Hand joint counts Flashcards
What are the specific Rx goals with hand Ra?
Local rest
ice or contreast baths (Except with raynuads)
Jt protection
What are 3 key points to Ax of disease activity in RA. What common sites do you find them in?
1) active joint count
2) vasculitis (inflam blood vessels in tips of fingers b/c smallest inflam cause black spots)
3) tenosynovitis (Synovitis - common extensor expansion, move wrist or fingers does not feel smooth w. movt)
What can cause tendon ruptures in Ra?
infiltration of adjacent synovuium (pannus)
Ischemia d/t presure by expansive synovium
Abrasion over roughened bony prom.
A pt is right handed and has early RA in this hand, will this hand be weaker, be at a greater risk for deformity and how would you measure ROM.
- handedness does not = deformity
- 50% will get deformity in 10yrs
- dominant hand 20% weaker (b/c of increased phsyical demand = jt inflam)
- measure on dorsum unless effusion, edema, jt contracture then lateral
What are the 5 major hand deformities in RA?
(BUST.W)
1) Boutonnieres
2) swan neck
3) ulnar drift
4) thumb deformity
5) wrist deformity
Describe the central mechanism to a BD
synovitis of PIPJ -> disrupts central slip-> stresses triangular lig -> lateral bands migrate volarly -> (Flexor @ PIPJ) -> ext force concentrated on distal phalanx = DIPJ hyperextension
- prox phalanx button holes dorsally through lateral bands
What can you use to Rx BD?
Anti B splint
(ABNS) blocks PIPJ Flexoin and flex
- work on active ext of PIPJ and active flex of DIPJ
What is a swan neck deformity?
chronic synovitis @ MCP ->triggers protective P. reflex -> intrinsic msucle (IM) spasm–> overactive IM overpower extrinsic flexors -> PIPJ hyperextension -> excessive MCP flexion cause lateral bands dorsally displaced -> DIPJ flexes in response to tension on FDP tendon
What test can you use to test for swan neck D. How do u know if its positive or not?
Bunnel littler test
- if you get more PIPJ flexoin when the MCP is in flexion vs hypextension means the jt was stiff and needs stretching
What gradinig system do you use for SND and what are the levels?
Nalebuff
1 - no limitation of PIPJ motion in any MCPJ position
2 - limitiation in PIPJ motion with MCPJ in extension and radial devidation
3- limit. of PIPJ motion w. any MCPJ position
4 - fused - stiff PIPJ w. jt destruction on radiograph
what is a Rx techn. for a positive Bunnel littler test?
passive stretch interossei
(ext MCP and passive flex PIP hold for 30sec 2-3 reps 3 days a week)
- can also Rx with splint
what is the most common patho in RA: BD, SND, Unlar drift, ext tendon sublux. /
Ulnar drift deformity most common
What are the pathomechanics of Ulnar deviation (UD)
synovial prolif -> attenuation of radial collateral lig and sagittla band –> EDCulnarly displaced
- ulnar displacment force > in full ext/or flex >60
- asymmetry in slope of metacarpal hd (radial > ulnar)
whats the diff b/w the mechanics behind UD and UD volar subluxation ?
attenuation of collateral lig & volar plate - fail to restrain extrinsic flexor force created by FDS and FDP –> the > MCPJ flexion angle = > volar sublux so the proximal phalanx subluxs
- tight interossei make this worse by increasing the volar plate sublux
How do you test for UD ?
MCP radial collateral lig test
Extensor tendon subluxation test (look for the tendon to sublux to the ulnar side )
How do you grade UD?
Millender and Nalebuff
Graded 1-4
1 - mild UD; mcpj synoviits; full active MCP flx/ext
4- severe; fixed & MCP articular destruction
What exs prescription and Rx exist for UD?
Radial finger walking
1) on table move radial; lift hand to put back dont use Ulnar muslces
( 5-10reps, once a day 2-3/wk)
- progress to against gravity
2) Isometric Radial intrsinsics
(70% MVC) hold 6sec
(5-10 once a day 2-3/wk)
3) education use hand so use radial muscles (jt protection)
What is the main deformity of the thumb joint?
