Wrist and Hand Complaints
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- Ethelbert Gilbert
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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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