University of Iowa Family Practice Handbook, Fourth Edition, Chapter 16

Orthopedics: Wrist and Hand

1. Ganglion Cyst. The most commonly noted nodule in the hand. Typical locations include the dorsal aspect of the lunate, radial volar aspect of the wrist, dorsal aspect of the hand, and palmar aspect of the fingers near the MCP joints. Typically accentuated with extreme flexion or extension of the wrist. If the cyst is small, aspiration of the cyst contents may be performed with an 18-gauge needle. Steroid injection adds nothing. About one-third will resolve with aspiration and it is unlikely that multiple aspirations will help if there is no resolution after the first aspiration. Most resolve over time but orthopedic referral may be considered for surgical removal, but even this has a limited efficacy.
2. Carpal Tunnel Syndrome.
   1. Clinical features. The symptoms are a result of median nerve dysfunction because of increased pressure within the carpal tunnel. The causes include overuse, ganglion cyst, amyloid, synovial proliferation, pregnancy, rheumatoid arthritis, and hypothyroidism among others. Typical symptoms are pain, paresthesia, hypesthesia, or numbness in the median nerve distribution of the hand usually in the thumb, index, middle, and radial aspect of the ring finger. Nocturnal paresthesia is characteristic.
   2. Exam. Tinel’s sign, which is a painful sensation of the fingers induced by percussion of the median nerve at the level of the palmar wrist, may be positive, but specificity only 54% and sensitivity 50%. Phalen’s sign, keeping both wrists in a palmar-flexed position may reproduce symptoms. Sensitivity varies from 10% to 88% depending on study; it has an 80% specificity.
   3. Treatment. The patient without thenar atrophy can be treated with conservative therapy, which includes a resting splint with the wrist in neutral position and NSAIDs. Steroid injections of the carpal tunnel may be effective. If EMG shows impaired conduction of the median nerve at the wrist, or the carpal tunnel symptoms do not improve in 6 weeks, or if there is evidence of thenar muscle weakness or atrophy, surgical referral is indicated.
3. Mallet Finger.
   1. Injury resulting from forced flexion of distal tip of a finger. Result is a stretching or rupture of the tendon of the extensor digitorum profundus or avulsion of part of the distal phalanx with tendon attached. Commonly occurs with basketball and baseball injuries.
   2. Exam reveals swelling, tenderness, DIP joint held in flexion with patient unable to extend it.
   3. Treatment.
      1. Splint finger in extension across DIP joint leaving PIP joint free to allow continued function. Splint for several weeks (6 to 12) with absolutely no flexion; longer times for injuries with delayed diagnosis.
      2. Operative repair is necessary for the minority of cases that don’t respond to splinting.
4. Fingertip.
   1. Paronychia. Infection under nail fold. Treatment consists of warm soaks, antistaphylococcal antibiotics (e.g., cephalexin, amoxicillin/clavulanate) for 5-10 days and drainage using an 11 blade or 18-gauge needle guided along the nail into the site.
   2. Felon. Infection in the digital pulp. Treatment consists of drainage and packing as well as antistaphylococcal antibiotics. Closely monitor treatment response.
5. Interphalangeal Joint Dislocation.
   1. Proximal interphalangeal joint.
      1. Mechanism is usually a hyperextension injury with the base of the middle phalanx displaced dorsally and proximally.
      2. Reduction may be done without anesthesia or with a metacarpal block.
      3. Reduction
         1. Hyperextend dislocated segment and then push with thumb straight distally on the base of the dorsally displaced phalanx.
         2. As base of middle phalanx engages the joint surface the direction of force changes to an arc to follow the phalanx into slight flexion.
         3. Examiner usually feels a sense of giving way as the joint reduces.
      4. Postreduction.
         1. X-ray to rule out avulsion fractures.
         2. Check active extension.
         3. Splint in full extension for 3 weeks then begin exercises to restore range of motion.

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See related Provider Topics Bones, Joints and Muscles, Injuries and Wounds or Wrist/Arm Injuries and Disorders.

See related Patient Topics Bones, Joints and Muscles or Injuries and Wounds.

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