Differential Dx of Wrist, Forearm and Hand

colle's fx

- common at distal radius
- FOOSH
- older individuals
- (+) x-rays
- swelling and p! at wrist; decreased AROM + strength due to p!

scaphoid fx

- most common carpal bone fx
- FOOSH
- younger people
- can result in avascular necrosis
- p! and tenderness in anatomical snuffbox
- limited and painful wrist motion, tenderness w palpation
- (+) x-rays

TFCC

- MOI: forced wrist extension + pronation, FOOSH, repeated gripping/wrist motions
- p! at ulnar side of wrist
- aggravated w pronation/supination
- (+) TFCC load test
- tender ulnar styloid w palpation
- decreased grip strength
- limited + painful wrist/forearm motions

ulnar tunnel syndrome

- compression in Guyon's canal
- seen in: long distance cyclists, extensive jackhammering, use of certain instruments
- paresthesia in ulnar 1.5 digits
- weakness of intrinsics innervated by ulnar nerve
- decreased sensation
- atrophy of hypothenars
- (+) Froment's sign

carpal tunnel syndrome

- most common in middle-aged women
- due to repetitive wrist motion, gripping, pinching
- predisposed: pregnancy, oral contraceptives, kidney dysfunction
- insidious onset
- paresthesia in palm, thumb and fingers 2 +3
- night burning
- aggravated ADLs
- altered sensation
- (+) Phalen's test, (+) hand elevation test, (+) EMG/NCV tests
- if chronic: atrophy of thenar eminence and weakness of muscles supplied by median n

dequervain's

- tenosynovitis of sheath of abductor pollicis longus and EPB
- overuse/repeated thumb abd and ext
- aching p! over snuffbox and radial styloid process
- aggravated w wrist + thumb motions
- painful resisted tests of thumb (abd + ext)
- tenderness/crepitus over snuffbox
- (+) Finkelstein's test

boxer's fx

- fx of 5th metacarpal
- p! and loss of motion at MCP
- p! and swelling of 5th MCP joint
- decreased AROM and PROM
- (+) x-rays

gamekeeper's thumb/skier's thumb

- trauma of ulnar side of thumb resulting in ligament laxity and instability of MCP joint
- MOI: valgus injury (ext or abd of thumb)
- swelling if acute
- p! over ulnar side MCP joint
- (+) valgus stress test

rheumatoid arthritis (RA)

- chronic, systemic inflammation of synovium
- begins in smaller joints (wrist and fingers)
- Bilat
- insidious, atraumatic onset
- fatigue, morning stiffness, flu-like sx, loss of appetite
- signs of inflammation at joints
- snapping/locking w ROM due to synovitis
- muscle weakness
- (+) serology
- ulnar drift

mallet finger

- avulsion fx of a finger extensor tendon
- traumatic, forceful flexion of distal phalanx (tip of finger hitting ball)
- tenderness at DIP
- can't actively extend DIP
- normal PROM

trigger finger

- painful snapping condition from inability of a flexor tendon to glide smoothly through flexor sheath (due to stenosis or thickening of tendon)
- underlying conditions: diabetes, RA, post-menopause
- common in thumb, digits 3+ 4
- insidious onset of clicking/snapping of involved finger
- p!
- palpable nodule in involved tendon

clinical prediction rule to ID presence of CTS

1. age >45
2. shaking out hands to relieve sx
3. wrist-ratio index >.67 (don't really use anymore)
4. decreased sensation at tip of digit 1 compared to thenar eminence
5. Symptoms Severity Score > or = to 1.9