Elbow, Hand, Wrist Flashcards by Salma Elsayed

What is edema?

Excess fluid buildup in the interstitial tissues that causes swelling

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What agents are released as a result of inflammation?

release of chemotactic agents

acute factors: histamine, prostaglandins, bradykinin, substance p, complement and platelet factors

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Does chemotaxis cause vasoconstriction or vasodilation?

Vasodilation

Increases interstitial fluid, macrophages, activates fibroblasts, blocks venous and lymphatic drainage

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What are the physiological and clinical characteristic present during the first stage of healing? Ideally, how long should this first stage last?

Physiology: release of tissue factors, blood clot in tissues/fracture, WBC migration, hyper vascularity

Clinical: ecchymosis, EDEMA, pain, loss of motion

Time: 0 to 3 weeks post injury (ideally)

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What are 3 early therapy techniques and modalities used to treat inflammation and edema?

RICE for edema management
Pain control
Controlled AROM of fingers to prevent stiffness, adhesions and jt. contracture

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Chronic inflammation is characterized by what 2 characteristics?

Exuberant fibrous tissue/scar

2. Loss of tissue elasticity

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What is the ultimate goal for treatment of the hand?

Rapid recovery of a functional hand:

Comfortable sensation
Stable motion, pinch, grasp and strength.

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What are the 5 essential sensory functions of the hand?

Exploration
Fine touch
Protective sensation Temperature
Stereognosis

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What are the 3 essential motor functions of the hand?

Fine grasp
Gross grasp
Power grip

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What part of the body has the most extensive motor and sensory cortical representation of any body region?

HAND

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What is the therapy paradox?

Healing requires immobilization, rehabilitation requires motion

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What is the treatment protocol for flexor tendon repair during the fibroplastic stage?

Scar orientation phase;

No splint but avoid forceful grip
Progress resistive exercises cautiously to regain muscle tone,
Light activity to regain function; 3rd to 6th week

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What areas of the hand are supplied by the median, ulnar, and radial nerves?

Median nerve: radial side of index finger
Ulnar nerve: ulnar side of small finger
Radial nerve: dorsum of the first web space

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What is Tinel’s sign? What does it test for?

Carpal Tunnel

Percussion (tapping) over irritated area of peripheral nerve elicits electrical sensation distally

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What is Phalen’s sign? What does it test for?

Carpal tunnel

Wrist flexion increases compression of median nerve at the wrist, reproducing symptoms of finger tingling

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What is carpal tunnel syndrome?

Acute or chronic compression of the median nerve at the wrist

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What is the TRIAD of symptoms associated with carpal tunnel?

Numbness of fingers
Tingling sensation in fingertips
Night pain

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What are the 5 risk factors for carpal tunnel?

Wrist fracture
Overuse
Awkward wrist position
Vibratory tools
Cold exposure

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What are the 6 treatment options for carpal tunnel?

Patient Education
Activity Modification (avoid flexed position)
Brace/custom splint
Ultrasound
Tendon gliding exercises
Injections of steroids

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What are the 3 indications for carpal tunnel surgery?

Sensory/Motor deficits
Persistent Pain
Symptoms despite supportive care

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What are 2 rare, but plausible complications of carpal tunnel release surgery?

Scar hypersensitivity

2. Hypertrophy (10% cases)

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What is an hour glass deformity of the median nerve?

Prolonged compression causes the median nerve to become narrow, fibrous and pale

Nerve findings in the hand can originate from what 4 places?

Elbow
Brachial Plexus
Cervical Spine
CNS

What is deQuervain’s tenosynovitis?

Entrapment and inflammation of tenosynovium of extensor tendons to the thumb, at the wrist

What 3 signs are associated with deQuervain’s tenosynovitis?

1. Tenderness at 1st dorsal compartment of the wrist (the s-ex, l-ab tendons) 2. No joint pathology or nerve dysfunction 3. + Finkelstein test: pain reproduced by passive stretch of tendons

What are the 5 treatment options for deQuervain’s tenosynovitis?

1. Rest! (modify therapy or exercise program temporarily) 2. Heat and anti-inflammatory modalities 3. Protective splint in position which relaxes tendon 4. Steroid iontophoresis or steroid injection 5. Surgical release of extensor compartment (chronic or unresponsive cases)

What are 2 ways in which hand fractures are commonly treated? What are the benefits?

