10/11 - Wrist & Hand Complex Flashcards
what patients are more appropriate to refer out to OT
more significant injuries/burns that need splinting
what are 3 considerations when thinking ab if pt more appropriate for you or OT
scope of practice
skill set
comfort level
what bones articulate w the distal radius and how
scaphoid and lunate
- radius is concave distally
what bones does the distal ulna articulate with and how
w the distal radius
- ulna is convex distally
triquetrum
what bone is the most fractured carpal and why
scaphoid
- has a narrow central waist
what bone is the most dislocated carpal and why
lunate
- weak volar ligaments
what ligament is the pisiform embedded in
flexor carpi ulnaris (FCU)
what are the proximal row of carpals (radial to ulnar side)
scaphoid
lunate
triquetrum
pisiform
what is the smallest carpal bone
pisiform
what are the distal row of carpals (radial to ulnar side)
trapezium
trapezoid
capitate
hamate
what is a characteristic of the distal row of carpals
stable
what are the 2 main surfaces of the trapezium for articulation
1st CMC joint
volar groove for FCR tendon
what does the trapezoid articulate with
2nd MC
what is the largest and keystone distal carpal
capitate
what are the proximal and distal articulations of the capitate
prox: scaphoid, lunate
distal: trapezoid, hamate, 2-4
what attaches at the hook of hamate
flexor retinaculum
what is the primary motion of the distal radioulnar joint (DRUJ)
radius moving over ulna
what type of joint is the distal radioulnar joint (DRUJ)
uniaxial pivot joint
what is the primary goal of the triangular fibrocartilage complex (TFCC)
provide stability to DRUJ
what are the 5 components making up the TFCC
articular disc
wrist UCL
ECU tendon sheath
meniscus homologue
radioulnar ligaments
norms for wrist flexion
65-90
norms for wrist extension
60-70
norms for radial deviation
15-20
norms for ulnar deviation
30-45
what are normal motions at the carpal joint (4)
flex
ext
radial dev
ulnar dev
what type of joint is the 1st CMC joint
saddle joint
what are the articulations of the 1st CMC joint
trapezium and 1st MC
what are the normal motions of the 1st CMC joint and norms
thumb flex (20)
ABD (50-55)
what is the difference b/w extrinsic vs intrinsic ligaments of the wrist and carpals
extrinsic - radius/ulna to carpals or carpals to MC
intrinsic - intercarpal (one carpal to the next)
how are MCP joints are stabilized
strong collateral ligaments
what type of joints are PIP and DIP joints
hinge joints
what is the importance of the pulley system with extrinsic flexor ms
sheathes restrain the tendons creating a pulley effect
- prevents bowstringing of tendons w distal movements
- contributes to efficient function
what is seen if the tendon sheaths for extrinsic flexors are damaged
pulley system damaged
- bowstringing and limits amt of flex
see limitations in AROM but not necessarily PROM
what are 4 intrinsic ms of the hand
lumbrical
interosseous
thenar
hypothenar
what is the path of the median n.
crosses the wrist deep to flexor retinaculum
- thru carpal tunnel (of 9 flexor tendons)
what is the path of the ulnar n.
superficial to flexor retinaculum
enters ulnar tunnel
- b/w pisiform & hook of hamate
- divides into superficial and deep branches
what sx make you think of a nerve distribution
burning
numbness
tingling
what are the two branches of the radial n.
sensory branch - superficial
motor - post. interosseous n.
what pathology do you usually see as a result of repetitive motion
dequervain’s synovitis
what are 4 differential dx for proximal origin pain
cervical radiculopathy (C6-8)
thoracic outlet syndrome
cubital tunnel syndrome (ulnar n.)
pronator syndrome (median n.)
