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Hand
Orthopedics
| Question | Answer |
|---|---|
| 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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