Exam 5: Anatomy of the Forearm, Wrist and Hand through CRPS Flashcards
The wrist has __ bones, more than __ joints, and __ ligaments
8, 20, 26
The (hand/wrist/forearm) accounts for approximately 90% of upper limb function
hand
The hand accounts for approximately ___% of upper limb function
90
What are the three digits that make up the 90% of upper limb function of the hand
thumb (40-50%) Index finger (20%) middle finger (20%)
Why do we have more ulnar deviation than radial deviation
Because the ulnar styloid is 1/2 inch shorter than the radial styloid
List the proximal row of carpals
scaphoid, lunate, triquetrum and pisiform
List the distal row of carpals
trapezium, trapezoid, capitate, and hamate
What are the 5 joints of the wrist and hand
distal radial ulnar radiocarpal carpometatcarpal metacarpalphalengeal interphalangeal (PIP and DIP)
(extrinsic/intrinsic) ligaments provide the majority of wrist stability
extrinsic
(extrinsic/intrinsic) ligaments serve as rotation restraints
intrinsic
What are the four important ligaments of the hand
UCL, RCL, transverse retinacular ligament, and oblique retinacular ligament
Which ligament of the hand holds the extensor mechanism at the PIP joint
transverse retinacular ligament
The transverse retinacular ligament hold the (flexor/extensor) mechanism at the ___ joint
extensor; PIP
Which ligament inserts on the distal phalanx along with the distal insertion of the extensor mechanism
oblique retinacular ligament
Where does the oblique retinacular ligament insert at
the distal phalanx along with the distal insertion of the extensor mechanism
annular means _____
straight
cruciate means ____
crossed
In the pulley system, which fingers are correlated with the annular system
fingers A1-A5
thumb A1 and A2
In the pulley system, which fingers are correlated with the cruciate system
C1-C4
What is the function of the pulley system? What anatomical structure makes this possible?
The pulley system is a series of ligaments that restrain the flexor tendons to the bone’s surface to prevent bowstringing. The flexor retinaculum is what prevent bow stringing in the wrist.
The volar plate provides (weak/strong) capsuloligamentous support and attaches firmly to the base of the (proximal/distal) phalanx
strong; proximal
What allows us to form a lumbrical grip or have straight fingers while flexing at the MCP joint
extensor mechanism
What are the 6 compartments of the extensor retinaculum
- Abductor pollicis longus and extensor pollicis brevis
- Ext. carpi radialis longus/brevis
- Ext. Pollicis longus
- Ext. Digitorum and indicis
- Ext. Digiti minimi
- Ext. carpi ulnaris
What ligament makes up the flexor retinaculum
Transverse carpal ligament
Where does the TCL/flexor retinaculum attach
radial side: tubercle of trapezium and scaphoid
ulnar side: hook of hamate and pisiform
Which muscles attach at the flexor retinaculum
thenar and hypothenar muscles
The flexor retinaculum maintains the ___ ____ arch, acts as a restraint for bowstringing of the extrinsic (flexor/extensor) tendons , and protects the ____ nerve
transverse carpal, flexor, median
True or False:
The transverse carpal ligament is the same thing as the flexor retinaculum
true
What does TFCC stand for
triangular fibrocartilage complex
True or false:
The TFCC is on the radial side of the wrist
false, ulnar
What is the function of the TFCC
improve joint congruency and cushion against compressive forces
TFCC transmits about 20% of the axial load from the ___ to the ____.
