wrist differential dx

fractures

- typically made with diagnostic imaging

- mgmt through internal fixation or immobilization

Colles fracture

- one of the most common fx sites

- fracture of distal end of radius

- FOOSH

- individuals >60y/o

- weakened bones and susceptibility to falls

- may be associated with carpal and distal ulna fx, intercarpal ligament sprains, TFCC injuries, median nerve injuries

Colles fx clinical presentation

- FOOSH

- c/o pain and loss of motion at wrist

- pain and swelling at wrist

- may support forearm to unload pressure on wrist

- decreased AROM and strenght d/t pain

- (+) radiographs

scaphoid fx

- most common carpal bone fx

- FOOSH

- occurs in younger people with a strong and healthy radius

- can result in avascular necrosis if not treated

scaphoid fx tests and measures

- FOOSH

- c/o pain and tenderness in anatomical snuffbox or scaphoid tubercle

- limited/painful wrist motion

- tenderness with palpation

- (+) radiographs

boxers fx

- fx of the 5th MC

- traumat to 5th MC

- common MOI: striking the wall with clenched fist

- c/o pain and loss of motion of 5th MCP

- pain and swelling noted about 5th MCP joint

- decreased AROM and PROM

- (+) radiographs

mallet finger

- results from avulsion fx of a finger extensor tendon

- MOI is usually traumatic

- forceful flexion of the distal phalanx

- tenderness at DIP

- unable to actively extend DIP

- normal PROM

TFCC

- MOI typically involves forced wrist extension and pronation

- FOOSH or repeated gripping or wrist motions

- pt. c/o pain at ulnar side of wrist aggravated with supination/pronation movements

- limited and painful wrist/forearm motions with possible click/crepitus

- tenderness with palpation at ulnar styloid

- may experience decreased grip strength

- (+) TFCC load test

ulnar tunnel syndrome

- compression of the hand involving tasks with pressure to the area (extensive jackhammer, long distance cyclist, certain musicians)

- trauma, use of crutches and bone or soft tissue injury

- c/o paresthesia in the ulnar one and a half digits

- weakness of intrinsic muscles innervated by ulnar nerve

- decreased sensation along ulnar nerve distribution

- atrophy of hypothenar eminence

- (+) froments sign

carpal tunnel syndrome

- compression of median nerve through carpal tunnel

- middle to older adults

- 2x more common in women than men

- repetitive wrist motion, static or dynamic gripping or pinching causing swelling of median nerve or flexor tendon sheath

- situations altering fluid balance (pregnancy, oral contraceptive, kidney disfunction)

carpal tunnel clinical presentation

- c/o insidious onset of paresthesia and/or pain in palm, thumb, and 2nd-3rd fingers

- nocturnal burning pain in hand is common

- sx aggravated with ADLs requiring use of hand

- loss of dexterity interfering with ADLs

- altered sensation in median n. distribution

- (+) Phalens, tinel's, carpal tunnel compression test, EMG/NVC

- may observe atrophy of thenar eminence and weakness of hand muscles innervated by median nerve

DeQuervain's tenosynovitis/tendinopathy

- tenosynovitis of common sheath of AbPL, EPB

- overuse activities requiring repeated thumb abduction and extension

- more prevalent in women then men

- later stages of pregnancy and during lactation

- c/o aching pain over snuff & radial styloid

- aggravated wrist and thumb motions

- painful resisted tests of thumb abduction & extension

- tenderness/crepitus along the tendons course and snuffbox

- (+) finkelstein, reduced/painful pinch or grip strength

Gamekeeper's thumb (skier's thumb)

- trauma of ulnar side of thumb resulting in ligament laxity and instability of MCP joint

- MOI: traumatic injury resulting in valgus injury of thumb (ext. or abd.)

- c/o pain and instability at the thumb

- swelling may be present in acute injury

- pain over ulnar side of MCP joint

- (+) valgus stress test

scapholunate ligament injury

- FOOSH is common MOI

- c/o radial sided wrist pain and may c/o clicking or sense of instability with wrist ROM

- pain with palpation over the scapholunate interval or anatomical snuff box

- may observe swelling, decreased grip strength, and pain/limited wrist ROM

- (+) Watson Scaphoid Test

RA

- c/o insidious, atraumatic onset of pain/inflammation in multiple joints of the wrist/hand

- c/o other systemic sx such as fatigue, morning stiffness, flu-like sx, loss of appetite

- observed inflammation at joints, joint deformities

- snapping or locking with ROM due to synovitis

- general muscle weakness

- (+) serology (erythrocyte sedimentation rate, rheumatoid factor)

OA

- age related, biomechanical, physiological, and/or psychological factors

- often occurs at 1st CMC

- middle aged and older adults

- pain and weakness at base of thumb with gripping, grasping, and pinching, or using thumb to apply force

- motion may be limited and more difficult d/t pain and eventual weakness

- may observe swelling and an enlarged appearance of the CMC joint in later stages

- (+) CMC grind test

trigger finger

- painful, snapping condition resulting from inability of a flexor tendon to glide smoothly through flexor sheath, due to either stenosis or thickening of the tendon

- diabetes, RA, post-menopause

- most commonly seen in 3rd or 4th fingers

- insidious onset of clicking or snapping of involved finger

- often associated with pain

- palpable nodule in involved tendon