Evaluation of Disorders of the Hands and Wrists

1
Evaluation of Disorders of the Hands and Wrists
2
Case

• 27 yo female with 6 month history of right
  forearm and hand pain
• Works as secretary, symptoms are interfering with
  her job duties
• Complains that she is dropping objects and right
  hand feels weak

3
Carpal Tunnel Syndrome
Median nerve distribution
Ulnar nerve distribution
Carpal Bones
Median Nerve
4
Carpal Tunnel Syndrome

• Findings
• Tinels Sign Phalens Sign

5
Case

• 27 yo female
• 6 mo hx of bilateral thumb pain
• Has worked for the past year on a factory
  assembly line
• Symptoms are interfering with her job performance

6
De Quervains Tenosynovitis

• Pain and tenderness in the area about the radial
  styloid that is worsened with movement
• Due to inflammation of the abductor pollicis
  longus or extensor pollicis brevis
• Often due to overuse (repetitive grasping with
  the thumb against resistance)

7
De Quervains Tenosynovitis-Finklestein Test-
8
Case

• 37 yo male carpenter
• 6 mo history of wrist swelling

9
Ganglion Cyst

• Cystic mass that arises in the proximity of the
  joint capsule or tendon sheath
• Associated with repetitive strain, trauma, or
  inflammatory arthritis
• Most commonly arises on the dorsal aspect of the
  wrist
• Usually asymptomatic

10
Case

• 56 yo male
• PMH DM
• Progressive loss of range of
• motion of 3rd 4th fingers

11
Dupytrens Contracture

• Thickening and shortening of the palmar fascia of
  the hand
• May be unilateral or bilateral
• Results in flexion contractures of the fingers

12
Case

• 29 yo female
• Professional musician
• CC Intermittant locking up of fingers

13
Trigger Finger

• Inflammatory process of the flexor tendon sheath
• Associated with repetitive trauma, RA, diabetes
• Causes pain and catching with flexion

14
Case

• 73 yo female with a 10 year history of gradually
  progressive pain in her hands. Pain is most
  severe in her fingers and the base of her thumbs.
• Her hands are stiff when she first gets up in the
  morning.
• She has trouble opening jars and has been doing
  less knitting because of her pain.

15
Distribution of Pain and Disease Association
DIP OA, Psoriatic, Reiters
PIP OA, RA, SLE, Psoriatic
MCP RA, Pseudogout, Hemochromatosis
1st CMCOA
Wrist RA, Pseudogout, ganglion cyst, carpal
tunnel syndrome
DeQuervains tenosynovitis
16
Physical Exam
17
Osteoarthritis- Physical Exam

• Bony hypertrophy (heberdens and bouchards
  nodes)
• Crepitus
• Minimal heat or effusion

Bouchards Node
Heberdens Node
18
Osteoarthritis (OA)

• Most common arthropathy of adults
• Noninflammatory condition
• Degeneration and loss of cartilage
• Site DIPs, PIPs, 1st CMC, hips, knees, cervical
  spine, and lumbar spine

19
Case

• 37 yo female with a 6 month history of pain and
  swelling in her hands
• She has worked for the last year on an assembly
  line in a local factory
• Her symptoms are worse in the morning and get
  better as the day goes on

20
Physical Exam
21
Rheumatoid Arthritis (RA)

• Chronic, progressive, symmetric arthritis
• Small joints of the hands and feet (MCPs, PIPs,
  wrists, and MTPs)
• Prolonged morning stiffness (gt30-60 minutes)
• 75-85 are RF positive

22
RA-Physical Findings

• Warmth
• Erythema
• Synovitis
• Nodules
• Loss of function
• Deformity
• Swan-neck
• Boutonniere
• Ulnar drift

Swan- neck
Boutonniere
23
Rheumatoid Nodules
24
RA
Ulnar deviation, MCP joint subluxation,
rheumatoid nodules
25
Case

• 60 yo male with a 2 day history of pain and
  swelling in his left wrist
• He doesnt recall any recent trauma.
• He has had similar but less severe episodes in
  other joints in the past.

26
Physical Exam
27
Synovial Fluid Analysis
Axis
28
Radiographs

• Soft tissue alterations
• Effusion, swelling, calcification
• Articular malalignment
• Joint space loss
• Changes in cortical bone
• Fracture, erosions, osteophytes, periosteal
  reaction

29
OA-Radiographic Features

• Loss of joint space
• Osteophytes
• Subchondral sclerosis

DIP
30
RA-Radiologic Findings

• Soft tissue swelling
• Juxtaarticular osteopenia
• Erosions
• Loss of cartilage

31
Radiographic Features of Erosions

• RA

• Gout - Punched-out marginal erosions with
  sclerotic borders

32
(No Transcript)
33
Findings in Scleroderma
Raynauds Phenomenon
Calcinosis Cutis
Digital Pitting Scars
34
(No Transcript)
35
Systemic Sclerosis
Acrosclerosis and Terminal Digit Resorption
Edematous Phase
36
(No Transcript)
37
Gout with DIP Involvement
38
(No Transcript)
39
SLE Jacouds arthropathy
40
(No Transcript)
41
Dermatomyositis Gottrons Papules
SLE Interarticular Dermatitis
42
(No Transcript)
43
Psoriatic Arthritis
Nail Dystrophy
Nail Pitting
Sausage swelling, Rash, DIP Swelling
44
Nailfold Capillary Exam
Systemic Sclerosis
Normal
Adult Dermatomyositis
Juvenile Dermatomyositis