Hand Eval Diagnosis and Treat

Question 1

When the radial nerve is compressed, it leads to radial tunnel syndrome and ___ syndrome. Does it mainly have motor or sensory deficits?

Answer 1

Posterior Interosseus Nerve (PIN) syndrome

Motor

Question 2

Which muscles in the thumb and fingers are innervated by the radial nerve?

Answer 2

Abductor pollicis longus
Adductor pollicis brevis
Extensor indicis

Question 3

What types of loss happen with a PIN laceration?

Answer 3

Only motor - no sensory loss

Question 4

What innervates supinator?

Answer 4

Radial n.

Question 5

T/F: whether there is a forearm or elbow radial laceration, sensory loss is the same.

Answer 5

True. Only interwebbed space between 1st and 2nd digit

Question 6

Radial nerve lesions: what can you do?

Answer 6

RLP splint to bring into some ext and help with function.

Question 7

What sensory deficits come with a high level median nerve injury?

Answer 7

Thumb, index, middle, and radial half of ring finger (dorsal and volar)

Question 8

What can you do with a median nerve lesion?

Answer 8

Opposition splint - puts thumb into opp.

Question 9

What are some key symptoms with CTS?

Answer 9

• Nocturnal pain &
• numbness
• Clumsiness
• Paresthesias
• Muscle atrophy/sensory loss
• Radiating pain

Question 10

What are some common causes of median nerve lesion? What about ulnar nerve?

Answer 10

MEDIAN
Humeral fractures
Elbow dislocations
Distal radius fractures
Dislocation of lunate into carpal canal
Volar wrist lacerations

ULNAR
Fracture of medial epicondyle, humerus, or olecranon
Lacerations (wrist level)

Question 11

What key sign makes it apparent there is an ulnar nerve lesion and what is the name of the test for it? Is there something that happens in the thumb as well?

Answer 11

Abductor digiti minimi: Wartenberg’s sign

Thumb: Froment’s sign - thumb IP flexion with MCP extension with attempted lateral pinch

Question 12

Anastomosis between median and ulnar nerve can happen in the forearm and hand. There is a Martin Gruber and Riche-Cannieu anastomosis. Which happens where?

Answer 12

MG - forearm (AIN to ulnar or medain to ulnar in middle)

RC - hand (in palm)

Question 13

What motion provokes cubital tunnel syndrome symptoms?

Answer 13

Elbow flexion, esp. at night.

Question 14

What diagnostic tools can you use to diagnose cubital tunnel syndrome?

Answer 14

Elbow flexion test

• Tinel’s sign
• Semmes-Weinstein
• Weakness/atrophy

Question 15

Describe the location of A1, A2 and A4 pulleys and their importance.

Answer 15

A1: at the MCP joint
A2: along the proximal phlange
A3: along the PIP joint
A4: along the middle phlange

A2 and A4 need to be preserved

Question 16

Describe the flexor tendon zones (I-V). Hint: starts at the fingertips.

Answer 16

Zone I – Distal to the FDS
insertion
Zone II – From insertion of the FDS tendon to the A-1 pulley in the palm
Zone III – From the A-1 pulley to the distal end of the carpal tunnel.
Zone IV –Within the carpal tunnel extending from distal and proximal borders of the flexor retinaculum
Zone V –Proximal to the carpal tunnel

THUMB:
III = themar eminance

Question 17

When is a tendon weakest post surgery?

Answer 17

4-5 days. From day 5-21, tensile strength increases as the collagen matures and cross linking continues. Look at AROM 3 weeks out.

Question 18

What are 2 issues with tendon repair? What’s important with regards to sutures?

Answer 18

Gapping: occurs at repair site
Adhesion formation: within flexor sheath

Fewer surface loops = less surface scar tissue. Most surgeons use 4 strand core repair

Question 19

Name 3 different approaches to tendon repair.

Answer 19

Immobilization
-3 to 4 weeks in brace, no PROM or AROM

Early Passive Mobilization (Kleinhart; Duran)(Dorsal Block Splint)

• 24hrs to 2 days post surgery
• Passive flexion glides the tendon proximally, and limited active extension glides the tendon distally

Early Active Mobilization

Question 20

What position of the hand requires maximum FDP gliding? What about FDS?

Answer 20

FDP
Fully closed fist

FDS
Straight fist - straight DIP

Question 21

What is a protocol outline for a FDP/FDS tendon repair at 2 days, 3 weeks and 8 weeks post surgery?

Answer 21

DAY 2

• dorsal-bloch splint
• passively flex, actively extend (duran)

WEEK 3

• no carrying
• educate with use like opening doors
• don’t overextend wrist

WEEK 8

• light gripping
• no brace unless in crowd
• yoga or pilates with modified hand positions;

Protected function
Pain should be no more than 3-4

Question 22

Name the zones of the extensor tendon and name a fracture at each odd one.

Answer 22

I - DIP (mallet fracture)
II
III - PIP (boutonniere splint)
IV
V - MCP
VI
VII - Scaphoid/Radius

Question 23

How do you characterize a brawny edema?

Answer 23

Presence of fibrinogen.

Question 24

How do you calculate Total Active ROM?

Answer 24

(Summation of digit flex) – (Summation of digit ext deficits)
Total ~290