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7 Hand and Wrist Conditions N ot to Miss

7 Hand and Wrist Conditions N ot to Miss. Jacob Christensen, D.O. Learning Objectives. Become more familiar with diagnosis and treatment of common hand/wrist injuries which may need referral to orthopedic surgery or hand surgery.

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7 Hand and Wrist Conditions N ot to Miss

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  1. 7 Hand and Wrist Conditions Not to Miss Jacob Christensen, D.O.

  2. Learning Objectives • Become more familiar with diagnosis and treatment of common hand/wrist injuries which may need referral to orthopedic surgery or hand surgery. • Briefly review anatomy related to the above mentioned injuries. • Understand the importance of a detailed physical exam of the hand/wrist for appropriate diagnosis.

  3. Physical Exam • Follow the same pattern you would follow for any exam • Inspection • Palpation – Be very SPECIFIC! Review anatomy if not confident. • ROM – Active first, then passive if concern. • Strength testing – Be SPECIFIC! • Special tests • Neuro/vascular exam • Video of thorough hand and wrist exam • https://www.youtube.com/watch?v=C92dQxxxmC8&t=0s

  4. Ulnar Collateral Ligament Injury Also known as “Skier’s thumb” or “Gamekeeper’s thumb.” Presentation: Pain at the base of the thumb after an injury with forced abduction of the thumb. • Exam: • Reduced ROM at the MCP joint with TTP over ulnar aspect of MCP joint. • Stress examination of the UCL is important, especially if no avulsion is seen on xray. • >35 degrees deviation or >15-20 degrees deviation compared to the contralateral thumb is indicative of significant injury. • Should test in both neutral and flexed positions of the MCP joint. • May have decrease strength in pinch grip of the thumb and index finger.

  5. Ulnar Collateral Ligament Injury • Imaging: Xray exam of the hand may reveal avulsion fracture. Take care to look for other pathology as there can be concomitant fractures. • Treatment: • Partial strains and small non-displaced avulsion fractures which are stable on stress testing can be treated with thumb spica splint for 4 weeks followed by gentle ROM and isometric strengthening. • If instability continues, refer to surgery. • Refer to surgery if: • No end point felt on stress testing. • Deviation >30 degrees on stress testing. • Deviation >15-20 degrees compared to opposite side. • Displaced avulsion fracture. • Stener lesion.

  6. Ulnar Collateral Ligament Injury • Refer to surgery if: • No end point felt on stress testing. • Deviation >30 degrees on stress testing. • Deviation >15-20 degrees compared to opposite side. • Displaced avulsion fracture. • Stener lesion.

  7. Bennet’s Fracture • Two part, oblique intra-articular fracture and subluxation of the proximal 1st metacarpal. • Most common 1st metacarpal fracture. • Small volar/ulnar fragment retains ligamentous connection to trapezium at the 1st CMC joint. • Important to look for concomitant injuries (i.e. scaphoid fracture, UCL injury) • Refer to surgery.

  8. Avulsion of the FDP from the DIP • Also known as “jersey finger.” • Presentation: • Swollen, bruised, painful distal digit. • History of injury involving sudden extension of an actively flexed DIP. • Most commonly the ring finger. • Exam: • Check FDP function by blocking the PIP joint in extension and then ask the patient to actively flex at the DIP joint. • Careful specific examination of each flexor tendon. • This injury is often missed if the patient is only asked to “make a fist.”

  9. Avulsion of the FDP from the DIP • Imaging: • Radiographs can be useful, but are not diagnostic as they are often negative. • There may be an avulsion fracture • Treatment: • Regardless of radiograph findings, splint in slight flexion and REFER URGENTLY TO HAND SURGEON! • Significant tendon retraction results in pulley collapse and loss of tendon blood supply. • Primary repair difficult after 7-10 days.

  10. Volar Plate Injury • Strong fibrous stabilizing structure connecting the palmar aspect of the middle and proximal phalanges. • Can be disrupted in forced hyperextension mechanism injuries. • Plain radiographs are needed for assessment. True lateral is the key view to inspect for avulsion fracture, dislocation, subluxation, and “V” sign. • Fracture involving >40% of the articular surface or subluxation (including positive “V” sign) merits surgical referral.

  11. Diagnosis?

  12. Boxer’s Fracture • Mechanism is implied in name. • Bony TTP over 4th or 5th metacarpals. • Xrays for diagnosis. Ultrasound can be used as an initial tool. • Examine angulation and rotational deformity.

  13. Boxer’s Fracture GOOD NOT GOOD

  14. Boxer’s Fracture • Treatment: • For appropriately selected patients: • Ulnar gutter splint for 3-4 weeks. • F/U after a week with repeat imaging to look for worsening deformity. • F/U at 2 weeks intervals with repeat imaging looking for clinical and bony healing. Once evidence of healing is present, d/c splint. • Usual healing time is 4-6 weeks. • Refer to surgery if: • Open fracture or neurovascular compromise present (uncommon). • Complex fractures (i.e. comminuted fractures). • Any rotational deformity. • Angulation >30 degrees.

  15. Diagnosis?

  16. Scaphoid Fracture • Scaphoid fractures make up 50-80% of all carpal injuries. • Occurs most often after fall on outstretched hand (FOOSH). • Snuffbox tenderness to palpation after wrist/hand injury. • Pain in the wrist with axial loading of the thumb (grind test). • Can occur concurrently with other acute fractures of the wrist. • GET XRAYS PLEASE. • If xrays are negative, but scaphoid fracture is suspected, IMMOBILIZE in thumb spica splint for 1-2 weeks and re-image. • If very high concern for scaphoid fracture, some evidence for early MRI. • Refer to hand surgeon.

  17. Scaphoid Fracture

  18. Scapho-Lunate Dissociation • Occurs most commonly after trauma (FOOSH injury). • Tear of the scapholunate ligament. • Can present as occult tear. • Progresses to dissociation  Carpal Collapse  Scapholunate advanced collapse (SLAC) wrist and disabling arthritis • Diagnosis requires high degree of suspicion, as physical exam tests (e.g. Watson test) for laxity of the scaphoid ligaments have limited specificity. • Xrays show positive “Terry Thomas Sign.” • interosseous distance >3mm between the scaphoid and lunate • Refer these injuries to hand surgery.

  19. Scapho-Lunate Dissociation • “Terry Thomas Sign” • “Michael Strahan Sign”

  20. References • Commonly Missed Orthopedic Problems – AAFP https://www.aafp.org/afp/1998/0115/p267.html • Common Finger Fractures and Dislocations - AAFP https://www.aafp.org/afp/2012/0415/p805.html • Four hand injuries not to miss: avoiding pitfalls in the emergency department. Yoong, P., Johnson, C., Yoong, E., and Chojnowski, A. (2011) European Journal of Emergency Medicine. DOI: 10.1097/MEJ.0b013e328342f252 • https://radiopaedia.org/cases/scaphoid-fracture-13 • http://www.raleighhand.com/cms/wp-content/uploads/2011/08/MCfx.jpg • http://epmonthly.com/article/all-in-the-wrist/

  21. Resident School Evaluation Form

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