Chapter Seventeen: Orthoses for the arthritic hand and wrist Flashcards
Osteoarthritis usually affects what joints in the hand?
DIP
PIP
CMC
What are the common symptoms of ostearthritis?
Joint tenderness sometimes accompanied by crepitus pain and pain progression at night
What is the longitudinal arch?
It extends from wrist to the tip of the third digit, and is deepened by the flexion of the digit.
What is the distal transverse arch?
It is the metacarpal joint.
It is deepened by the mobility of the first, fourth, and fifth metacarpals around the stability of the second and third metacarpals.
What is the proximal transverse arch?
The arch at the radiocarpal/ulnarcarpal joint or the arch at the wrist.
What joint does Rheumatoid arthritis usually affect?
Wrist joint
What are the three pathological processes that can alter the carpus directly and produce deformity in Rheumatoid arthritis?
Cartilage degradation
Synovial expansion with erosion
Ligamentous laxity
When is cartilage degradation usually seen in rheumatoid arthritis?
Early
What can synovial expansion and erosion lead to in rheumatoid arthritis?
Ruptured tendons, especially the extensor tendons of the ulnar fingers or the flexor pollicis longus.
It may also lead to volar subluxation of the proximal carpal row.
What can ligament laxity in rheumatoid arthritis cause?
wrist instability and further carpal derangement, which in turn can lead to a radial shift of the carpus on the radius.
What joint is often involved in rheumatoid arthritis?
Radial ulnar joint.
Radial ulnar joint involvement in rheumatoid arthritis does what?
Prevents supination and pronation and prevents the forearm from full rotation.
Destructive synovitis in Rheumatoid arthritis produces what, which can cause what?
Distal radial ulnar joint instability with dorsal subluxation of the ulna on the radius and plamar subluxation of the extensor carpi ulnaris tendon resulting in pain, weakness, and decreased ROM.
Extension of the wrist does what?
Relaxes the extensors and increases the mechanical advantages of the flexor muscles.
Which orthosis is the most common orthosis for rheumatoid arthritis?
Cockup wrist splint.
What position does the cockup wrist splint place the hand?
10-30 degrees of extension at the wrist to allow max function.
What is the goal of the cockup wrist splint?
Immobilize the radiocarpal joint, providing rest and stability and allowing reduction of inflammation and pain.
It also protects the extensor tendons which may be at risk of rupture in rheumatoid arthritis.
When is a resting hand orthosis used ?
In acute rheumatoid arthritis to decrease pain and the align the joint sin a normal anatomic position to avoid the zigzagging pattern.
What position is the resting hand orthosis usually in?
10-20 degrees of wrist extension
20-30 degrees metacarpophalngeal joint flexion,
0-20 degrees of PIP flexion
slight flexion of DIP
Thumb CMC in slight extension and abduction
MP and IP of the thumb in slight flexion.
What percent of patients with rheumatoid arthritis experience the ulnar drift deformity of the MP joints.
45% of patients whose disease has persisted longer than 5 years
What is the ulnar drift deformity?
Deviation of the phalanx from the Metacarpal head and lateral shift of the phalanx upon the metacarpal.
What are contributors to the ulnar drift deformity in Rheumatoid arthritis?
Synovitis within the MP join alters the supportin gstructures. The radial collateral ligaments, which are weaker than the ulnar counterparts stretch.
Extensor tendons migrate toward the ulnar side
As the fingers flex, the flexors pull the digit ulnarly
Contracture of the intrinsic muscles caused by a reflex protective muscle spasm secondary to the synovitis contribute an MP volar displacing force
MP joint cartilage loss and bony erosion lead to volar subluxation
Flexor tenosynovitis can lead to volar subluxation at the MP joint
Which orthosis can be used to help or prevent ulnar drift of the MP joints in rheumatoid arthritis?
Ulnar deviation orthosis.
When is a thumb spica indicated?
Acute rheumatoid arthiritis
Osteoarthritis
To decrease pain and provide stability
What are the two most common thumb deformities?
Boutonniere deformity
Swan neck deformity
What is the boutonniere deformity?
MCP joint flexion and IP joint hyperextension
What is the swan neck deformity?
MCP joint hyperextension and adduction
IP joint flexion
What causes boutonniere deformity?
Synovitis at the CMC joint
What causes swan neck deformity?
Synovitis at the CMC joint followed by stretching of the joint capsule and radialward subluxation of the base of the metacarpal.
What are the stages of a boutonniere deformity?
Stage I exhibits slight extensor lag and light loss of DIP flexion
Stage II A 40 degree PIP flexion deformity
Stage III: The PIP joint has a fixed flexion deformity
For swan neck and boutonniere deformities in the fingers, what orthosis is commonly used?
A figure-of-eight ring orthosis or tripoint finger splint
