Exam 4 Flashcards
what is the major contribution of the wrist complex?
To control the length tension relationships to allow fine adjustment of grip
how many carpal bones
8
phalange bases are convex or concave
concave
phalange heads are convex or concave
convex
MCP joint is loose in what position
extension
MCP joint is tight in what position
flexion
where is the volar plate
loosely attached to metacarpal and firmly attatched to the proximal phalanx.
when does the volar plate sldie
during flexion
what is the function of the volar plate
stability, allow for circumduction, and increases the extension at the MCP
what type of joint is the MCP joint
condyloid
what type of joints are the PIP and DIP joints
hinge
which has more mobility DIP or PIP
DIP (we get more mobile the distal we go)
function of the pulley systems in the hand
to keep efficiency of the tendons and prevent bowstrining
what innervates the dorsal and volar interossei
Deep branch of the ulnar nerve
what innervates lumbricals 1-2
median n
what innervates lumbricals 3-4
ulnar n
function of the lumbricals
extensor of the IP joints and flexor of the MCP joints
Lateral thenar muscles are innervated by what and do what
- median n
2. control fine positioning of the thumb
Medial thenar (adductor pollicis and deep head of FPB) muscles are innnervated by what nerve and do what
- Ulnar n
2. give thumb strength
function of palmar aponeurosis
protects underlying neruovascular and tendon structures
are flexor or extensor tendons more vulnerable
flexor
do flexor or extensor tendon heal with a lag
extensor
does the dorsal or palmar side of the hand have looser skin
dorsal
Functional position of the hand (where we tend to rest it)
- Wrist extended 20 degrees
- Ulnar deviation of 10 degrees
- fingers joints slighly flexed
- thumb at mid-range
most commonly dislocated carpal bone and most commonly fractured carpal bone
lunate, scaphoid
80% of compressive force of the wrist occurs thru what joint
radiocarpal
resting position of RC joint
neutral
closed packed position of the RC joint
extension
resting position of distal radioulnar joint
10 degrees of supination
closed packed position of distal radioulnar joint
5 degrees of supination
what is the primary stabilizer of the distal radioulnar joint
TFCC
what does the TFCC do
cushions and protects the ulna
is the TFCC thicker or thinner on the inside
thinner (thicker on the outside)
where does most of the motion come from in wrist flex
midcarpal joint
where does most motion occur with wrist extension
at the radiocarpal joint
ulnar deviation occurs with wrist flex or ext
flex
radial deviation occurs with wrist flex or ext
ext
most radial deviation comes from where
radiocarpal joint
most ulnar deviation comes from where
midcarpal joint
true or false: full ROM of forearm rotation (supination and pronation) is limited with full elbow extension bc the olecranon becomes fixed in the hinge
true
where would suspect the issue to be if there is pain with wrist flex and/or ulnar dev
midcarpal joint
where would you suspect the issue to be if there is pain with wrist ext and/or radial deviation
radiocarpal joint
Pain with grasp or loading may indicate what type of pathology
TFCC pathology
function of the extensor retinaculum
to prevent bowstrining of the extensor tendons
what two tendons are in extensor compartment 1?
Abductor pollicis longus
Extensor pollicis brevis
which dorsal compartment does Dequarvains occur in and what two tendons are affected
1,
Abductor Pollicis longus
Extensor Pollicis brevis
which two dorsal compartments does intersection syndrome occur in
1 and 2 (the intersection of these two)
which dorsal compartment does EPL insert into and is the site of Drummer’s wrist/EPL tenosynovitis
3rd
which dorsal compartment does EDC tendosynotivits occur in
4th
purpose of the flexor retinaculum (aka transverse carpal ligament)
to preposition tendons for power and creates the tunnel for the carpal tunnel
conservative management for DeQuervain’s
1.) thumb spica
2.) 1st dorsal compartment stretches (gently)
3.) anti inflammatory
4.) soft tissue mobs
5
what two tendons are invovled with intersection syndrome
ECRL and ECRB
is pain more ventral or dorsal with intersection syndrome compared to DeQuervains
dorsal
where does OA of the thumb most often occur
at the CMC/TMCJ (more force proximally at the thumb than distally)
clinical signs of OA of the CMC/TMCJ
- TTP at base of 1st metacarpal
- pain with ROM, sustained pinch/grasp,
- squaring or boxing of the 1st metacarpal head
- dorsal subluxation of the CMC/TMCJ
test for OA at the thumb
grind test (axial compression with rotation and shift of the 1st metacarpal on the trapezium)
treatment for OA of the thumb
- pain relief is #1 goal
- functional ROM
- modalities (heat)
- ) protective/positional splinting for stablization
what is a Bennet’s fracture?
