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Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Wrist,

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Presentation on theme: "Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Wrist,"— Presentation transcript:

1 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Wrist, Hand, Ankle, and Foot Glen Xiong, MD Christopher Meyer, MD Gordon Reeves, MD Amir Kahn, MD Editor: Amy Shaheen, MD, Assistant Professor of Clinical Medicine Duke University Medical Center

2 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Learning Objectives Demonstrate the basic elements of the wrist and hand exam and understand the clinical implications of findings. Understand the diagnostic approach to and management of carpal tunnel syndrome. Understand and be able to apply the Ottawa Ankle Rules. Understand the basic management of foot fractures including indications for emergent and non-emergent referrals.

3 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Wrist and Hand

4 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Inspection –Start with hands open and palms facing down Evaluate alignment of digits, muscular atrophy (thenar eminence), bony enlargement, swelling –Inspect nails Pitting, onycholysis, brown yellow discoloration (Psoriasis) Redness and telangectasias of nail-fold capillaries (connective tissue disease)

5 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand Anatomy patient/pated/wrist om/ knee.html

6 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont Hand Function –Ask patient to open and close the hand Look for smooth and full movement –Grip strength Objective measurement of strength of hand and forearm muscles Can be estimated by gripping of the examiner’s fingers Dynometer is more accurate and reproducible

7 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont. Hand Function continued –Evaluate range of motion of wrist and all hand joints –Evaluate sensation of the hand Pulp of index finger – median nerve Pulp of the 5 th finger – ulnar nerve Dorsal web space between the thumb and index finger – radial nerve

8 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont DIP and PIP joints –Palpate by squeezing the joints medially and laterally between the thumb and index finger –Evaluate for enlargement, tenderness and/or synovial thickening

9 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont MCP Joint –Palpate by squeezing the joint from between the thumb and fingers –Swelling seen as fullness in the “valleys” normally found between the knuckles –Pain with squeezing or swelling Single joint –Trigger finger, posttraumatic arthritis Multiple joints –RA (symmetric), psoriatic arthritis (asymmetric or symmetric)

10 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont Palpate the eight carpal bones by squeezing between your index finger and thumb Palpate the wrist with thumb over dorsal aspect and fingers beneath –Palpate the groove of the wrist, the distal radius and ulna –Palpate the anatomic snuff box More visible with lateral extension of the thumb away from the hand

11 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont Palpate flexor tendons –Feel for tenderness or cyst formation –Pain with passive stretching of the tendon in extension indicates active tenosynovitis Palpate palmar fascia –Feel for nodularity –Nodularity may indicate palmar fibrosis, which leads to Dupuytren’s contractures

12 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Hand and Wrist Exam Cont Inspect the dorsum of the hand –Evaluate for mucinous cysts may indicate herpetic whitlow, foreign body reaction, abscess or dermatofibroma –Ask patient to actively extend DIP joints against resistance Deficiency in patients with repeated blows to the tip of the finger –Mallet finger

13 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Mallet Finger topics.asp?Topic_ID=19 articles/ asp

14 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Clincal Pearls Bony enlargement of PIPs (Bouchard’s node) and/or DIPs (Heberden’s Node) with minimal inflammation – likely OA

15 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Clincal Pearls Symmetric deformity/inflammation in MCPs, PIPs, wrists over several weeks – likely RA –If DIP involvement and/or asymmetric with nail changes consider psoriatic arthritis Thenar atrophy – likely median nerve compression from carpal tunnel syndrome Hypothenar atrophy – ulnar nerve compression

16 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Clinical Pearls Cont. Loss of smooth motion of trigger finger + flexor tendon tenderness over MCP + pain with extension of the finger = likely trigger finger Flexion contractures of the ring, 5 th, and 3 rd fingers – think dupuytren’s contractures Inability to flex tip and characteristic deformity = mallet finger Tenderness over “snuffbox” – consider scaphoid fracture Tenderness over over ulnar styloid – consider Colles’ Fracture