1. Pinning 2. Internal Fixation Allows early, controlled mobilization of uninvolved joints Maintains fracture position but may not completely stabilize the fragments (cautious therapy)

What fracture is most common in adults?

Colle's fracture

What is a Colle's fracture?

Fracture of the distal radius, usually dorsally displaced

What 5 conditions may occur as a result of a Colle's fracture?

1. wrist stiffness 2. pain 3. persistent swelling 4. weakness 5. post traumatic arthritis

External fixators allow for what 2 factors?

1. Immediate skin and edema care | 2. Joint mobilization

What is an internal fixation of the distal radius? What are the benefits?

System locks screws into plate, creating very stable joint in the operating room 1. No cast necessary, but splint for protection 2. May start active motion immediately: more rapid recovery, but not necessarily better final motion

Which ligament tear in the hand will not heal?

Complete S-L (scapholunate) ligament tear will not heal

What are the symptoms of a Scapholunate ligament tear (S-L)?

1. Persistent pain 2. Clicking/shifting sensation 3. Tenderness with palpation and stress to S-L joint

Which fracture of the hand will not heal?

Scaphoid fracture ***if scaphoid is not displaced, it will heal with immobilization If NOT immobilized early, will require surgery

What is basilar arthritis? Who does it affect? How is it treated?

Osteoarthritis of carpal- metacarpal joint of thumb Common, disabling Women in 40’s and 50’s 80% controlled by therapy (pain modalities, anti-inflammatory modalities, protective splint), or injections

How is basilar arthritis treated surgically?

Interposition arthroplasty Trapezium is removed, space is cleared of osteophytes, and trapezium placed back in OR tendon is used as a spacer in place of trapezium

What is the purpose of the elbow and forearm?

To position and propel hand in space for ADLs

How many degrees of elbow flexion/extension is needed for optimum motion and functional motion?

Optimum motion = 0-145 degrees Function motion = 30-130 degrees

What 3 joints make up the forearm?

Proximal radioulnar joint Distal radioulnar joint Interosseous membrane

___ % of hand strength is in the forearm muscles

50%

What treatment protocol is required for displaced forearm fractures in adults?

Surgical fixation and early, controlled mobilization Referred to as FRACTURES OF NECESSITY because they require surgical treatment

Aside from displaced forearm fractures, what other fracture is also called a fracture of necessity?

Femoral neck fractures

What is the most common injury resulting from a fall on an outstretched hand (FOOSH)?

Radial head fracture

What is the most common elbow fracture? What is the MOI?

Radial head fracture MOI: indirect force from fall on hand (FOOSH)

If an articular (joint) fracture heals displaced, what may occur?

Limited elbow/forearm ROM Causes arthritis

What is the rehabilitation protocol following a radial head fracture?

1. Controlled AROM and gravity assisted ROM 2. Protect extremity between therapy sessions ***Avoid capsule adhesions and joint contractures

What is the most common problem after elbow/forearm fracture?

CONTRACTURE

What is the goal for rehabilitation post joint contracture? What should be avoided?

Goal: reshape scar tissue to regain functional range 1. Slow stretch avoids inflammation and joint stretch 2. AVOID forceful manipulation which tears tissues, increases scar and promotes heterotopic bone (myositis ossificans)

What is lateral epicondylitis? What are the risk factors associated with this pathology?

Tear of extensor carpi radialis brevis origin at lateral epicondyle Risks 1. tennis 2. overuse 3. palm down lifting

What are the 4 symptoms and signs associated with lateral epicondylitis?

1. Elbow ache with activity, relieved by rest 2. Pain and tenderness at lateral epicondyle 3. Normal joint motion and exam 4. Pain reproduced by resisted extension of wrist and elbow

What are 4 treatments for lateral epicondylitis?

1. Modify or stop aggravating activity 2. No elbow splint 3. Wrist splint for typists 4. Many modalities for pain, inflammation, muscle recovery

What is rheumatoid elbow? How is it treated?

Potentially devastating, joint ankylosis affects essential daily activities Characterized by joint swelling, loss of motion by therapist Aggressive care of joint inflammation flare may prevent joint destruction ***Misdirected therapy may worsen contracture, motion, inflammation or instability