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Wrist:

Carpal Tunnel Syndrome

  • Cause/Pathophysiology

    • Compression on the median nerve

  • History and symptoms

    • Pain, numbness, tingling, and/or burning in palm thumb pad, index, and middle fingers

    • Frequently at night

    • may be intermittent or constant 

  • Exam Findings

    • +/- altered sensation median nerve distribution (thumb, index, middle fingers)

    • +/- thenar atrophy

    • +/- finger grasp strength

    • +/- Carpal Tunnel Compression, Tinel's, Phalen tests

  • Imaging/Diagnostic Studies

    • EMG/NCV​

  • Treatment​

    • Rigid wrist bracing (especially at night)​

    • Vitamin B6 ?

    • Cortisone injection

    • Carpal Tunnel release 

  • Common ICD-10 codes​​

    • G56.00

 

 

 

 

 

 

 

 

 

 

 

 

 

De Quervain's Tenosynovitis

  • Cause/Pathophysiology

    • Inflammation of the extensor pollicis brevis and/or abductor pollicis longus near the base of the thumb

    • overuse, can be acute or chronic 

  • History and symptoms

    • pain at the base of the thumb near the anatomic snuffbox and radial styloid

    • increased pain with use of the hand (gripping, lifting, twisting)

  • Exam Findings

    • tender to palpation base of the thumb and radial styloid

    • +/- crepitus over tendons

    • + Finkelstein's test

  • Imaging

    • clinical diagnosis​

  • Treatment​

    • Firstline

      • NSAIDs or short course of steroids​

      • Ice

      • Thumb spica wrist brace 4-6 weeks

      • PT/OT may be helpful

    • Secondline

      • Cortisone injection

    • Surgery

      • De Quervain's release​

  • Common ICD-10 codes​​

    • ​M65.4​

 

 

 

 

 

 

 

 

 

 

 

 

Sprain

  • Cause/Pathophysiology

    • Stretch/tear injury to any of the radiocarpal, ulnar carpal, or inter carpal ligaments

    • Usually acute, but can have chronic inter carpal ligament tears

  • History and symptoms

    • Fall on outstretched hand (FOOSH)

    • +/- pain at rest

    • Pain with wrist motion

  • Exam Findings

    • +/- swelling

    • Tender to palpation over injured ligament

    • +/- ROM limitation

  • Imaging

    • Negative X-Ray​ for fracture, but may see joint space widening with certain inter carpal sprains (scapholunate)

    • MRI arthrogram if no resolution with conservative treatment

  • Treatment​

    • Firstline​

      • RICE​

      • Rigid wrist brace up to 6 weeks

      • +/- PT or OT, post-acute

    • If conservative management fails and MRI arthrogram shows significant ligament injury, surgery may be indicated

  • Common ICD-10 codes​​

    • S63.509 add A, D, or S

 

 

 

 

 

 

 

 

Triangular Fibrocartilage Complex (TFCC) Tear

  • Cause/Pathophysiology

    • Chronic or Acute tearing of the TFCC

    • Usually resulting from repetitive or forceful acute wrist extension, ulnar deviation, and/or rotation

  • History and symptoms

    • Pain with activity that requires wrist extension (push-ups, bench press, etc), rotation with ulnar deviation (swinging a baseball bat, golf club, or racket)

    • +/- pain at rest or painful clicking

  • Exam Findings

    • Tender to palpation ulnar carpal joint

    • +/- pain with forced end-range wrist extension and/or ulnar deviation

  • Imaging

    • Negative X-Rays​

    • MRI arthrogram for definitive diagnosis

  • Treatment​

    • Firstline​

      • Acute tear - immobilization in cast or brace for 4-6 weeks, some may heal​

      • Chronic - brace 4-6 weeks

    • Second line

      • Cortisone injection​

    • Surgery if conservative treatment fails

  • Common ICD-10 codes​​

    • S63.599 add A, D, or S

 

 

 

 

 

 

 

 

 

 

 

 

 

Fractures  

Distal Radius/Ulna Fracture

  • Cause/Pathophysiology

    • Majority result from a fall on an outstretched hand

  • History and symptoms

    • mechanism of injury

    • pain

    • +/- deformity

  • Exam Findings

    • +/- deformity

    • swelling

    • tender to palpation

    • +/- crepitus

  • Imaging

    • X-Rays​

    • CT scan - consider if intra-articular or for surgical planning if significant comminution and/or displacement

  • Treatment​

    • Casting​

      • Non-displaced or minimal displacement/angulation ​

      • Usually 

    • Closed reduction and casting

      • Acute injury with unacceptable angulation and/or displacement​

        • ADULT: >5º loss radial inclination, >5mm radial shortening, >5º dorsal tilt or >20º difference from the opposite side

        • PEDIATRIC:

    • Closed reduction and pinning (CRPP)

      • usually pediatric or adolescent age that fail closed reduction and splinting/casting​

    • Open reduction and internal fixation (ORIF)

      • Significant angulation/displacement that fails ​reduction

      • Significant comminution, particularly dorsally

      • intra-articular if step off >2mm

  • Common ICD-10 codes​​

    • S52.501A

    • S52.602A - ulna

 

 

Scaphoid Fracture

  • Cause/Pathophysiology

    • FOOSH

  • History and symptoms

    • MOI

    • Radial sided wrist pain, may be constant or associated with ROM if not acute

  • Exam Findings

    • +/- swelling

    • Tender to palpation in "anatomic snuffbox"

  • Imaging

    • X-Ray - AP, lateral, oblique​e , Scaphoid views

      • may not show initially​

    • CT

    • MRI

  • Treatment​

    • Thumb spica casting​ ~8 weeks

      • acute, non-displaced​

    • Surgery

      • displaced, chronic, or non-union​

  • Common ICD-10 codes​​

    • S62.009A

 