17 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Carpal Tunnel Syndrome 10 ACP medicine (Online) ACP medicine [electronic resource]. New York, N.Y. : WebMD

18 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Carpal Tunnel Syndrome 3,4 Pain and loss of hand function due to median nerve compression as it passes through the carpal tunnel in the wrist Prevalence – approx 3% of the adult population. Women more than men approx 3:2 or 1. Associated conditions (up to 1/3 of cases) –Pregnancy, diabetes, hypothyroidism, inflammatory arthritis, amyloidosis, Colle’s fracture, use of corticosteroids and estrogens. Associated occupations (repetitive wrist/hand activities) –Food processing, manufacturing, construction, logging Natural History is variable – can lead to permanent nerve damage and hand dysfunction or be self-limiting.

19 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum CTS – Diagnosis 4 Little to no data on physical diagnosis in pts presenting to PCP – studies generally based on referral population. Three tests most predictive of electrodiagnosis: –Hand symptom diagrams (pt fills in hand diagram depicting symptoms): +LR 2.4, -LR 0.5 Classic or probable pattern: at least 1 of digits 1,2,3; wrist pain radiating proximally; palmar pain unless solely ulnar. –Hypalgesia: +LR 3.1, -LR not significant Diminished sensation to painful stimuli on the palmar aspect index finger –Weak thumb abduction strength testing: +LR 1.8, -LR 0.5 Weakness in mov’t of thumb to right angle of hand.

20 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum CTS – Diagnosis cont 4 May be helpful but not well validated –Square wrist sign (requires calipers), –Flick sign (ask pt to show you what they do when symptoms at their worst – pt flicks wrist) –Close fist sign (symptoms reproduced when open and close fist x 60 sec). Phalen and Tinel signs found to be of limited utility. Thenar atrophy – low sensitivity but specific. Likely represents advanced disease. Electrodiagnosis –Although used as the gold standard for diagnosis in most studies of clinical diagnosis has false positives and false negatives. –Best used in symptomatic pts to confirm diagnosis, e.g. prior to surgery, or to identify nerve entrapment at other locations.

21 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum CTS – Treatment 5,6 Conservative treatment –Wrist splints – neutral position; relieve symptoms in up to 80% of pts. –NSAIDs Not supported by evidence, but typically done in practice –Activity modification –Corticosteroid injections – after above treatments have failed Short-term (1-3 months) improvement in symptoms compared to placebo or oral steroids. Long term not studied. No improvement compared to splinting + NSAIDs in one study –Ineffective or mixed results Likely ineffective - Diuretics, pyridoxine, non-steroidal anti- inflammatory drugs, yoga and laser-acupuncture There is conflicting evidence for the efficacy of ultrasound and oral steroids.

22 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum CTS – Treatment cont 7,8 Surgical division of transverse carpal ligament –Although response to conservative treatment is initially good, most have recurrence. –Failure of conservative treatments or thenar atrophy are indications for referral. –Surgery provides better relief than splinting at 3mo and 1yr f/u. –Good results with low complication rates –Can require weeks of missed work to recover –Various techniques can be open or endoscopic alternatives to standard open carpal tunnel release not clearly better. Conflicting evidence if endoscopic carpal tunnel release allows quicker return to ADLs/work.

23 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Common causes of foot pain 9,10 Forefoot –Hallux valgus, hammer toe (PIP flexion), claw toe (PIP and DIP), and mallet toe (isolated DIP) Footwear with greater forefoot width and depth, orthoses, rarely surgery –Morton neuroma: entrapment neuropathy of the interdigital nerve, esp between 3 rd and 4 th metatarsal heads Orthoses, glucocarticoid injection, surgical excision. Midfoot –Arthritic changes or arch deformity –Tarsal tunnel syndrome – post tib nerve entrapment Pain and paresthesia over plantar and distal foot, + Tinel sign Splinting, NSAIDs, steroid injection, surgical decompression.

