curled hand position)
7. Clumsiness in hand in fine motor skills (from sensory problems, not motor)

Question 5

CTS cluster of S/S (10)

Answer 5

1. Pregnancy-fluid accumulation
2. Diabetes
3. Colles wrist frature
4. Systemic, endocrine, metabolic disorders
5. Occupational (Secretary/Power tools)
6. Exam
7. EMG/NVC (nerve conduction test)
8. Alcoholism
9. Anything with peripheral neuropathy
10. Using lumbricals

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Question 6

CTS Treatments (4 general things)

Answer 6

1. Change causative factors
2. Splinting in neutral position (not cock-up)
3. PT modalities, Mobs, Exercises, stretching, etc.
4. Inject area (not the nerve) with corticosteroid (lidocaine, kenalog)

(modalities research doesn’t have consistant outcome)

Question 7

Carpal Tunnel Release Surgery? (4 things about when it could be considered)

Answer 7

1. symptoms > 3 months
2. sensory deficits (objective)
3. > 3.61 Semmes-Weinstein microfilaments
4. maybe thenar atrophy/weakness

One of the most common surgeries performed

Question 8

Carpal Tunnel Release Surgery types and duration

Answer 8

Takes ~ 10 minutes

1. Open CTS release: 10-15% complications
2. Arthroscopic: 2-3x more complications at 35% (bc more conservative with cutting

Question 9

CTS release Surgery recovery

Answer 9

1. Dressings
2. Fingers open (increased scaring if not kept open)
3. Elevation
4. No evidence for immobilization

Early mobilization: gentle composite fist

1. 2 weeks: sutures removed and scare management (mobs) is important
2. <5% recurrance
3. Tendon gliding exercises important

Question 10

Wrist tendonitis/osis

Answer 10

same principles apply from Dr. davies lecture on tendonitis/osis for elbow

Question 11

Where are the most common locations for hand tendonitis/osus?

Answer 11

1st, 2nd, & 6th dorsal wrist extensors

There is also Tenosynovitis

(but more along the lines of senosing tenosynovitis)

Question 12

Stenosing tenosynovitis

Answer 12

Narrowing of a tendon sheath from chronic pressre/inflammation that leads to fibrosis

DeQuervain’s/trigger finger

Question 13

What is a very good treatment for tendonosis and why?

Answer 13

eccentric exercises because it realigns the collagen fibers

Question 14

Draw/explain Tendinosis cycle

Answer 14

Question 15

DeQuervains

Answer 15

Stenosing Tenosynovitis of the abductor pollicis longus and extensor pollicis brevis at radial styloid ; Tested by Finklestein Test

Question 16

Wrist sprain grades (3)

Answer 16

Grade I: ligaments stretched or slightly torn

Grade II: ligaments partially torn

Grade III: ligaments completely torn

Question 17

Wrist sprain treatment

Answer 17

Splinting to help calm down

Then Therapy: gentle strenthening

Question 18

TFCC Injuries (MOI)

Answer 18

activities that involve ulnar deviation and vibration

power tools

gymnasts

Question 19

TFCC Injuries (characteristics - 5)

Answer 19

1. Acute Onset
2. CKC exposed to injury
3. Typically due to hyperextension and ulnar deviation
4. Easily confused with UCL sprains
5. Extensor Carpi Ulnaris Tendon attaches on the TFCC

Question 20

TFCC injury symptoms

Answer 20

deep pain on ulnar side of wrist axial loading through 5th metacarpal

Question 21

Arthroscopic TFCC Repair

Answer 21

debridement or repair with sutures

Wafer Procedure

Question 22

ulnar fovea sign

Answer 22

tests for TFCC injury or ulnotriquetral ligament tear (TFCC will have an associated DRUJ instability)

• palpate the soft spot between the ulnar styloid process, pisiform, anterior surface of the ulnar head, and the FCU.
• positive: reproduction of the pt’s symptoms

Question 23

“wafer” prodecure (describe it, indications, contraindications)

Answer 23

• a wafer of up to 2-4 mm of distal ulnar head is removed, while the styloid process, TFCC, and attatched ligaments remain attached;
• the procedure is contra-indicated if more than 4 mm of positive variance;
• may be indicated for symptomatic positive ulnar variance, ulnocarpal impaction syndrome, or symptomatic TFCC tears;

saw used to cut ulnar head and remove “wafer” at lateral side of TFCC while styloid process still intact. TFCC reattached.