 

 

 

 

 

 

 

 

 

 

Torus/Buckle Fracture

  • Cause/Pathophysiology

    • Pediatric injury 

    • FOOSH

    • Hyperflexion/Hyperextension

  • History and symptoms

    • MOI

    • Wrist pain, can be constant or intermittent and associated with use

    • Decreased usage observed by others

  • Exam Findings

    • +/- Swelling

    • TTP distal radius and/or ulna

  • Imaging

    • X-Ray - cortical "buckle", no visible fracture line​

  • Treatment​

    • Velcro wrist brace or short arm cast until nontender​

    • usually 4-6 weeks

  • Common ICD-10 codes​​

    • S52.521A 

 

 

 

 

 

Hand:

Trigger finger/Stenosing Tenosynovitis

  • Cause/Pathophysiology

    • Flexor tendon gets "stuck" or "catches" in the A1 pulley

  • History and symptoms

    • Finger pain

    • Finger gets stuck or catches in flexion

  • Exam Findings

    • Visible and/or palpable click or catch when extending the finger from a flexed position

    • May have to manually extend it

  • Imaging

    • Clinical diagnosis, but X-Rays can evaluate for any significant arthritic envolvement​

  • Treatment​

    • Cortisone injection​

    • Surgical trigger finger release

  • Common ICD-10 codes​​

    • ​M65.30​

Mallet finger

  • Cause/Pathophysiology

    • Rupture or bony avulsion of the extensor digitorum on the distal phalanx

    • Usually a direct axial blow to the finger-tip

  • History and symptoms

    • MOI

    • +/- pain

    • Characteristic deformity

  • Exam Findings

    • Resting flexion deformity at the DIP

    • Inability to actively extend finger at the DIP

    • +/- TTP

  • Imaging

    • X-Rays - flexion deformity, possible bony avulsion dorsally, make sure no j​oint subluxation

  • Treatment​

    • Stax splint x 6 weeks​

    • Surgery if large avulsion or joint subluxation

  • Common ICD-10 codes​​

    • M20.019

FRACTURES  

Metacarpal Fracture

  • Cause/Pathophysiology

    • 5th metacarpal neck (Boxer's fracture) most common

    • Trauma - punching, MVA, direct blow

    • Usually at neck or shaft

  • History and symptoms

    • MOI

    • Pain

    •  +/- deformity

    • Disuse

  • Exam Findings

    • Swelling

    • +/- deformity, MAKE SURE TO EVALUATE FOR ROTATIONAL DEFORMITY IN EXTENSION AND FLEXION

    • TTP

    • +/- Crepitus

  • Imaging

    • X-Ray - Hand AP, lateral, oblique ​

  • Treatment​

    • Splint/Casting - SA with the MP flexed 70-90°

      • If no rotational abnormality and angulation is acceptable

      • As a general rule the 5th can tolerate 40° angulation and decreases by 10° with each of the other metacarpals (4th - 30°. 3rd - 20°, etc.)

      • ​Neck fractures may be able to tolerate more as long as they have full motion and no rotational abnormalities​

    • Surgery if unacceptable deformity

  • Common ICD-10 codes​​

    • 62.399A

 

Phalanx Fractures

  • Cause/Pathophysiology

    • Trauma

  • History and symptoms

    • MOI

    • Pain

    • +/- deformity

  • Exam Findings

    • Swelling

    • +/- deformity, MAKE SURE TO EVALUATE FOR ROTATIONAL DEFORMITY IN EXTENSION AND FLEXION

    • TTP

    • +/- ROM deficit

  • Imaging

    • X-Ray - AP, Lateral, Oblique

  • Treatment​

    • Conservative​ splinting 

      • Most non or minimally displaced or angulated fractures

      • If angulated or displaced, closed reduction 

    • Surgery

      • Unacceptably angulated or displaced, irreducible, or failed reduction​

  • Common ICD-10 codes​​

    • S62.609A

 

Tuft Fracture

  • Cause/Pathophysiology

    • Trauma

  • History and symptoms

    • MOI

    • Pain

  • Exam Findings

    • Swelling

    • +/- subungal hematoma

    • TTP

  • Imaging

    • X-Ray

  • Treatment​

    • Symptomatic​ - Ice, cushion wrap or Stax splint

    • If there is a significant subungal hematoma (>50% of the nail surface), high likelihood there is a laceration of the nail bed, therefor making the fracture an open fracture requiring nail removal, laceration repair, and antibiotic coverage in addition to splinting

  • Common ICD-10 codes​​

    • S62.609A

 
 
 
 
 
 
 
 
 
 
 
 

Possible Location of Carpal Tunnel Syndrome Symptoms

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Possible Location of DeQuervain's Tenosynovitis Symptoms

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Possible Location of Wrist Sprain Symptoms/Tenderness

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Possible Location of TFCC Injury Symptoms/Tenderness

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Possible Location of Distal Radius/Ulna Fracture Symptoms/Tenderness

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Possible Location of Scaphoid Fracture Symptoms/Tenderness

Possible Location of Distal Radius/Ulna Torus Fracture Symptoms/Tenderness

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You will not likely see a torus fracture in an arm this hairy.  It's a pediatric injury solely.

Possible Location of Trigger Finger Symptoms/Tenderness

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Location of Mallet Finger Symptoms/Tenderness

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Location of Metacarpal Fracture Symptoms/Tenderness

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Depends on which is broken

Location of Phalanx Fracture Symptoms/Tenderness

Depends on which is broken
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Location of Phalangeal Fracture Symptoms/Tenderness

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Depends on which is broken