Hand Flashcards
Describe the S/Sx for CTS
- compression of med nerve > reduced blood flow > edema > ischemia to the nerve
- paresthesia median nerve distribution
- reduced grip strength
- abductor poll brev wasting (usually in older people who’ve ignored it for awhile)
- sensory changes before motor
What are the clinical tests for CTS?
Monofilament testing
Phalens
Tinels
APB testing (test this is palmar abduction)
Describe Mx of CTS
- night spint in neutral - 10 days to 6 weeks
- nerve flossing
- postural advice
- APB strengthening
When to refer?
- failure to improve
- APB wasting
- constant numbness
S/Sx for DeQuervains
- radial wrist pain related to overuse
- APL + EPB - degenerative tendinosis in 1st dorsal compartment
- 30-50yrs;F>M
- thumb abd + RD+UD
- can also be d/t blunt trauma/cyst/tumor (rare)
Describe the pathophysiology of DeQuervains
- repetitive gliding from mm use in the first dorsal compartment causes shear trauma
- non inflammatory process
- thickened retinaculum, narrowed canal so imparied gliding of tendons in the canal
Clinical tests for DeQuervains?
- pain over radial styloid; swelling/thickening too
- pain on thumb extension; limited thumb extension
- crepitus
- finklesteins +ve
Mx for DeQuervains
- thermoplastic splint for 6 weeks - then start strengthening + replace with neoprene splint
- ice
- avoid agg activities (pulling up the sheets is characteristically painful!)
- radial nerve glides if needed
- gentle ROM ex
- steroid injection might be needed if not improving- cures 83% of cases
- surgery = longitudinal release of the tendon
what are 3 complications of CSI?
- skin pigment changes
- tendon deterioration
- subcut fat atrophy
Describe trigger finger
- nodule is caught proximal to A1 pulley
(A1 @ MCP, A3 @ PIP, A5 @ DIP) - click or snap when trying to straigthen out the fingers
- agg by repeated gripping
Describe distal radius fracturse
Most common
Younger people 18-25
Mx depends on stable or unstable
can have median nerve injury or intra articular damage
Describe the rehab of the STABLE distal radius fracture
- keeping DPC free:
- finger + thumb ex’s
- ## forearm/shoulder/elbow ex’s (elbow flex/ext/sup/pron/hand behind back/behind neck)
Post op rehab of distal radial fracture (ORIF)
- RICE
- thermoplastic resting splint over a tubifast sleeve with padded straps with DPC and thenar eminence free
- Scar care
- ROM ex + tendon gliding ex as well
(ROM eg. table top, hook fist for FDS/FDP, wrist ext/flex, supin/pron) - begin strengthening at 6-8 weeks
Describe scaphoid fracture
FOOSH injury
px in snuffbox
XR might be negative for 10days to 2 weeks so treat as if they do have a fracture
Can do bone scan at 48 hrs (15% false +ve)
What are indications for conservative treatment for scaphoid fractures?
stable, undisplaced waist #
- this take 6-12 weeks to heal with 60-90% union)
tubercle fractures
- (wrist splint 3-4 weeks)
What are indications for surgical treatment for scaphoid?
- unstable displaced fracture
- fracture/dislocation
- proximal pole fracture
- non union
- pathological fracture
- carpal instability
- ORIF = quicker RTW/RTS
What is post op Mx for scaphoid #?
- immob for 7-10 days
- gently unresisted ROM ex - splint between ex sessions
- avoid contact sports until healing/union confirmed with XR - can be 3 months
- most regain good motino with simple home program
Describe the scaphoid shift test
- apply pressure AP to the scaphoid tubercle with wrist in UD
- bring wrist into RD passively
- if there’s SLL laxity then will be able to push the scaphoid back over rim of the radius
- on release might here a clunk as scaphoid relocates back into lunate fossa
What is the ring sign and when do you see it?
- when there is rotation of the scaphoid as seen with scapholunate dissociation, the ring sign appears due to the the foreshortening of the scaphoid
- also see Terry Thomas sign
What is mx for SLL?
- splint 6 weeks
- exercise in dart throwing motion of wrist (minimizes motino between scaph+lunate)
- grip strengthening only when pain free
- progress to proprioception (slosh pipe)
Which muscles are good for the SL and which are bad?
Good:
- ECRL
- APL
- FCU
Bad:
- ECU
What are S/Sx of TFCC injury?
- ulnar wrist pain
- prominent ulnar styloid (aka supinated carpus)
- reduced grip strength
- weak grip/pain in pronation = ulnar impingment or TFCC
Describe the TFCC shear test
- stabilize ulna and glide the piso-triquetral complex dorsally
- +ve if there’s pain
- sens/spec = 66%
Describe the TFCC shear test with compression
- still gliding PT complex AP but adding axial compression and ulnar deviation whilst doing it
Describe the Gripping Rotary Impaction test (GRIT test)
- arm by side at 90º flexion
- measure grip in full sup/full pron/neutral position
- ratio of supinated grip/pronated grip
- if > 1 then ulnar impaction syndrome
- UIS = abutment of the ulnar into the TFCC and ulnar sided carpals which results in degeneration of the TFCC and chondromalacia of the ulna+carpas + disruption of triquetrolunate ligament
What is the management for TFCC injury (conservative?)
- might need to support ulnar carpals for 4-6 months
- activity mod - avoid loading ulnar side
- PQ strengthening
- grip strengthening in pain free ranges of wrist rotation
What is the presetnation of TMC OA? (OA of the first MCPJ)
- painful, achy, locally tender
- joint thickening
- deformity with subluxation at base of 1st MC
What is the TM grind test?
Stabilise the trapezium and axially load and rotate the metacarpal
Describe self management for CMC OA
- Education (proper alignment, better work methods to reduce joint stress)
- Aids to help with ADLs without causing pain
- Cryotherapy/heat therapy
- Massage
- Preserving PROM of CMC joint - web stretch/trigger point/self traction
- Weight loss (OA and obesity has inflamm link)
What are other options for treating CMC OA besides self management?
- Splinting
- Exercise (proprio/neuromm/strength)
- Neural glides
What predisposes one to CMC OA?
- Genetics
- Joint incongruity
- Thumb ligament insufficiency
- Poor neuromm control of joint
