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WRIST AND HAND DISEASES

WRIST PAIN
De Quervains Tenosynovitis
Acute and Occult Wrist Injuries
Scaphoid Injuries
Kienbock's Diseases
Scapholunate Advance Collapse
Carpal Tunnel Syndrome

HAND PAIN
Dupuytren's Contracture
Gamekeeper's (Skier) Thumb
Trigger Finger (Stenosing Tenovaginitis)
Mallet Finger
Raynaud's Phenomenon
Heterotopic Ossification
Ganglion


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DE QUERVAIN'S TENOSYNOVITIS

  -  Aka stenosing tenosynovitis
  -  Anatomical snuffbox – superior border: EPL, inferior border:
       1st tunnel (APL and EPB) 
  -  Pain and swelling of the tendon sheath of the abductor pollicis longus
       (APL) and the extensor pollicis brevis (EPB) ms near the area of the
       radial styloid at the wrist.
  -  Localized thickening of the tendon sheath in the area – increased
       friction.
  -  With a hx of a rapid repetitive movements of the thumb and a vocational
       stresses and commonly with RA and due to trauma.

  PE:
  -  Swelling and palpable tenderness of the APL and EPB tendon sheaths at
       the lat border of the anatomical snuffbox.

  Special test: finkelstein’s test

  -Tx: 
    1. Activity alterations
    2. NSAID’s
    3. Local steroid injection
    4. Immobilize the thumb – thumb post splint (in neutral) or
         Dequervain’s splint
    5. Physical modalities – heat, TENS, massage, hydrotherapy

  -  Surgical release – severe cases refractory to the treatment.

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ACUTE AND OCCULT WRIST INJURIES

  -  Usually treated by emergency medicine or orthopaedic specialist.
  -  Repeat pain radiography or bone radionuclide scintigraphy often
       demonstrates occult bony pathology.
  -  Complications: radial fractures (colles fx)

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SCAPHOID INJURIES

  - Scaphoid  - most commonly injured carpal bone
        -  Its transfer’s axial load from the distal radius to the distal
            carpal row.
        -  Mechanism of injury: direct fall on an outstretched arm with a
       hyperextend wrist.
  -  Dx is made from classic traumatic hx, in the presence of pain and
       tenderness over its location at the anatomical snuffbox.
  -  Ancillary procedure: plain radiographs – if fracture is suspected. 
  -  Bone scan- considered for px with normal radiographs but there is
       strong clinical suspicion of trauma.
  -  Px with normal radiographs but a classic hx and findings should be
       placed in a short arm plica cast and re- evaluated in 2 weeks.
  -  Meticulous follow up is needed bec. of the high incidence of the
       scaphoid non-union after fracture.

  * Frequency of non-union fracture increases as the location moves from
       more distal to proximal and correlates directly with the amount of
       blood supply.

  - Nondisplaced fracture in the distal 3rd
          - Excellent blood supply
          - Frequently heal effectively within a period with proper 
             immobilization.

  - Fracture in the middle 3rd
          - Have up to 30% incidence of non-union despite adequate 
             immobilization.

  - Fracture in the proximal 3rd of the scaphoid
          - Poorest blood supply
          - 90% of risk not to heal

  - Scaphoid non-union can be asymptomatic but is associated with high
       incidence of late development of OA and carpal collapse.

  - Tx:
   1. Pulse Electromagnetic Stimulation
    -  To promote healing if it is less than 5 y/o and relatively
        asymptomatic and if there is no degenerative changes.
   2. Short arm thumb splica cast for 2 weeks
   3. Surgery: open reduction and internal fixation including bone grafting.

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KIENBOCK'S DISEASES

  -  Wrist pain sclerosis and collapse of the lunate secondary to
       avascular necrosis.
  -  Most common in the dominant wrist
  -  15-40 y/o men with hx of preceding trauma.
  -  Flattening/absence of prominence of 3rd metacarpal.
  -  (+) Pain and limited wrist flexion.
  -  Tx: splint, pain mx, lunate is removed replaced
       with a prosthetic bone.
  -  Surgery is indicated when satisfactory relief of pain is not obtained
       with conservative management.
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SCAPHOLUNATE ADVANCE COLLAPSE


  -  Most common form of the chronic wrist arthritis.
  -  Post traumatic rotary subluxation that causes the scaphoid and lunate
       to separate and the capitate to migrate proximally.
  -  Impingement and osteoarthritis change can result in neuropathies and
       extensive arthropathic changes.
  -  Readily identified with plain radiography.
  -  Other focal pain syndromes of the wrist are often associated with
       the presence of ganglia, intercarpal ligament tears and failed
       tunnel surgery. 

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CARPAL TUNNEL SYNDROME


 - Muscles passing the carpal tunnel:	4 FDS
				4 FDP
				1 FDL
				1 medial nerve

 - Signs and symptoms:
  1. Weakness of thumb muscles
  2. Clumsy (frequent drop objects)
  3. Numbness in the thumb, index, middle and ½ of ring finger
      but sensation in the thenar eminence is intact (this is the 
      main difference of CTS from Pronator Teres Syndrome because
      PTS has the same manifestation + numbness of the thenar 
      eminence)

  - Can still do OK sign
  - Most common condition affecting man, women, young and old
  - Most common entrapment nerve
  - Affects people involved in repetitive wrist and hand motions like 
     carpenter, cook, typist, people with RA, DM, lymph edema, gout,
     obesity, pregnancy, colle’s fracture
  - Nerve is compress because the volume of the carpal tunnel is 
     decreased
  - NOCTURNAL PARESTHESIA – pain severe at night because swelling 
     is severe at night