90/90 deformity that happens w. BND
Its ranked as (I) on the Nalebuff classification ratiing
What does the BND deformity of the thumb look like? Describe the mechanics of it.
BND THUMB: d/t synovitis - causes the EPB tendon to ulnar deviate and valar slide
- causes: Flexion of the MCPJ and hyper-ext of the IPJ
What are the Rx options for thumb BND?
1) complete resection of the trapezoid
2) lig reconstruction
3) tendon reconstruction
What is the difference b/w SND and BND at the thumb?
SND - synoviitis at the CMCJ- causes the jt to sublux dorsal and radially - also d/t spasm of ADDP
CMCJ - flex/add/sub
– > MCPJ hyperextend and the IPJ flex
Therefore the mechanics of the SND are more to do with the CMCJ then the MCPJ
- Want to check for issues around the CMCJ for arthritis then b/c this is where this deformity starts
What are the Rx options and Ax TESTS used for SND in the thumb?
1) Gind test:
- text for arthritis in CMCJ; axial compression with rotation of joint
- ++ P , +/- crepitus
2) Crank Test:
- tests or same as above
- add now dorsal and valar glide to jt
- ++ P, +/- crepitus
TREATMENT for over all THUMB EXS: FOR both deformities
1) Massage the websace 2) stretch the space (hand over other wrist watch the angle of the thumb) 3) opposition/abd exs (making a mouth with your hands working jt into abductoin)
What are all the different deformities of the hand? Make a note about what each one looks like.
1) boutonnieres
2) Swan neck deformity
3) Ulnar drift
4) Thumb (#1 BND; #2 SND)
5) Wrist deformity
What are the deformities of the wrist?
1) DRUJ inistability
2) Vaughn jackson deformity
3) Zig Zag deformity
Describe a DRUJ deformity
- synovitis - stretches UCL - dorsal dislocation of ulna & sup of carpus on the ulna (possibly d/t to pull of the ECU tendon which has subl on volarly)
- ECU now flexes
- Increases chance of tendon rupture
- decreases ROM +/- P
- decreased strength wrist
Describe a Vaughn Jackson deformity.
- at the wrist
- complete ext tendon ruputre
- send to surgeon right away
Describe a zig zag deformity
synovitis - jt laxity and subluxation - carpal movt ulnarly & radial rotation of metacp - fingers go ulnar side
Best Ax tools for wrist arthritis and deformity is what?
Ballottment piano key test
- Ax DRUJ
- elbow flex to 90
- stab radius, sup - dorsal and ulnar glides - then do same thing in pronation
- ++ P, +/- excessive movt, tenderness relative to the other side
What options do you have to Rx. wrist deformities? What is the goal of Rx?
Rx instabiltiy d/t recurrent synovitis
protect small jts
can do flexion exs but NEED to be careful
1) AROM
2) Tendon glides
3) Splints
4) Surgery
Describe AROM exs for the wrist
1) AROM of wrist
- ext MCPJ, flex the PIP , can stab MCPJ with other hand
(10 Reps 1x/day every day)
Describe tendon gliding exs
Tendon glides:
What are the main goals to tendon glides?
- Jt to go through full ROM - increase jt cartilage nutrition
- prevent adhesions- they result from synovitis
- allow max excursion of jt & flex/ext tendons
WHa are indiciations for surgery and what are the 4 R’s
1) if tendon rupture looks possible
2) relief p
3) incre func
4) cosemetics
Repaire
Remove
Replace
Rest
What is the most common surgery performed/
Tendon tsf most common
What types of splints can be sued?
1) Static (writing splints)
2) dynamic (Dynamic extension splints)
What are the different kinds of grips
1) latera
2) trip pod
3) tip grip
4) hook grip
5) Spherical grip
6) cylindrical (hammer)
check for the normal attitude of the hand