24 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ankle & Foor Ankle & Foot

25 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ankle Tendons and ligaments Lateral view of tendons and ligaments responsible for maintaining ankle articulation. Wexler RK. The Injured Ankle. Am Fam Physician Feb 1;57(3):

26 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ankle tendons & ligaments (2) Medial view of tendons and ligaments responsible for maintaining ankle articulation. Wexler RK. The Injured Ankle. Am Fam Physician Feb 1;57(3):

27 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Common Causes of Foot Pain 10 ACP medicine (Online) ACP medicine [electronic resource]. New York, N.Y. : WebMD

28 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Common causes of foot pain 9,10 Hindfoot –Plantar fasciitis – most common cause (up to 15% of foot symptoms requiring medical attention) Runners, military, obesity, prolonged standing, pesplanus, reduced ankle ROM Pain over plantar heel to midfoot. Most pts improve regardless of therapy in 6-12 months. Orthoses, avoid barefoot walking, plantar and heel cord stretches, NSAIDs, steroid injections, surgery. –Achilles tendonitis or associated bursitis Running/sports, ankylosing spondylitis, Reither syndrome, fluoroquinolones (also associated with rupture), steroid use Orthoses - particularly heel lifts, NSAIDs.

29 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Plantar Fasciitis Exercises Towel Stretch Sit on the floor with your legs stretched out in front of you. Loop a towel around the top of the injured foot. Slowly pull the towel towards to keeping your body straight. Hold for 15 to 30 seconds then relax - repeat 10 times. (http://www.plantarfasciitisbraces.com/plantar_fasciitis_st retching_exercises.html)

30 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Plantar Fasciitis Exercises Calf/Achilles Stretch Stand facing a wall place your hands on the wall chest high. Move the injured heel back and with the foot flat on the floor. Move the other leg forward and slowly lean toward the wall until you feel a stretch through the calf, hold and repeat.

31 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Plantar Fasciitis Exercises Stair Stretch Stand on a step on the balls for your feet, hold the rail or wall for balance. Slow lower the heel of the injured foot to stretch the arch of your foot.

32 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ottawa Ankle Rules Clinical "decision rules" to predict fractures, allowing radiography to be used more selectively 750 adult patients were evaluated in two emergency departments after presenting with acute blunt ankle injuries Follow-up study by applying the rules during evaluation of 2,342 patients with acute ankle injuries Stiell et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:

33 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ottawa Ankle Rules An ankle radiographic series is required only if patient has pain in malleolar zone and any one of the following findings: 1. Bone tenderness at the posterior edge or tip of the lateral malleolus 2. Bone tenderness at the posterior edge or tip of the medial malleolus 3. Inability to bear weight both immediately and in emergency department Stiell et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:

34 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ottawa Foot Rules A foot radiographic series is required only if patient has pain in midfoot zone and any one of the following findings: 1. Bone tenderness at the base of the fifth metatarsal 2. Bone tenderness at the navicular 3. Inability to bear weight both immediately and in emergency department

35 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Ottowa Ankle & Foot Rules Ottawa Ankle & Foot Rules pdf

36 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Toe Fractures Most common type of foot fracture –Estimate to account for 9% of all fractures seen in the primary care setting Commonest etiologies: axial loading (“stubbing” toe), hyperabduction, or crush injury Clinical presentation usually localized pain; although also with difficulty fitting into shoe or altered walking

37 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Toe Fractures: Clinical Presentation Ecchymosis and edema within first hours after injury Point tenderness characteristic of underlying fracture; however diffuse soft tissue inflammation and tenderness is common Rotational deformity of nail bed (relative to adjacent nail beds) indicative of displacement Distal phalynx fracture can present as subungal hematoma

38 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Toe Fractures: Diagnosis Plain films should be obtained with AP, oblique and lateral views Remember to evaluate for additional fractures after identifying one fracture site is important—often multiple phalanges involved Distal phalynx fractures commonly are comminuted

39 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Toe Fractures: Indications for Referral Emergent referral for open proximal phalanx fractures, fractures associated with gross contamination, or circulatory instability Dislocation of great toe, instability of reduced great toe fracture, or displaced intra-articular fractures (can lead to DJD) Management of open fractures in diabetics or immunosuppressed patients Complications from toe fractures (nonunion, chronic pain, osteomyelitis)

