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