Wrist and Hand Complaints

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1 Wrist and Hand Complaints Charles S. Day, M.D., M.B.A. Chief, Hand & Upper Extremity Surgery St. Elizabeth s Medical Center Tufts University School of Medicine Primary Care Internal Medicine 2018

2 Outline Terminology and Axes of Motion Fundamental Surface Anatomical Landmarks Physical Examination & Diagnoses for PCP s

3 Hand Dorsal surface Terminology Volar or palmar surface Radial and ulnar borders Palm Thenar area Mid-palm area Hypothenar area Palmar view of the hand

4 Terminology Fingers Thumb, index, middle/ long, ring, & small (1 st to 5 th ) Each digit (except thumb) 3 phalanges (prox, middle, distal) metacarpal

5 Each finger has three joints: Metacarpophalangeal (MP) Proximal interphalangeal (PIP) Distal interphalangeal (DIP) Thumb Two phalanges & two joints (MP, IP) Terminology

6 Hand Motion Standardized Forearm Wrist

7 Hand Motion Standardized Digits Center of hand Long finger ray

8 Thumb Motion Standardized Flexion Extension (Planar abduction) Extension ( ) Essentials of Hand Surgery 2002

9 Thumb Motion Standardized Abduction (Palmar) Essentials of Hand Surgery 2002

10 Thumb Motion Standardized Opposition Abduction Flexion (Adduction) Pronation Essentials of Hand Surgery 2002

11 Surface Anatomy of Hand Bones Metacarpal Phalanges Joints DIP, PIP, IP, MCP

12 Dorsal Surface Anatomy Bones Metacarpal Phalanges Joints DIP, PIP, IP, MP

13 Palmar Surface Anatomy MP?

14 Wrist

15 Anatomical Structures of the Wrist # bones: 15 # joints: 17 # tendons: 24 (25)

16 Surface Anatomy of Wrist First landmark: Snuff box CMC thumb Thumb Extensors Scaphoid

17 Surface Anatomy of Wrist Dorsum of the Wrist Second Landmark Lister s tubercle Distal Radius Scapho-Lunate Ligament

18 Surface Anatomy of Wrist Third Landmark Distal Ulna Extensor Carpi Ulnaris (ECU) Tendonitis Triangular Fibro- Cartilage Complex (TFCC) ligament Dorsum of the Wrist

19 Surface Anatomy Summary Volar MP joints PIP and DIP Joints Metacarpals Phalanges Snuffbox Lister s Tubercle Distal Ulna

20 P.E. & Diagnoses of Hand & Wrist Pain

21 47 y.o. woman c/o 6 months h/o of numbness and tingling in right hand Wakes her up at night

22 Finger Sensation to Light Touch Normal? Symmetric?

23 Tinel s Carpal Tunnel Syndrome

24 Median Nerve Compression (Durkin) Carpal Tunnel Syndrome

25 Phalen s Carpal Tunnel Syndrome

26 Carpal Tunnel Syndrome 2 x 1 cm 2

27 CTS Treatments

28 Clinical messages Clinician Ask about night pain May lead to irreversible median nerve damage Refer to hand surgeon if splint not helpful Patient Start with wrist splints at night F/u if symptoms no better

29 53 y.o. male with diabetes c/o clicking in right ring finger joint Worse in the mornings Sometimes the finger sticks

30 Trigger Finger

31 Flexor Tendon Normal Finger Cascade

32 Flexor Tenosynovitis (Trigger Finger)

33 Treatment

34 Clinical messages Clinician Examine the volar MP joint of the finger Increased risk in diabetics and rheumatoids Patient Therapy is unreliable Steroid injection has 70% success rate

35 27 y.o. male RHD (right-hand dominant) male accidentally cut his left index finger while opening up frozen hamburger patties

36

37 Flexor Digitorum Profundus

38 Flexor Digitorum Superficialis

39 Treatment

40 Clinical messages Clinician Urgent hand surgery referral Check digital sensation Patient May need surgery

41 24 y.o. male fell on outstretched hand (FOOSH) while skateboarding on sidewalk, now has wrist pain

42 Radial Wrist Pain

43 Radial Sided Wrist Pain

44 Radial Sided Wrist Pain

45 Snuffbox Palpation

46 Scaphoid Fracture

47 Treatment

48 Clinical messages Clinician Thumb spica splint/ cast if h/o of FOOSH and snuffbox tenderness Refer to orthopaedic surgeon Patient Need to follow up for persistent wrist pain after falls

49 31 y.o. woman who has a 2 month old baby at home c/o right thumb/ wrist pain for the last month Worse with picking up baby

50

51 De Quervain s Tenosynovitis Finkelstein s Exam

52 Treatment

53 Clinical messages Clinician Thumb spica splint and NSAIDs Steroid injection is 70% effective Patient Try not to extend the thumb, especially young mothers

54 67 y.o. woman c/o 1 year h/o of pain in her right wrist area Worse with turning on ignition Worse with twisting open bottle caps

55 Bony Prominence Distal to Snuffbox

56 CMC arthritis of the Thumb

57 CMC arthritis of the Thumb

58 CMC arthritis of the Thumb (Grind Test)

59

60 Treatment

61 Clinical messages Clinician Thumb spica splint Steroid injections ONLY 40% effective Patient Activity modification, ie, opening bottle caps

62 24 y.o. male fell on outstretched hand (FOOSH) while skateboarding on sidewalk, now has wrist pain

63 Distal Radius Fracture Lister s Tubercle

64

65 Treatment

66 Clinical messages Clinician When in doubt, immobilize 30% fractures do not show up on initial xrays Patient Be careful when ground is slippery or uneven

67

68 Scapholunate Ligament Tear

69

70 Treatment

71 Clinical messages Clinician Thumb spica splint/ cast if h/o of FOOSH and SL ligament tenderness Refer to orthopaedic surgeon Patient Need to follow up for persistent wrist pain after falls

72 Ulnar Sided Wrist Pain

73 Ulnar Sided Wrist Pain (Distal Ulna Landmark)

74 ECU Tendon Palpation

75 ECU Tendonitis

76 ECU Tendon Resistance Test

77 Treatment

78 Clinical messages Clinician Wrist splint and NSAIDs Steroid injection effectiveness unknown (risk of tendon ruptures) Patient Avoid activities that aggravate the tendonitis

79 24 y.o. male fell on outstretched hand (FOOSH) while skateboarding on sidewalk, now has wrist pain

80 Triangular FibroCartilage Complex (TFCC) Injury

81 TFCC Schematic

82

83 P.E. & D.Dx. Summary P.E. for MC/ Phalanx Fx Trigger Finger FDS/ FDP Injuries Carpal Tunnel Syndrome Scaphoid Injury CMC arthritis of the Thumb DeQuervain s Tendonitis Scapho-Lunate Injury TFCC Injury

84 Questions? Charles S. Day, MD, MBA

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