what are the goals for general fracture management (3)
- obtain and maintain appropriate reduction (closed or ORIF)
- restore joint congruence
- optimal pain-free ROM and strength
what are 2 important considerations w general fracture management
minimize duration of immobilization
consider healing times of all involved structures
- not just bone
why should pediatric fractures be treated w caution
growth plate involvement
what is the most common type of fracture seen
distal radius
what are the two types of distal radius fractures and their MOIs
colles - fall in hyper-ext & sup
smith - fall in flex & pron
why is it appropriate to start wrist ROM @5 weeks after a distal radius fx
people won’t be fully heald but looking for enough callus formation for safe ROM
what is an important piece in the progression of rehabing a distal radius fx
follow up imaging to see how and the quality of healing
- know this before moving around
what is a consideration when first initiating forearm rotation when rehabing a distal radius fx
first needs to be cleared by imaging
second keep elbow at side to dec the lever arm
what is the most common type of carpal fracture
scaphoid
where is the scaphoid most vulnerable
the waist
why is the scaphoid vulnerable at the waist
dec blood supply there -> harder to heal
- can move onto a nonunion and is harder to deal with
what is an important PT implication for scaphoid fx
lower threshold for imaging
- even if aligned, won’t necessarily heal
what is a huge detriment to a PT intervention for a scaphoid fx
has to be immobilized for a long time to heal bc of poor vascularization
what is the focus on rehab for a scaphoid fx
endurance and dexterity
what is the second most common carpal fx
triquetrum
what is MOI for scaphoid fx
fall backward onto hand; wrist hyperext
what is MOI for triquetrum fx
fall w hyper-ext and ulnar dev
what carpal bone is usually also fx if the triquetrum is fx
trapezium
what injuries are trapezium fx associated with (3)
triquetrum fx
1st MC fx
distal radius fx
where part of the hamate is often fx
hook
what are hamate fx typically associated with
ulnar neuropathy
what is the MOI for hamate fx
compressive force at base of palm
what is a consideration of diagnostic tools for hamate fx
radiographs will often be (-)
- small bone and fx usually won’t look significant
treatment for nondisplaced vs displaced hamate fx
nondisplaced = immobilization 6-8weeks
displaced = surgical fixation
what is a Boxer’s fracture
displaced, apex dorsal fx at 5th MC neck
early vs late phase of rehab for a boxer’s fx
early phase - ROM to promote tendon gliding
- prevent adhesions
late phase - adequate healing occurs
- strengthening, dexterity, & endurance
stable vs unstable fx
stable = buddy taping
unstable = orthotic device or pin fixation
what is a concern w a FOOSH
significant soft tissue trauma at the wrist
MOI for distal radioulnar joint implication w a FOOSH (3)
fall on pronated & ulnarly deviated hand
forceful twisting
forced hyperpronation or forced supination
what are sx of distal radioulnar joint implication w a FOOSH (3)
ulnar sided wrist pain w forearm rotation
ulnar head prominence
instability
what injuries can the TFCC be disrupted by
distal radioulnar joint FOOSH
distal forearm fx
MOI for a disrupted triangular fibrocartilage complex (2)
axial load to extended, pronated wrist
twisting ulnarly deviated wrist
what motions cause ulnar sided pain w a disrupted triangular fibrocartilage complex (3)
pronation
supination
gripping
what is the the MOI for a wrist dislocation
fall onto pronated hand
- wrist hyper ext and ulnar deviation
what bones are impacted by a wrist dislocation
scaphoid
lunate
lunotriquetral (less common)
what is the interventions for carpal instability (3)
protection
examine associated regions
stabilize (isometrics)
what is the most common hand injury in sports
thumb dislocation
- via ulnar collateral ligament involvement
what are we concerned about with a thumb dislocation
stener lesion
- avulsion that will require surgical repair
MOI for a thumb dislocation
hyper ext w radial dev
what types of thumb dislocations are there
acute - skier’s thumb
chronic attentuation - gamekeeper’s thumb
what is the key principle of UCL rehab in thumb dislocations
stability over motion
why is tip pinch avoided for 8 weeks with a thumb dislocation
tip pinch load to structures that is imposed
grade 1 and 2 thumb dislocation rehab guidelines (3)
thumb spica 2-4wks
key pinch and gentle thumb strengthening for next 3-4wks
avoid tip pinch and grasping for 8 weeks
grade 3 thumb dislocation rehab guidelines (3)
stener lesion so surgical management
- immobilization in thumb spica for 4-6wks
- gradual mobilization and strengthening
CRPS 1 vs CRPS 2
1 - formerly known as reflex sympathetic dystrophy
2 - same sx but cause is partial or complete nerve injury
biggest diffference b/w acute and atrophic phases of CRPS
acute - arguably reversible
atrophic - permanent changes within structures
sx and timeline of acute phase of CRPS
10days to 2-3mo
- flushed, warm, dry
- diffuse, severe pain
- edema and hair growth inc
sx and timeline for dystrophic phase of CRPS
3-6mo
vasomotor instability
- cool limb
- pale, mottled, boggy edema
- severe pain remains
- nails crack
- osteoporosis
sx and timeline of atrophic phase of CRPS
6mo +
cold end phase
more of dystrophic phase
- less movement
slightly less pain
permanent changes within structures
what are 6 things to exam for CRPS
pain
edema
skin temp
ROM
WB
function
what is the importance of including WB in the interventions for someone with CRPS
lot of people can have apprehension w WB in closed chain (esp seen in plantar grade position)
- WB can impact pain and function
- WB help to avoid osteoporotic changes
what is an important education point for patients with CRPS
avoid being static
maintain some level of activity
what is a key approach to interventions to appropriately manage CRPS
interdisciplinary approach
- pain modulation w meds, psych
who are patient at high risk for CRPS
all recent out of cast or injured pts a potential
what is the best way to approach PT interventions
prevention
- avoid prolonged immobilization
- early movement after healing
what are two key PT interventions for CRPS
work on edema reduction and early motion
normalize sympathetic response
- desensitize, different textures
where can the ulnar nerve become entrapped
elbow - cubital tunnel
wrist - guyon’s tunnel
how does ulnar nerve entrapment present
ulnar motor weakness
- challenges w opposition
how can ulnar nerve sx present and change
they are site dependent
- prox to guyon’s canal: mixed
- within guyon’s canal: motor
- distal to guyon’s canal at hook of hamate: motor
- in palmaris brevis: superficial branch (sensory)
what is a test for ulnar nerve entrapment
froment sign
what are 3 etiologies of carpal tunnel syndrome
sustained flex/ext posture
external pressure on volar wrist
prolonged hand vibration
why could direct pressure lead to carpal tunnel syndrome
median n. is so superficial in flexor retinaculum
- direct pressure on median n.
