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Hand Hx: significant parts Handedness; Trauma; Numbness, paresthesias; Triggering
Hand Exam: Inspection Swelling, nodules, masses
Hand Exam: Palpation: Tenderness
Hand Exam: ROM Symmetry; Triggering; FDP and FDS
Hand Exam: Strength testing Grip, abduction
Hand Exam: Neurovascular Sensation; 2 pt discrim; Capillary refill
Hand ROM Flexion; Extension; Abduction; Adduction
Hand Radiographs AP. Lateral, Oblique; Order specific thumb or finger films
Hand: Check films for: Alignment of joints; Cortical defects; Joint space narrowing; periarticular bony erosions, sclerosis, or spurring
CMC Osteoarthritis: S/S Pain over Thumb CMC
CMC Osteoarthritis PE: Compression test; Grind test
CMC Osteoarthritis: Compression test moving CMC Joint w/ longitudinal load applied
CMC Osteoarthritis: Grind test grab the metacarpal base & rotate thumb
CMC Osteoarthritis: Radiographs show: marginal osteophytes, joint space narrowing, & sclerosis
CMC Osteoarthritis: Tx Trial of thumb spica & NSAIDs; Corticosteroid injection; CMC arthroplasty with tendon interposition
Dupuytren Contracture: most common at: Ring & Small fingers
Dupuytren Contracture: more common in: men over 40 yo (get FH)
Dupuytren Contracture: Rx No conservative Rx; Surgery indicated for fixed contracture of more than 30 degree
Trigger Finger = Stenosing Tenosynovitis
Trigger Finger: Sx: Finger will lock, hurt, or be stiff
Trigger Finger: more common in: RA, OA & DM
Trigger Finger: Etiology Congenital
Trigger Finger: PE: Painful thickened flexor tendon or nodule at the A1 pulley
Trigger Finger: Injection: At site of tenderness/ nodule; Marcaine/ Kenalog; 25 g needle into sheath, not tendon
Trigger Finger: If recurrence after 2-3 injections: surgical release is indicated
Trigger Finger: sequelae Pt prone to triggers in other fingers
Hand Lacerations: Check: tendon integrity
Hand Lacerations: No Mans Land = btw distal palmar crease & PIP joint crease
Hand Lacerations: S/B repaired: by hand surgeon
Hand Lacerations Prone to: infection
Septic Tenosynovitis = Bacterial infection of a tendon & tendon sheath
Septic Tenosynovitis: Hx puncture, bite, or tooth wound (fight bite); progressive swelling & pain over 24-48 hr; Kanavel Sx:
Kanavel Sx: Fusiform swelling of finger; sig tenderness along course of tendon; marked pain on passive extension; flexed finger at rest
Septic Tenosynovitis: Etiology: Staph, Strep, MRSA
Septic Tenosynovitis: Rx: IV Abx, I&D if progressing; consider tetanus & rabies prophylaxis
Most common digital infection = Infection: Paronychia
Infection: Paronychia = Localized staph cellulitis in gutter along fingernail
Infection: Paronychia Rx: Soaks, PO antibiotics; digital block & I&D when abscess is organized
Infection: Felon = Abscess of pulp space of distal phalanx
Infection: Felon S/S: Localized erythema, swelling & throbbing pain
Infection: Felon: Requires: I & D, PO or IV antibiotics
Subungual Hematoma: MOA Crush injury
Subungual Hematoma: Tx Evacuate hematoma; trepanation (burr hole into nail); X-ray
Subungual Hematoma: If > 50% of nail is affected: nail s/b removed & laceration sutured
Osteoarthritis: Heberdens nodes: DIP joint
Osteoarthritis: Bouchards nodes: PIP joint
Osteoarthritis: Sx Hard & painless; Bony overgrowth; Thumb CMC early sx in women
Osteoarthritis: Rx: NSAIDs, injections, arthrodesis, arthroplasty
Rheumatoid: Sx Ulnar deviation of fingers; chronic swelling, decreased ROM; Rheumatoid nodules
Rheumatoid: deformities seen Swan neck deformity; Boutonniere deformity
Rheumatoid: Rx: DMARDs, surgery
Boutonniere Deformity = Loss of central slip insertion on proximal dorsal middle phalanx
Boutonniere Deformity S/S Flexion of PIP & hyperextension of DIP
Boutonniere Deformity Rx: Surgical
Acute Boutonniere Deformity = Central slip rupture of extensor tendon over PIP causing PIP flexion contracture with DIP extension contracture; Forced flexion of actively extended PIP
Acute Boutonniere Deformity: PE: TTP over dorsal PIP, loss of motion, & extensor lag
Acute Boutonniere Deformity: Rx: Serial casting, static extension splint
Swan Neck Deformity = Joint Synovitis secondary to RA
Swan Neck Deformity on physical exam: Flexion of the DIP & hyperextension of the PIP
Swan Neck Deformity: Rx: Surgical correction
Skiers Thumb AKA: Gamekeepers thumb
Skiers Thumb = UCL injury: Abduction stress
Skiers Thumb: consider: X-Ray prior to exam
Skiers Thumb: S/S Non-displaced fx or mild laxity
Skiers Thumb: Tx Immobilize 3-6 weeks; thumb Spica Cast
Skiers Thumb: Tx: Avulsion fx >1 mm displaced: surgical fixation
Skiers Thumb: 3rd degree, complete tear: Significant laxity; Stener lesion; surgical fixation
Skiers Thumb: Stener lesion = Aponeurosis interposed between ligament
Bennet Fx = Fx of thumb metacarpal base
Bennet Fx: MOA Axial blow or adduction stress to thumb; APL inserts into base of thumb causing displacement of fragment
Bennet Fx: Tx: Unstable fx must have ORIF
Bennet Fx: Tx: Comminuted = Rolando fx
Metacarpal Fx: 5th MC neck fx = Boxers fx
Metacarpal Fx: MC Neck: may have: loss of prominence of MCP head
Metacarpal Fx: MC Neck: Tx: with > 40 degree angulation or extension lag: CRPP
Metacarpal Fx: MC Neck: necks other than Boxers fx: Index 10, middle 20, ring 30
Metacarpal Fx: Metacarpal shaft & base: Tx Nondisplaced: cast for 4 wks, then functional splint
Metacarpal Fx: Metacarpal shaft & base: Tx Displaced fx may angulate, rotate, or shorten & s/b evaluated for CRPP
Hook of Hamate Fx = Direct impact from racquet, baseball bat
Hook of Hamate Fx: PE: TTP over hamate, check ulnar n.