hand; forearm
How many extrinsic muscles originate in the forearm and insert in the hand
15
State the flexors muscles that originate in the forearm and insert in the hand
- Flexor carpi ulnaris
- Flexor carpi radialis
- Palmaris Longus
State the extensor muscles that originate in the forearm and insert in the hand
1 & 2. Extensor carpi radialis longus and brevis
3. Extensor carpi ulnaris
State the volar muscles that originate in the forearm and insert in the hand
- Flexor digitorum superficialis
2. flexor digitorum profundus
State the dorsal muscles that originate in the forearm and insert in the hand
- Extensor digitorum
- extensor indicis
- extensor digiti minimi
State the thumb muscles that originate in the forearm and insert in the hand
1 & 2. Extensor pollicis longus and brevis
- Abductor pollicis longus
- flexor pollicis longus
There are ___ muscles that arise and insert within the hand
19
State the muscles in the hypothenar eminence that arise and insert within the hand
- abductor digiti minimi
- flexor digiti minimi
- Opponens digiti minimi
State the muscles in hand/fingers that arise and insert within the hand
Interossei, lumbricals
State the muscles in the thenar eminence that arise and insert within the hand
- Abductor pollicis brevis
- flexor pollicis brevis
- opponens pollicis
- adductor pollicis
What are the four nerves that run through the forearm, wrist, and hand`
radial, ulnar, median, digital nerves
The (radial/ulnar) nerve can be found in the posterior interosseous and recurrent branch
radial
The (radial/ulnar) nerve can be found in the anterior interosseous and recurrent branch
ulnar
Explain where the peripheral nerve distribution of the radial nerve is located
On the dorsal surface of the thumb, index, middle, and half of the ring finger
Explain where the peripheral nerve distribution of the median nerve
on the plamar surface of the hand everywhere except the pinky and half of the ring finger
Explain where the peripheral nerve distribution of the ulnar nerve
On the dorsal and palmar surface of the pinky and half of the ring finger
What are the 6 arteries in the hand
Brachial Radial Ulnar Deep palmer arch Superficial palmer arch Digital
What are the 6 motions of the wrist
pronation, supination, flexion, extension, radial and ulnar deviation
(pronation/supination) is limited by bony impaction between the radius and ulna
pronation
What is pronation limited by
by bony impaction between the radius and ulna
(pronation/supination) is limited by the interosseous membrane and the bony impaction between the ulnar notch of the radius, and the ulnar styloid process
supination
What is supination limited by
the interosseous membrane and the bony impaction between the ulnar notch on the radius and the ulnar styloid
The majority of wrist flexion occurs at the _____ joints
midcarpal
The majority of wrist extension occurs at the _____ joint
radiocarpal
Radial deviation primarily occurs between the two _____ ____. RD is limited by the impact of the ____ bone onto the radial styloid and the UCL
carpal rows; scaphoid
What is radial deviation limited by
The impact of the scaphoid bone onto the radial styloid and UCL
Ulnar deviation occurs primarily at the _____ joint and is limited by the RCL
radiocarpal
What is UD limited by
the RCL
What are the normal and functional ROM’s for wrist pronation
norm: 85-90
functional: 0-50
What are the normal and functional ROM’s for wrist supination
norm: 85-90
functional: 0-50
What are the normal and functional ROM’s for wrist flexion
norm: 80-90
functional: 0-10
What are the normal and functional ROM’s for wrist extension
norm: 70-90
functional: 0-40
What are the normal and functional ROM’s for wrist radial deviation
norm: 15
functional: 0-40 (RD and UD combined)
What are the normal and functional ROM’s for wrist ulnar deviation
norm: 30-45
functional: 0-40 (RD and UD combined)
What are the normal ROM’s for thumb flexion at the CMC, MCP, and IP joints
CMC: 45-50
MCP: 50-55
IP: 85-90
What are the normal ROM’s for thumb extension at the MCP and IP joints
MCP: 0
IP: 0-5
What is the normal ROM for thumb adduction
30
What is normal ROM for thumb abduction
60-70
From the pulp of the thumb to the base of the small finger, opposition should measure ___ centimeters
0 cm
Is flexion or adduction occurring when the thumb moves across the palm
flexion
`What are the three functional arches of the hand and what are their functions
There 2 transverse arches and 1 longitudinal arch. The intercarpal articulations allow for cupping and un-cupping/all for the finger and thumb to hold objects in the hand
What position of the wrist creates the greatest flexion force of the fingers
Wrist in neutral deviation and slight extension
What position of the wrist creates the weakest flexion force of the fingers
wrist flexion
A hook fist has maximum differential glide between the ____ and ____.
A straight fist has maximum ____ excursion.
A full fist has maximum ____ excursion.
FDS and FDP
FDS
FDP
What does this say in layman’s terms
“The pulley system maintains constant relationship between the tension and joint axis to provide for maximum joint motion within the limits of the muscle excursion.”
