Wrist and Hand | Basics of Ortho

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, obliquee , 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 joint 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

Carpal Tunnel Syndrome

De Quervain's Tenosynovitis

Wrist Sprain

TFCC Tear

Distal Radius/Ulna Fracture

Scaphoid Fracture

Torus Fracture

Trigger Finger

Mallet Finger

Metacarpal Fracture

Phalanx Fracture

Tuft Fractue

Possible Location of Carpal Tunnel Syndrome Symptoms

Possible Location of Carpal Tunnel Syndrome Symptoms

Possible Location of DeQuervain's Tenosynovitis Symptoms

Possible Location of Wrist Sprain Symptoms/Tenderness

Possible Location of TFCC Injury Symptoms/Tenderness

Possible Location of Distal Radius/Ulna Fracture Symptoms/Tenderness

Possible Location of Scaphoid Fracture Symptoms/Tenderness

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

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

Location of Mallet Finger Symptoms/Tenderness

Location of Metacarpal Fracture Symptoms/Tenderness

Depends on which is broken

Location of Phalanx Fracture Symptoms/Tenderness

Depends on which is broken

Location of Phalangeal Fracture Symptoms/Tenderness

Depends on which is broken