Hook of Hamate Fx: XRay: CT view; may need CT scan
Hook of Hamate Fx: Rx: Excision of fragment vs 4-6 wks casting
Phalanx Fx: Distal Phalanx: Tx: Non-displaced: Rx w/ protective DIP splint symptomatically
Phalanx Fx: Distal Phalanx: Tx Displaced: consider CRPP
Middle / Proximal Phalanx fx: Assess: stability (rotation, displacement, shortening)
Middle / Proximal Phalanx fx: Rx: Splint or buddy tape stable fx for 3-4 wks
Middle / Proximal Phalanx fx: Tx: Displaced/unstable: ORIF; Protect w/ activity for 8 wks
Metacarpal Fx: MC Neck: Tx: < 40 degree angulation & no extension lag Ulnar gutter splint or cast for 3-4 wks, then functional splint
Collateral Ligament Tears = Varus or valgus stress to PIP
Collateral Ligament Tears: PE: assess stability passively & actively
Collateral Ligament Tears: Tx: If no laxity active testing: may buddy tape 4 wks w/ protected ROM
Collateral Ligament Tears: Tx: If unstable w/ active ROM: surgery indicated
Mallet Finger = Rupture of extensor tendon distal to DIP
Mallet Finger: MOA Axial load causing forced flexion
Mallet Finger: PE: Unable to actively extend DIP
Mallet Finger: PE: Stable if: < 50% of articular surface involved
Mallet Finger: Rx: Stax splint or DIP extension splint 24/7 for 6 wks; mallet finger protocol
Jersey Finger = Forceful extension of DIP; FDP avulsion
Jersey Finger: S/S Pt unable to flex DIP; most common to ring finger
Jersey Finger: Tx Surgical repair
Most common PIP Dislocation: Dorsal
Dorsal PIP Dislocation: MOA Disruption of volar plate a&nd collateral ligaments
Dorsal PIP Dislocation: xray to R/O fx
Dorsal PIP Dislocation: Rx: Reduce; splint w/ PIP in 30 degree flexion for 2-4 wks
Dorsal PIP Dislocation: Volar: MOA (Rare); disruption of collateral ligs & central slip
Dorsal PIP Dislocation: dx/tx X-ray, Reduction; extension splint 4-6 wks
PIP Fx Dislocation: presentation Similar to dislocations
PIP Fx Dislocation: Rx: Unstable: (>30% of volar plate articular surface); Surgical fixation
PIP Fx Dislocation: Rx: Stable: Splint 3-4 weeks, early ROM exercises; may play buddy taped
Tests for carpal tunnel +Phalen, +Tinel; NCS/EMG to r/o neuropathy and as pre-op
Carpal tunnel tx wrist splinting; glucocorticoid injxn (or oral); OT/PT (carpal bone mobiln); n. gliding; NSAIDs; surgery
Carpal tunnel syndrome Dx clinical dx; pain / paresthesia in median n. dist: digits 1-3 & radial half of 4th; sxs worse at night
FOOSH, Radial fracture w/ dorsal displacement, dinner-fork deformity Colle Fx; tx = volar splint
Typing, secretary wrist pain and numb/tingling from wrist to hand. New mothers, pregnant may worsen Carpal Tunnel syndrome
Pain at base of thumb, distal radial styloid. Pain reproduced with ulnar deviation of clenched fist (finkelstein test) deQuervain’s tenosynovitis (APB inflammation)
Hand injury after a punch Boxer’s fracture
Enlarged PIP, DIP Osteoarthritis (Herberden: DIP; Bouchard: PIP)
Rupture of Ext Digitorum Longus at dorsal DP = mallet finger (tx extension splint 6-8 wk)
weakness of abduction & apposition of thumb: indicates: carpal tunnel
stenner lesion on xray = gamekeepers thumb (UCL): I-II splint, III surgery
Thickened palmar fascia forms nodules over the flexor tendons causing a flexion contracture Dupuytren contracture
Carpal tunnel syndrome: MOAs with distal radial Fx, or overuse
Ulnar nerve palsy: MOAs with elbow Fx / dislocation, or impingement
Boxer's fx tx Ulnar gutter w/ intrinsic plus positioning. ORIF if angulation > 40 degress
gamekeepers thumb (UCL) mgmt I-II splint, III surgery
TFCC Tear = Triangular Fibrocartilage Complex (Stabilizes distal radioulnar joint)
TFCC Tear: dx tests X-Ray (Look for ulnar variance); MRI / Arthrogram
TFCC Tear: Rx: Splint, NSAIDs, PT; injection; arthroscopic repair
Created by: Abarnard
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