sx of carpal tunnel syndrome (3)
pain
paresthesia
numbness
what is the significance of weakness/atrophy in thenar musculature in CTS
if atrophy, happen long enough and significant enough that needs to be addressed
why is nocturnal numbness an important question to ask about
does it wake you up at night?
want to understand the severity
- get a feel for the need of a potential carpal tunnel release
what are 4 tests for CTS
tinels
phalens
monofilament testing
2 point discrimination
what is the biggest differential dx to be considering w CTS
cervical spine involvement (specifically C6)
- often can see CTS and c spine involvement
what are 4 differential dx for CTS
C-spine involvement
thoracic outlet syndrome
diabetic neuropathy
pronator teres syndrome
what are 5 education points for pts w CTS
eliminate aggravating factors
neutral wrist position
avoid prolonged wrist pressure
avoid vibration
avoid forceful gripping (esp w combined wrist flex/ext)
what are 2 conservative management interventions for CTS
splinting/bracing - neutral splint at night
neural mobilizations
why use neural mobilization w CTS? what is a consideration?
using a nerve glide technique
- general mobility to move nerve within sheath that might have gotten bogged down
important to be gentle bc can cause irritation
what are the most concerning signs when assessing severity of CTS and might mean surgery is the best option
atrophy
weakness
why should you refrain from forceful gripping or lifting in post op management of CTS or in general
flexor tendons run thru that flexor retinaculum also
- the more you use those flexors, the more irritation to those tendons in the retinaculum
what are 3 exercises to avoid in post op management of CTS and why
repetitive gripping/pinching
use of theraputty
use of hand grippers
contributes to inflammation in flexor sheath
why is strengthening not an included intervention in post op management of CTS
strengthening occurs thru daily use
what are 3 post op CTS interventions and general timeline
early mobilization (ie gentle fist)
2 weeks - scar mob after suture removal
4-6 weeks - full activity
what is a differential dx often overlooked when treating CTS
cervical radiculopathy
- that is what could be causing the sx
could be concurrent w CTS but CTS may be less severe than cervical involvement
- need to address both
why is early identification key with CTS
sx >1yr is a factor that is associated w poor outcomes
esp if atrophy and weakness - more severe
what are 3 main presentations of RA at the wrist/hand complex
ulnar drift
boutonniere deformity
swan neck deformity
what damage causes ulnar drift in RA
damage to collateral ligaments & extensor mechanism
- first at the MCP then at wrist
what does ulnar drift in RA look like
ulnar deviation, pronation, palmar subluxaiton
what damage causes boutonniere deformity in RA
damage to common extensor tendon of PIP
what does a boutonniere deformity in RA look like
flexion of PIP, hyper ext of DIP
what damage causes a swan neck deformity in RA
to oblique retinacular ligament leading to dorsal displacement of extensor mechanism
what does a swan neck deformity in RA look like
flexion at DIP and hyper-ext at PIP
what is the most important intervention during a flare up of RA
pain reduction - want to avoid overstressing tissues
what is the most important intervention after a flare of RA
teach joint conservation techniques
where in the wrist/hand is OA the most common and why
1st CMC or scaphoid articulations
- likely d/t amt of mobility that is there
what is the goal of interventions in OA
maximize mobility and strength
- try to redistribute load so that nearby ms can do more work and dec load at joint
what should be avoided with interventions for OA and why
end range positions
- more load on joint
why is imaging so important
is fx in vulnerable area - blood flow?
quality of healing?
what should be considered ab soft tissues when managing hand/wrist complex injuries
trying to unload these tissues
- when tissue calm down, can work on gradually changing overall mechanics
