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Orthopedics: Wrist Conditions and Exams

CARPAL TUNNEL SYNDROME
--CTS-->median nerve compression neuropathy (pinkie & 1/2 ring finger not involved)
--swelling, inflam, pressure in tunnel
--ETIO: trauma, overuse (flex, ext, gripping, keyboard), constriction (tenosynovitis of flexor tendons, RA, osteoarthritis, ganglion or neuroma) systemic conditions (diabetes, pregnancy, obesity, hypothyroid, renal dz)
--S/Sx: pain in wrist and hand, burning, numnbness and tingling in fingers, weak thumb abduction (thenar atrophy), usu worse at night, mb retrograde pain to elbow/shoulder), "flick sign"=relief by flicking wrist as if shaking down thermometer, often bilateral but greater on one side
--Tx: avoid aggrav, ice/heat, ultrasound, laser, brace, anti-inflam, local injx
--Dx: nerve conduction velocity test 84% true positive, 95% true negative
--Tx: surgical release 80% success
--Dx: Phalen's test, Tinel's sign, weak thumb abduction, thenar atrophy

PHALEN's Test = very sensitive test for CTS (two versions) 1) pt hold hands back to back in front of abdomen, forearms level(ish) and fingers pointing downward, with maximal wrist flexion for 1 minute, or 2) examiner hold wrist flexion for 1 minute. (+) = numb/tingle in median nerve distribution, increased anterior wrist pain, weakness of thumb opposition (additional sensitivity for CTS with examiner pressure over carpal tunnel during wrist flexion)

Tinel's sign = doc taps on carpel tunnel of wrist to see if median nerve is aggravated

Thumb abduction Strength Test = pt hold palm to doc, attempts to lift thumb from palm while doc resists thumb abduction. Also view thenar pads (lateral 2 lumbricals, opponens pollicis, abductor pollicis breivs, flexor pollicis brevis) for atrophy. (+) = weakness of thumb abduction, indicates median nerve neuropathy.

DEQUERVAIN'S SYNDROME
--tenosynovitis of extensor pollicis brevis and abductor pollicis longus
--S/Sx: squeaky thumb, crepitus, pain localized at base of thumb
--S/Sx: pain/weakness w/ mvt esp w/ motion that stretch tendons and resist thumb mvts
--S/Sx: minor swelling if any
--(+) Finkelstein's test
--Tx: rest, immob, avoid aggrav, PT, ice, laser, anti-inflam, corticosteroid injx, surgery

Finkelstein's Test = make fist with thumb inside, ulnar deviate and extend wrist by patient or examiner (+ = lateral wrist pain->tenosynovitis of thumb muscles)

SCAPHOID FRACTURE
--most common carpal fx
--ETIO: wrist impact trauma, FOOSH, hyperext, radial dev, forearm pronation
--blood supply to bone is better distally and worse proximally, delayed union or avascular necrosis is common
--Tx: do not release for full duty or sport until rule out fracture, refer

Bracelet Test = doc puts hand around posterior wrist and compresses the sides, lateral compression around distal radius and ulna (or just below, depending on which image or person you ask) (+) = lunate disloc, scaphoid fx, lig laxity, RA or DJD at wrist

Scaphoid test = Examiner grab pts thumb with examiner's thumb pressed into pts snuffbox, directly on scaphoid bone, (+) = pain at scaphoid

LUNATE DISLOCATION
--most common carpal dislocation
--mb assoc w/ scaphoid fx
--ETIO: FOOSH on thenar eminence, hyperext, ulnar deviation, shift of capitate between scaphoid and lunate
--S/Sx: write pain, swelling, deformity, local tenderness over dorsal wrist (3rd metacarpal), possible parestheia in median nerve distribution
--(+) bracelet test, carpal joint laxity, and grip strength weakness
--Tx: orthopedic referral, potential avascular necrosis or carpal instability

** remember for boards:
--anatomical snuffbox bordered by tendons of extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus.
--floor of snuffbox: scaphoid, trapezium, 1st metacarpal, styloid process of radius, radial artery

COLLES FRACTURE
--fx of distal radius and ulna
--ETIO: FOOSH
--S/sx: swelling, pain deformity, "silver fork deformity" on x-ray
--Tx: immobilize, refer to orthopedist

WRIST SPRAIN/STRAIN
--traumatic overstretching of ligaments-->pain and decreased ROM
--ETIO/MOI: FOOSH, wrist hyperextension, wrist hyperflexion
--Dx: rule out fracture
--Tx: RICE, immobilize, anti-inflam, soft tissue healing

TENDONITIS/TENOSYNOVITIS
--inflam of tendon and/or synovial sheath
--MOI: repetitive wrist ext/flex
--S/Sx: weakness, pain over tendon during contraction or passive stretch
--Tx: RICE, anti-inflam, wrist protection/immob, exercises for stretch & strength

TFCC = TRIANGULAR FIBROCARTILAGE COMPLEX INJURY
--twisting injury to cartilage/ligaments on ulnar side of wrist
--S/sx: pani on ulnar side of wrist, with clenched fist and pronate/supinate
--clicking, grinding or catching with mvt
--MOI: FOOSH, swinging a bat or racquet, violent compression or twist of wrist
--Tx: RICE, wrist protect and immob, orthopedic consult for second opinion, imaging, r/o fracture

GANGLION CYST
--many spontaneously resolve
--?? stat not clear, appears to be: 40% disappear within a year after aspiration
--surgical scars can be more painful than ganglion
--recurrence after surgery, 10% for dorsal, 30% for ganglia adjacent to radial artery
--Tx: reassurance, aspiration (what about the bible treatment??)
--Tx: surgical referral if incomplete aspiration, solid lesion, or recurrence

DUPUYTREN'S CONTRACTURE
--hypertrophic nodular fibroplasia of palmar aponeurosis
--flexion contracture deformity of fingers (won't straighten)
--usu ring & little finger
--usu midlife onset
--ETIO: unknown, familial
--Tx: conservative stretching, surgery

GAMEKEEPER'S THUMB, aka SKIER'S THUMB
--partial or complete rupture (sprain) of ulnar collateral ligament of thumb MCP joint
--ETIO: forceful abduction or hyperextension of thumb (bent back)
--pain/tenderness over joint, limited/painful AROM of thumb, mb hypermobile on PROM w/ pain
--Tx: protect, immobilize, PT: ice, laser, avoid aggrav.
--Tx: surgery if severe, unstable dt ligament rupture, avulsion, failure to respond to conservative care
--Thumb Abduction stress test: stabilize MCP and abduct thumb, + = pain over ulnar collateral lig or excessive motion
--Pinch test: tip to tip, if no can do tip to tip, only weakly or only pad to pad, may indicate this dysfx

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