Question 24

How many Trigger Finger people are helped in the short term by one Corticosteroid inection?

Answer 24

~66%

Question 25

What is the primary treatment for Jersey finger

Answer 25

Surgical repair (mobilize ASAP!)

Question 26

UCL injury to thumb is called (two names)

Answer 26

gamekeepers thumb Skier's thumb

Question 27

Differential Fisting (purpose and 5 positions)

Answer 27

Used for Tendon Gliding 1. Open hand 2. MCP Flexion 3. Hook Fist 4. Straight Fist 5. Composite Fist

Question 28

UCL of thumb tear symptoms

Answer 28

1. Painful/Swollen 2. Pinching and grip difficult 3. Sometimes can feel little bump where ligament should be the UCL test tests at extension and slight flexion because there are two fiber bundles in UCL

Question 29

Ganglion cysts

Answer 29

don't forget about them

Question 30

Bible Bump Test

Answer 30

Burst the Ganglion Cyst

Question 31

Flexor Tendon Rehab progression

Answer 31

Phase I: day 5-3 weeks (PROM, AAROM, AROM) Phase II: Weeks 4-6 (splints removed) Phase III: Weeks 6-12 * Week 7 light resistive exericses * Week 8 PROM bilateral comparison WNL * Week 10-12 BEgin light ADL's * Week 12 All ADL's and start resistance trn Weekss 14-16: BEgin heavy and sustained lifting ex and tight gripping ex

Question 32

characteristics of Flexor Tendon Repair recovery

Answer 32

* Flexor tendon repair * early protected PORM: dorsal blocking splint * Early post -op - Progression to “careful ROM” * Place and hold exericses (sub max isometrics) in shortended position (progression to mid-lengthend positions) * Splinting Tech: blocking or dynamic splints ( orn 4-6 weeks) * Tendon glide assessment * Joint mobilizations * Progress to resistive exercises

Question 33

scaphoid has _______ blood supply making it vulnerable to \_\_\_\_\_\_\_\_\_

Answer 33

retrograde avascular necrosis

Question 34

scaphoid fracture healing time

Answer 34

usually about 4 months because of delayed union

Question 35

Hamate fracture

Answer 35

usually when doing something with a club or holding something Handle bars?

Question 36

Lunate dislocation

Answer 36

usually caused by FOOSH most common dislocated carpal bone Murphy's sign may have pain there, but may spontaniously reduce so may not be able to feel it. Or Capitate may drop down into the gap Greater than 3mm gap between scaphoid and lunate on a fisted radiograph

Question 37

metacarpal fractures

Answer 37

may have a large bump and an effect on knuckle Usually casted and immobilized

Question 38

Boxer's Fracture

Answer 38

fracture of neck of 5th metacarpalfrequently sustained during a fight or from punching a wall in anger or frustrationcasted for 2-4 weeks Can see on observation May get Gutter splint

Question 39

gutter splint

Answer 39

splint located on the radial or ulnar side of the wrist

Question 40

Bennet fracture

Answer 40

* fracture of the base of the first metacarpal (thumb) * usually extends into the joint * usually has some dislocation. ORIF with Kirschner pins Thumb splint might be used

Question 41

PIP Joint Sprains and dislocations

Answer 41

Collateral ligaments

Question 42

DIP Joint fractures and Dislocations

Answer 42

happens

Question 43

Boutonniere deformity

Answer 43

RA. PIP flexion, DIP hyperextension can try splinting

Question 44

What are the nodes call for RA? OA?

Answer 44

RA nodes= Bouchard's nodes; OA nodes= Heberden's nodes

Question 45

swan neck deformity

Answer 45

sometimes you can do this if you have hypermobility Use swan neck splint RA