Special test:
  1.Phalen’s test – if you flex both wrist, it will result to narrowing 
    of the carpal tunnel
  2.Prayer’s sign – reverse phalen’s
  3.Carpal compression test – compress the carpal tunnel for 
    30 secs. To elicit the symptoms
  4.Flick’s test – ask the patient to shake hand to relieve pain
  5.Semme Weinstein Monofilament Test
  6.Tinel’s sign
  7.EMG-NCV – most definite, most specific, most sensitive and
    accurate test for CTS
  8.2 pt. discrimination test

Treatment:
  1. Correction of underlying problem – edema, RA, DM etc
  2. Conservative – immobilize the wrist for several days or weeks; 
       put the wrist in splint called Resting Hand Splint (in neutral
       position)
  3. Physical modalities
  4. Drugs – prednisone for anti-inflammation
  5. Surgery – if no relief after 2 yrs despite therapy and medication 
       or if there’s beginning weakness of the muscles

          ·Release of transverse carpal ligament to free the nerve
          ·Carpal tunnel is located 1-2 fingers (10 cm) distal to 
             the wrist crease
    



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DUPUYTREN'S CONTRACTURE


  -  Fibrous contracture of the palmar fascia leading to flexion contracture
       of the fingers.
  -  Causative factor is unknown
  -  M>F
  -  5th – 7th decade of life
  -  Unilateral but can be bilateral
  -  Frequently involved the 4th and 5th digit
  -  HALLMARK OF THIS CONDITION: thickening of this condition
  -  As the fascia progressively thickens, the arteries are compressed
       leading to further thickening, contracture and atrophy of the
       underlying skin.

  STAGES:
    1.  Progression of the nodule of the palmar fascia
    2.  Nodule with involvement of the skin
    3.  Subsequent flexion contractures of one or more fingers.
    4.  Fixed tendon and joint contracture.

  * Progressive stretching are typically of no benefits. Continued extensor
       stress may cause progression of the syndrome.
	
  - Tx: surgical release

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GAMEKEEPER'S (SKIER) THUMB


  -  Aka skier’s thumb
  -  Characterized by an injury to the ulnar collateral ligament and the
       insertion of adductor pollicis.
  -  Frequently seen in skiers and associated with resultant instability.
  -  Can occur with acute trauma or can develop gradually with acute stress.
  -  Can be identified radiographically
  -  Tx: surgical repair

  P.E.
    1.  Swelling and tenderness over the MCP jt. of the thumb
    2.  Pain elicited by passive motion and weakness in pitch.

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TRIGGER FINGER (STENOSING TENOVAGINITIS)


  -  Aka stenosing tenovaginitis
  -  Acute and chronic inflammation and flexor tendonitis can result in a
       disproportion between the flexor tendon and its sheath.
  -  Constriction at the pulley near the level of the metacarpal head is
       associated with painful snapping of the flexor tendon.
  -  Tx: local steroid injections, splinting and surgery
  
  -  Complications:
    -  Post-OP bowstring
    -  Painful scarring
    -  Digital nerve injuries.

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MALLET FINGER

  -  Can occur as a result of a tear of the extensor tendon from the
       attachment on the distal phalanx.
  -  Usually due to an acute flexion injury when the extensor tendon is taut
  -  Tendon itself is torn on the insertion.
  -  Tx: immobilization of the distal phalanx in the hyperextension with the
       middle phalanx in flexion for 6-10 wks.
  -  Surgical repair is considered if functional recovery is inadequate.
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RAYNAUD'S PHENOMENON

  -  Vasomotor instability triggered by gold or stress
  -  Result in syndrome of pain, burning sensation, cyanosis, numbness and
       swelling of the UE.
  -  Result of increase sympathetic response to stress
  -  Bilateral, seen in women in their 40’s
  -  Pattern: pallor - cyanosis - hyperemia with reflex vasodilatation
  -  1st clinical sign of scleroderma other collagen disorders or
       vasculitides
  
  -  Mx: avoidance of precipitating factors, biofeedback, and
       medical management.

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HETEROTOPIC OSSIFICATION

  -  Abnormal formation of mature lamellar bone in soft tissue.
  -  Characterized by a matrix and crystalline form of true bone that
       develops outside the confines of the normal periosteum with
       a distinct vascular supply.

  Precipitating factors:
    -  Neurological insult
    -  Burns
    -  Direct trauma
    -  Surgery
    -  Hereditary disorders

  -  Seen most commonly in shoulders and elbow
  -  Swelling, moderate pain, joint limitation, localized warmth and
       tenderness and occasionally low grade fever.
  -  Alkaline phosphate levels can be elevated early course of the disease
       is usually negative with calcifications appearing later. 
  -  Bone scan is more sensitive early in the process.
  
  - Tx:
    -  ROME
    -  Modalities for pain relief
    -  NSAIDs with indomethacin
    -  Etidronate disodium (didronel)- use in early course of the disease
       to minimize eventual ossification

  -  Prophylactic preoperative use of local radiation treatment can be
      effective but its indications and uses are complex and controversial.

  * Surgical removal is contraindicated in the acute phase.

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GANGLION

  - most common tumor of the hand
  - common site: dorsum near the radius
  - tense, rounded, not fixed
  - herniation of synovial tissue but a a colloid degeneration of the
     connective tissue of the joint
  - give mild pain

  ganglion can:
  - dissapear spontaneously
  - has to be operated
  - benign tumor

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