The stronger the grip, the more flexed the fingers will be. The pulley system makes this happen my preventing bow stringing
Which annular ligaments of the pulley system are the most critical and why
A2 and A4 are most critical because they create composite flexion
When will bowstringing of a tending occur
when a pulley is absent
If bowstringing of a tendon occurs, the moment arm (increases/decreases) requiring (increased/decreased) tendon excursion to produce the same arc of motion
increase, increase
What did complex regional pain syndrome used to be called
reflex sympathetic dystrophy
What condition is a chronic neurological syndrome characterized by tenderness and pain of varying intensity that is disproportionate to the precipitating injury or disease or disease usually to a hand or a foot
reflex sympathetic dystrophy
What are three things that are associated with RSD
vasomotor instability (heat flashes) skin changes osteoporosis
What does CRPS stand for
complex regional pain syndrome
CRPS has two types. Which type relates to RSD
type 1
CRPS has two types. Which type relates to causalgia
type 2
CRPS (RSD/Causalgia) can be described as a pain syndrome triggered by a noxious event that is not limited to a single peripheral nerve
RSD
CRPS (RSD/Causalgia) can be described as a pain syndrome that involves direct partial or complete injury to a nerve or one of its major branches
causalgia
Describe the history behind CRPS
First noted in soldiers who sustained nerve injuries. Causalgia is named after “kausos” meaning heat and “algos” due to the burning and hyperesthesia pain as well as trophic changes and glossy skin
Trophic changes are correlated with the _____ nervous system
autonomic
What are the four diagnostic criteria for CRPS type I/RSD
- An initiating noxious event or cause of immobilization
- Allodynia, hyperalgesia, and continuous disproportionate pain
- Evidence of edema, skin blood flow changes, or abnormal sudomotor activity
What are several clinical characteristics of CRPS type 1
burning stinging pain allodynia hyperalgesia hyperesthesia hyperpathia swelling trophic changes fatigue sweating
How many stages are there of CRPS type 1
3
Describe stage 1 of CRPS type 1
onset of severe pain
start of hyperesthesia
swelling/cramps
warm dry red skin that starts to change to cyanotic and cold and sweaty
Can the first stage of RSD-CRPS subside or respond to treatment
yes in mild cases
Describe stage 2 of CRPS type 1
pain becomes more severe
swelling spreads and becomes brawny
hair and nail changes
osteoporosis and muscle wasting begins
How long does CRPS type 1 stage 1 last
a few weeks
How long does CRPS type 1 stage 2 last
three to six months
Describe stage 3 of CRPS type 1
irreversible atrophy
intractable pain involving the entire limb instead of at the injury site
May develop general RSD that affects the entire body
How long does CRPS type 1 stage 3 last
a lifetime
Type 1 CRPS affects more (men/women) and has an average age onset of mid ___.
women, 30’s.
Explain the mechanism behind RSD type 1 or in other words, what is the pathology behind this syndrome
Normally, the SNS is activated during a fight or flight response. Blood vessels contract which forces blood deep into muscles, which is normal, and usually shuts down within minutes to hours. In RSD type 1, it continues to stay activated and causes an inflammatory response in which the blood vessels spasm and lead to increased swelling and pain.
What are the diagnostic tests used to confirm CRPS type 1
Thermogram Bone scan Sympathetic blocks X-rays, EMGs, CT scan MRI to rule out other pathologies
What is the most widely used diagnostic test to diagnose CRPS type 1
Thermogram
____ ____ is the cornerstone in the treatment of RSD and encourage the patient to use the affected part as much as possible
patient education
What type of medication treatment for CRPS type 1 would be used for a patient in constant pain
Narcotics
What type of medication treatment for CRPS type 1 would be used for a patient with pain that is causing sleeping problems
Antidepressants
What type of medication treatment for CRPS type 1 would be used for a patient with inflammatory pain
NSAIDS
What type of medication treatment for CRPS type 1 would be used for a patient with spontaneous spasms
anti-convulsants
What type of medication treatment for CRPS type 1 would be used for a patient with muscle cramps
Klonopin
What type of medication treatment for CRPS type 1 would be used for a patient with sympathetic maintained pain
Clonidine patch, neurontin
What are the 9 types of treatment styles that can be used for CRPS type 1
Patient education Medication Sympathetic blocks Sympathectomy Spinal cord stimulation Psychological Intervention Biofeedback PT
If a sympathetic block is used in the treatment of CRPS type 1, what type of block would be appropriate for the UE
Stellate ganglion block
If a sympathetic block used in the treatment of CRPS type 1, what type of block would be appropriate for the LE
Lumbar sympathetic block
When would sympathectomy be appropriate in the treatment of CRPS type 1
for patients with chronic intractable sympathetic maintained pain and for patients who have responded well to a series of 3-6 blocks
Why is spinal cord stimulation appropriate for the treatment of CRPS type 1
Because it replaces the area of intense pain with a more pleasant tingling sensation which will remain relatively constant
True or false:
Immobilization is appropriate for the treatment of CRPS type 1
False do not do it
What modalities are appropriate with the treatment of CRPS type 1
contrast baths - avoid ice
most heat, fluidtherapy
TENS
How would a PT control edema while treating CRPS type 1
compression gloves
gentle soft tissue mobilization
jobst pump
elevation of involved limb
are open or closed chain activities better for treating CRPS
closed
During the patient education part of treating CRPS, it is import to tell the patient to modify activities and avoid what three things
avoid caffeine, alcohol, and environmental extremes
What does the newest CRPS research involve about treatment
laterality, imagery, and mirror therapy can be useful
Prognosis for CRPS is (good/variable/poor) if the patient is in stage 1 and/or intervention began 3-6 months after onset of symptoms
good
Prognosis for CRPS is (good/variable/poor) if the patient is in stage II and/or intervention began 6-12 months after onset
variable
Prognosis for CRPS is (good/variable/poor) if the patient is in stage III and/or interventions began 1 year after onset with pain persisting throughout the patient’s lifetime
poor
Treatments for CRPS are (brief/extensive) and (cheap/expensive)
extensive and expensive
