Hand and Wrist Injury Basics for the Physician Assistant Exam
The Physician Assistant Exam (PANCE) will ask questions about conditions affecting the hand and wrist. They range from benign cysts to minor sprains to out-and-out fractures, so make yourself familiar with the basics.
A common soft tissue mass that you can see on the hands and wrists is a ganglion cyst, also known as a bible cyst. Like a lipoma, it’s painless and moves about freely. This condition isn’t malignant. Aspiration of the cyst fluid is a possible treatment. Note that these cysts tend to recur and that surgical intervention may be necessary.
De Quervain’s tenosynovitis
Your arms contain many tendons, but you probably need to worry about only two, particularly if they get inflamed just before the PANCE. De Quervain’s tenosynovitis is an inflammation of the two tendons around the bottom of the thumb. An initial irritation of the tendons then causes the synovium to become inflamed and edematous; hence, the term tenosynovitis.
Many of the causes mimic those of carpal tunnel syndrome and can include repetitive activity/overuse, pregnancy, and rheumatologic conditions like rheumatoid arthritis. Also, de Quervain’s tenosynovitis is more common in older women.
Common presenting symptoms of de Quervain’s tenosynovitis include pain over the thumb and wrist. The person may also experience swelling and restriction of movement.
Finkelstein’s sign is linked to de Quervain’s tenosynovitis. For this sign, the person essentially makes a fist, placing the thumb across the palmar aspect of the hand and then wrapping the fingers around the thumb. He or she then ulnarly deviates the fist downward, causing the wrist/thumb to be more in extension. If this maneuver causes pain around the thumb area, the person may have tenosynovitis.
The treatment for tenosynovitis can be conservative, including immobilization of the affected area and anti-inflammatories and pain medication. Steroid injections into the affected area have been used, with modest relief of the condition. Surgical intervention is warranted when conservative measures fail.
Sprains and tears of the UCL
People can injure one of the ligaments of the thumb, namely the ulnar collateral ligament (UCL). A sprain of this ligament is called skier’s thumb. (Such a sprain can also affect your ability to properly hitchhike.) What causes this sprain? Falling on an outstretched hand.
Usual presentation of skier’s thumb includes pain and tenderness around the thumb’s metacarpophalangeal (MCP) joint. The patient can also have difficulty pinching things.
The treatment depends on whether you’re dealing with a sprain or with a UCL tear. If a sprain is present, splinting and immobilization is recommended; if there’s a tear, surgery may be needed.
If you see a fist come flying at you, you should duck — you’ll be helping the person throwing the punch reduce his or her risk of fracturing a metacarpal. A boxer’s fracture is a fracture of the second or third metacarpal, commonly seen among fighters and professional boxers. Besides having redness and swelling around the site of injury, the person may have trouble clenching and extending the affected digits.
A bar room fracture is a transverse fracture of the fourth or fifth metacarpal neck. That’s what happens when an unskilled fighter throws a punch down at the honky-tonk.
Fractured metacarpals are diagnosed through a radiograph of the hand. The immediate treatment includes ice, rest, and the use of an ulnar gutter cast or support splint. Severe angulation generally requires surgery to put in a pin. The long-term treatment also involves directed hand strengthening exercises — and not hitting solid objects with the fists. Anger management may be needed.