fracture or dislocation of the 1st MC base
what is a Rolando’s fracture?
communited intraarticular fracture of the 1st metacarpal base (3+ fragments)
what is gamekeeper’s (skier’s) thumb?
insufficiency of the UCL of the MCP joint of the thumb
Most common MOI for UCL tear/gamekeeper’s thumb
hyperextension of the MCP
what is trigger thumb
thickening of the FPL tendon or A1 pulley at the pulley site
basically a nodule of the tendon/restriction in the pulley that does not allow for normal excursion and glide of the FPL
what would suspect if someone had clicking at the IPJ of the thumb
Trigger thumb/stenosing tenosynovitis
what can trigger thumb progress to
locking of the IPJ into flexion or lack of adequate IPJ flexion
what pulley is the issue with trigger thumb
A1
true or false: elevated tunnel pressure can lead to carpal tunnel syndrome
true
true or false: flexor tendon synovial thickening causes pressure to increase within the carpal tunnel and can lead to CTS
true
true or false: elevated BP can lead to CTS
true
does CTS occur more often in men or women
women
name some risk factors for CTS
- obesity
- diabetes
- OA
- family history
- CV issues
- age over 50
what is the strongest link to CTS
forceful hand exertion (lots of gripping and repeitive work)
best reliability and diagnositic accuracy when patient shades where in their body chart? (THIS WILL BE A TEST QUESTION)
Volar middle finger
true or false: short. wide hands are more at risk for CTS
true
what muscle can lose bulk with CTS
Abductor Pollicis Brevis
describe the carpal compression test
direct compression to median nerve and then hold for 30 seconds and see if pain and numbness occurs
is there added value of doing a nerve conduction study if both phalen’s and tinel is postiive
no
does grip strength improve following CTS surgery
no
what is the purpose of conservative management with CTS
to reduce compression on median nerve, decrease demands on hand/wrist and reduce inflammation
what type of wrist position should be used with CTS
neutral
warm or cold for CTS
warm
phono or ionto for CTS
phono
how long to see improvment in CTS with conservative care
6-12 wks
indications for surgical tx
- thenar atrophy
- sensory loss
- sx presist longer than a year
Post op Precautions for CTS (ON TEST!!)
- avoid active wrist flex past neutral for 10-14 days post op
- avoid finger flexion with wrist flexion
- use extreme caution for first 3 weeks to prevent bowstrining of flexor tendons
position of max grip strength
- 35 degrees of wrist ex
- 7 degrees of ulnar deviation
ability to identify a number traced on the hand
graphesthesia
ability to distinguish between various shapes or textrues by touch
sterognosis
ability to distinguish between different weight
barognosis
what measures constant touch
Semmes Weinstein
most sensitvie clinical test for detecting nerve compression
Semmes-Weinstein
when will nocturnal CTS symptoms be the worst
when wrist is in a flexed positon
how is CTS surgery done
open incision. division of the transverse carpal ligament
what is the main issue that is seen with Dequervain’s
pinching and grasping
what is a Dupurtens contractrue
fibro proliferation of the palmar aponeurosis. seen in white men over the age of 40. a flexion contracture of the palmar fascia occurs
what happens in a colles fracture
the lunate strikes the distal radius and the distal end of the radius is what shears
Tx for colles fracture
surgery. immobilized for 6-8 weeks, then splint another 6-8 weeks.