40 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Toe Fractures: Primary Care Mgmt “Buddy taping” (taping fractured to adjacent toe) with cushioning agent in between to prevent maceration (gauze, etc) mainstay of treatment –Pain unrelieved with buddy taping may require further immobilization via short leg walking cast with foot plate APAP or NSAIDs usually adequate analgesia Continue immobilization until point tenderness resolves (usually 4- 6 weeks)

41 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures Second most common type of foot fracture after toe fractures Risk factors include osteoporosis, sedentary lifestyle, benzodiazepine use, diabetes (particularly in patients with >25 years of disease or increased physical activity) Twisting or direct blows are most common mechanism of traumatic injury –First metatarsal infrequently injured due to increased relative stability

42 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures: Stress Fracture First described in 1855 as "march fractures" due to predilection for military recruits In contrast to traumatic fractures, occur with repeated administration of forces not powerful enough to cause fracture with single occurrence Second most common type of stress fracture in athletes (other than tibial stress fracture)

43 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures: Presentation Traumatic fractures present typically with localized pain and difficulty ambulating Contrastingly stress fractures more sub-clinical –Dull aching pain during or immediately after activity –May present with poorly localized forefoot pain Pain with axial loading (applied pressure perpendicular to phalanx) differentiates fracture from soft tissue injury Greater pain with direct palpation compared to resisting plantar/dorsiflexion differentiates from tendon injury

44 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures: Referral Indications Tenderness of the tarsometatarsal joint (Lisfranc joint) Compartment syndrome rarely occurs –Pain with passive toe flex/extension early sign –Pallor, parasthesia, out of proportion pain, tense swelling should prompt consideration –Diminished or absent pulse is late finding Other indications include displaced 1 st metatarsal fractures, multiple fractures, intraarticular fractures, displaced fractures near metatarsal head

45 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures: Management Obtain AP, lateral, oblique plain film views Minimally displaced/nondisplaced fractures: non weight bearing for 3-5 days, elevation and ice for 24 hrs; then progressive weight bearing –After point tenderness resolves and callus formed on f/u plain film injury considered healed--usually at least six weeks Displaced fractures (greater than 3-4 mm or 10 deg angulation in dorsal or plantar plane) reduced with regional block and placement of toes in Chinese finger trap

46 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Metatarsal Fractures: Management Initial mgmt of displaced fractures followed by placement in bivalved cast for 1-3 weeks, then converted to short-leg walking cast with progressive weight bearing Stress fracture usually treated only with cessation of inciting activity for 4-8 weeks followed by gradual reintroduction –Fifth metatarsal stress fractures are exception due to high rates of nonunion and should be referred to orthopedics

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48 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Please click here to complete the course evaluation References follow this slide

49 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum References 1. Bickley L: Bates’ Guide to Physical Examination and History Taking 7 th Edition. Lippincott Williams & Wilkins Klippel J: Primer on Rheumatic Diseases, Edition 12. Arthritis Foundation, Katz JN, Simmons BP.Related Articles, Links Clinical practice. Carpal tunnel syndrome. N Engl J Med Jun 6;346(23): Review. 4. D'Arcy CA, McGee S.Related Articles, Links The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA Jun 21;283(23): Review. 5. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD Review. 6. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2002;(4):CD Review 7. Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(3):CD Review

50 Copyright © 2006, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum References Cont. 8. Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev Oct 18;(4):CD Review. 9. Essentials of musculoskeletal care / American Academy of Orthopaedic Surgeons, American Academy of Pediatrics ; Letha Yurko Griffin, editor. Rosemont, IL : American Academy of Orthopaedic Surgeons, ACP medicine (Online) ACP medicine [electronic resource]. New York, N.Y. : WebMD 11. Fracture care by family physicians. A review of 295 cases Fam Pract 1994 Mar;38(3): Fracture care by family physicians -- J Am Board Fam Pract 1993 Mar- Apr;6(2): DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed., Copyright © 2003 Saunders 14.


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