liveonearth (liveonearth) wrote,

Orthopedics: Wrist Conditions and Exams

--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.

--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)

--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

--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

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

--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

--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

--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

--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

--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

--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
Tags: diagnosis, hands, orthopedics

  • QotD: Pandemic Patriotism

    When stupidity is considered patriotism, it is unsafe to be intelligent. --Isaac Asimov, quoted in

  • QotD: Brits on tRump

    Copied from a friend (on fb). This is utterly brilliant. I wish I could take credit for writing it, but no. British wit to help get you through the…

  • QotD: Korea got the short end of the stick 1945

    Following the Axis surrender, Korea's fate, like that of Central Europe, was still to be worked out. Officially, the victorious Allies were committed…

  • Post a new comment


    Comments allowed for friends only

    Anonymous comments are disabled in this journal

    default userpic

    Your reply will be screened

    Your IP address will be recorded