Hand And Wrist Injuries

Introduction

Welcome to your comprehensive MCCQE1 preparation guide on hand and wrist injuries. This resource is tailored specifically for Canadian medical students preparing for the Medical Council of Canada Qualifying Examination Part I (MCCQE1). Understanding hand and wrist injuries is crucial for success in the MCCQE1 and for your future practice in the Canadian healthcare system.

Anatomy Review

Before diving into specific injuries, let's review the key anatomical structures of the hand and wrist:

Common Hand and Wrist Injuries

1. Scaphoid Fracture

Scaphoid fractures are particularly important in the Canadian context due to their potential for complications if missed.

2. Distal Radius Fracture (Colles' Fracture)

This is one of the most common fractures seen in Canadian emergency departments, especially during winter months due to ice-related falls.

3. Metacarpal Fractures

These fractures are common in the Canadian population, often resulting from sports injuries or workplace accidents.

4. Mallet Finger

A common sports injury in Canada, particularly in ball sports.

• Mechanism: Forced flexion of an extended DIP joint
• Presentation: Drooping of the distal phalanx, inability to extend the DIP joint
• Management: Splinting in extension for 6-8 weeks

5. Scapholunate Ligament Injury

This injury is important to recognize due to its potential for long-term complications if missed.

• Mechanism: FOOSH or axial load to an extended wrist
• Presentation: Pain in the dorsal wrist, especially with wrist extension
• Diagnosis: X-ray may show scapholunate widening ("Terry Thomas" sign)
• Management: Often requires surgical repair

Canadian Guidelines for Hand and Wrist Injuries

The Canadian Orthopaedic Association provides guidelines for the management of hand and wrist injuries. Key points include:

1. Early mobilization is encouraged for most hand injuries to prevent stiffness
2. Consider osteoporosis screening in older adults with low-energy wrist fractures
3. Use of ultrasound-guided nerve blocks for pain management in hand and wrist injuries is increasing in Canadian emergency departments

Key Points to Remember for MCCQE1

• 🔑 Always consider scaphoid fracture in wrist injuries, even with normal initial X-rays
• 🔑 Understand the "dinner fork" deformity associated with Colles' fracture
• 🔑 Know the management differences between stable and unstable fractures
• 🔑 Remember the importance of early mobilization in most hand injuries
• 🔑 Be familiar with Canadian-specific epidemiology, such as increased incidence of wrist fractures in winter

Sample Question

Sample Question

A 25-year-old man presents to the emergency department with right wrist pain after falling on an outstretched hand while playing ice hockey. He reports pain in the radial aspect of the wrist, particularly when moving his thumb. Physical examination reveals tenderness in the anatomical snuffbox. Initial X-rays appear normal. Which one of the following is the most appropriate next step in management?

• A. Discharge with a wrist splint and follow-up in 1 week
• B. Immobilize in a short arm cast and follow-up in 6 weeks
• C. Obtain a CT scan of the wrist
• D. Perform immediate surgical exploration
• E. Prescribe NSAIDs and advise return to normal activities

Explanation

The correct answer is:

• C. Obtain a CT scan of the wrist

This scenario strongly suggests a scaphoid fracture, which may not be visible on initial X-rays. The Canadian Orthopaedic Association recommends a low threshold for advanced imaging in suspected scaphoid fractures with normal initial X-rays. A CT scan can detect occult fractures and guide appropriate management, preventing complications such as avascular necrosis or non-union.

Option A is incorrect as it risks missing a fracture. Option B is overly aggressive without confirming the diagnosis. Option D is premature without confirming a fracture. Option E is inappropriate as it may lead to further injury if a fracture is present.

References

1. Canadian Orthopaedic Association. (2021). Clinical Practice Guidelines for Hand and Wrist Injuries.
2. Suh, N., & Grewal, R. (2018). Controversies in the Management of Distal Radius Fractures. Journal of Hand Surgery, 43(10), 972-976.
3. Porrino, J. A., et al. (2014). Diagnosis and Management of Scaphoid Fractures: A Literature Review. Current Reviews in Musculoskeletal Medicine, 7(3), 250-259.
4. Canadian Medical Association Journal. (2019). Management of Acute Wrist Injuries in the Emergency Department.
5. CanMEDS Framework. Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e (opens in a new tab)

This comprehensive guide should help Canadian medical students prepare effectively for the MCCQE1 exam, focusing on hand and wrist injuries within the Canadian healthcare context. Good luck with your studies!