true or false: edema management to prevent CTS from occuring is key in someone who has a colle’s fx
true; edema can lead to CTS
complications that can occur with a colle’s fracture
- CTS
- Shortened Radius
- Complex Regional Pain Syndrome (CRPS)
true or false: scaphoid fracture can lead to AVN
true
positive Watson’s test (scaphoid shift test) will be seen with people who have what
scaphoid fracture OR scaphoid instability
is the proximal or distal part of the scaphoid most a t risk for AVN following a scaphoid fx
proximal
will ORIF or thumb spica allow someone to recover faster following scaphoid fx
ORIF
how long will someone be in a spica with ORIF following a scaphoid fx
8 weeks (can begin strengtheing at 10 weeks)
when can someone begin strengenthening following a scaphoid fracture if ORIF was done
10 weeks
when can someone begin strengthening if a thumb spica is used for a scaphoid fx (no ORIF)
18 weeks
what is the primary stabilizer of the DRUJ
TFCC
true or false: the TFCC has poor central vascularity
true
true or false: the TFCC has good central vascularity
false
true or false: the TFCC has poor peripheral vasculaitty
false (good peripheral vascularity)
what would you suspect if someone has ulnar sided wrist pain or crepitus with rotation/grip/ulnar deviation
TFCC injury
what zone do flexor tendon injuries occur in
zone 2
MOI for flexor tendon injuries
trauma
what zone is the biggest and most difficult to repair
zone 2
Immobilization protocol for flexor tendon injury
-dorsal blocking splint in neutral wrist for 6 weeks allowing only PROM into flexion while in brace for 4 weeks; full hand use 12 weeks
early passive protocol for flexor tendon injury
dorsal blocking splint with wrist flexed. active ext at 5 weeks; begin active flexion at 5 weeks
early active protocol for flexor tendon injury
dorsal blocking splint with wrist flexed. Allow active flexion within 24-48 hours
which protocol is best for allowing increased strength sooner but can only be done if there is a clean repair (in regards to flexor tendon injuries)
early active
what tendon is inovled with mallet finger
Extensor Digitorum Longus (EDL)
true or false: extensor tendon injuries come from trauma
false (execept for mallet finger)
which zone does mallet finger occur in
zone 1
Result of tendon avulsion of EDL where it inserts into distal phalanx
Mallet finger
finger unable to extend due to EDL injury (unopposed pull of flexor digitorum)
Mallet finger
post op management for Mallet finger with an avulsion fx
Splint for 6-8 weeks. Night splint for another 4-6 weeks
post op management for Mallet finger without fracture
Immoblization of DIP in slight hyperextension for 6-8 weeks. Night splint for another 4-6 weeks
Closed Mallet finger deformity at the DIP can lead to what at the PIP due to secondary compensations
Swan neck at the PIP
true or false: zone 2 injuries are secondary to a laceration or crush injury
true
what zone do Boutonniere and Swan Neck deformities occur in
zone 3
what is it called when the PIP is in flexion and the DIP is in hyperextension
Boutonniere Deformity
what is it called when the pull of the extensor tendon is below the joint line
Boutonniere Deformity
what is the causes for a Boutonniere Deformity
Disruption of central slip at PIP
what is it called when there is hyperextension at the PIP and flexion of the DIP
Swan neck deforomity
is Swan neck or Boutonniere more common with RA
Swan Neck
what is the MOI for a Boutonniere Deformity
involuntary forceful flexion on an actively extended finger
what is the cause for a Swan Neck Deformitty
overly forceful intrinsice muscle contraction transmiting abnormally high forces thru the central slip, hyperextending the PIP
a tri point splint should be used for what
Swan neck deformity
most common place to see OA in the hand
CMC of the thumb
when is wrist arthroplasty most often used
late stage RA to improve ulnar drift
true or false: trigger finger is caused by size disparity in flexor tendons and pulley system
true
what is progressive fibrosis of the palmar fascia
Dupuytren’s contracture
true or false: Dupuytren’s contractures can become chronic and fixed
true
what type of contracture do Dupuytren’s contractures casue
flexion contracture of the MCP joint. can lead to PIP joint contracture
things to rule out with Dupuytren’s contracture
trigger finger and arthtiris
