Hand/Wrist Flashcards
The hand accounts for __ of upper limb function.
90%
The thumb is involved in __ of hand function.
40-50%
What is the functional range of motion of the wrist?
10 degrees extension
30 degrees flexion
The __ is convex and the __ is concave in the distal radioulnar joint?
Ulnar head
Ulnar notch of the radius
What does the distal radioulnar joint join together?
Distal radius
Ulna
TFCC (articular disc)
What is the open packed position of the distal radioulnar joint?
10 degrees supination
What is the close packed position of the distal radioulnar joint?
5 degrees supination
What is the capsular pattern of the distal radioulnar joint?
Pronation = supination
Pain at extremes of pronation/supination
What is the TFCC?
Triangular Fibrocartilage Complex
Fibrocartilage disc between the distal ulna and carpals in the medial wrist
What is the primary function of the TFCC?
Enhances joint congruity and cushion against compressive forces
Transmits ~20% of axial load from the hand to forearm
What does the radio carpal joint join together?
Radius
Scaphoid
Lunate
TFCC
What does the open packed position of the radio carpal joint?
10 degrees wrist flexion
Slight ulnar deviation
What does the close packed position of the radiocarpal joint?
Full extension with radial deviation
What is the capsular pattern of the radiocarpal joint?
Equal limitation all directions
What is the proximal part of the midcarpal joint made up of?
Scaphoid
Lunate
Triquetrum
What is the distal part of the midcarpal joint made up of?
Trapezium
Trapezoid
Capitate
Hamate
What does the open packed position of the midcarpal joint?
Neutral or slight flexion with ulnar deviation
What does the close packed position of the midcarpal joint?
Extension with ulnar deviation
What does the capsular pattern of the midcarpal joint?
Equal limitation in all directions
What is the articulation of the first CMC joint?
1st metacarpal and trapezium
The trapezium is concave in the __ direction and convex in the __ direction.
Concave: anterior/posterior
Convex: medial/lateral
The 1st MCP is concave in the __ direction and convex in the __ direction.
Concave: medial/lateral
Convex: anterior/posterior
What is the open packed position of the first CMC joint?
Midabduction and adduction in mid flexion and extension
What is the close packed position of the first CMC joint?
Full opposition
What is the capsular pattern of the first CMC joint?
Abduction most limited
Followed by extension
What is the open packed position of the 2-5 CMC joint?
Neutral position of the wrist
What is the close packed position of the 2-5 CMC joint?
Not described
What is the capsular pattern of the 2-5 CMC joint?
Equal limitation in all directions
What is the open packed position of the MCP joint of the 1st digit?
Slight flexion
What is the close packed position of the MCP joint of the 1st digit?
Maximal opposition
What is the capsular pattern of the MCP joint of the 1st digit?
Greater limitation in flexion than extension
What is the open packed position of the MCP joint of the 2-5 digits?
Slight flexion
What is the close packed position of the MCP joint of the 2-5 digits?
Full extension
What is the capsular pattern of the MCP joint of the 2-5 digits?
Equal restriction in all directions
What is the open packed position of the PIP joint of the 2-5 digits?
Slight flexion
What is the close packed position of the PIP joint of the 2-5 digits?
Full extension
What is the capsular pattern of the PIP joint of the 2-5 digits?
Greater limitation in flexion than extension
What is the open packed position of the DIP joint of the 2-5 digits?
Slight flexion
What is the close packed position of the DIP joint of the 2-5 digits?
Full extension
What is the capsular pattern of the DIP joint of the 2-5 digits?
Greater limitation in flexion than extension
Extensor retinaculum
Prevents tendons from “bowstringing”
Forms 6 compartments
Extensor hood
Complex tendon covering posterior aspect of the digits
ED, EI, EDM
Distal portion of hood receives tendons of lumbricals and interossei over prox phalanx
Between MCP and PIP, complete tendon splits into 3 parts: central slip and 2 lat bands
Arrangement creates cable system for extending MCP and IP joints
Compartment 1
Extensor pollicis brevis
Abductor pollicis
Compartment 2
Extensor carpi radialis brevis
Extensor carpi radialis longus
Compartment 3
Extensor pollicis longus
Compartment 4
Extensor digitorum
Extensor indicis
Compartment 5
Extensor digiti minimi
Compartment 6
Extensor carpi ulnaris
What is contained underneath the flexor retinaculum? (4)
Flexor digitorum profundus
Flexor digitorum superficialis
Median N
Flexor pollicis longus
What is the function of the volar plates/palmar ligaments at the IP joints?
Help prevent hyperextension of the IP joints
Oblique retinacular ligament
Helps the PIP/DIP move together
As the PIP extends through the central slip, tension is put not he oblique reticular ligament which then extends the DIP
Where is the flexor retinaculum located?
Spans area between pisiform, hamate, scaphoid and trapezium
What are the 2 functions of the flexor retinaculum?
Prevents bowstringing of flexor tendons
Protects the median N
What are the flexor pulleys?
Annular and cruciate connective tissues restrain flexor tendons to metacarpals and phalanges
Contributes to tunnels through which the tendons travel
Carpal Tunnel
Median N
9 flexor tendons: FDS, FDP, FPL
Tunnel of Guyon
Between the hook of the hamate and the pisiform
Passageway fro ulnar N and artery in hand
What is a double crush injury?
Nerve symptoms may start distally then move proximally
OR
Nerve symptoms may start proximally and move distally
What 2 muscles attach to the pisiform?
Flexor carpi ulnaris
Abductor digiti minimi
Pathology of Rhuematoid Arthritis
Systemic disease
Cycle of stretching, healing and scarring that occurs as a result of the inflammatory process
Significant damage to soft tissues and periarticular structures
Can lead to pain, stiffness, joint damage, instability, deformity
Name the 3 common deformities associated with RA
Ulnar drift
Boutonniere deformity
Swan-neck deformity
Intervention for RA
Control inflammation Focus on joint systems vs isolated joints Exercises Joint protection/energy conservation Splinting Pain management
Ulnar Drift
Result of interaction forces and damage to collateral ligaments and extensor mechanisms
Pulls the finger into ulnar deviation, pronation, anterior subluxation
Up to 45 degrees of lateral deviation can occur at the MCP joint
Boutonniere Deformity Description
Extension of MCP/DIP
Flexion of PIP
Boutonniere Deformity Mechanism
Common extensor tendon that inserts on the base of the middle phalanx is damaged
Damage to central slip insertion requires extra effort to extend joint, causing hyperextension at DIP
Lateral bands drift forward past axis of rotation of PIP and act as flexors while hyperextending DIP
Causes of a Boutonniere Deformity
Division, rupture, avulsion, closed trauma to common extensor tendon
RA
Boutonniere Deformity Examination
If more than 30 degree extension lag is present at PIP
Boutonniere Deformity Intervention
Immobilize PIP full extension with MCP/DIP free 6-8 weeks
Swan Neck Deformity Description
Flexion of DIP
Hyperextension of PIP
Swan Neck Deformity Mechanism
Destruction of oblique reticular ligament of the extensor mechanism leads to posterior displacement of lateral bands resulting in hyperextension of PIP
Pull on FDP tendon causes flexion of DIP
Swan Neck Deformity Intervention
Silver ring splint
TFCC Lesions
Disruption of articular disc
Following fall on supinated outstretched wrist or chronic repetitive rotational loading
TFCC Lesion History/Examination
Medial wrist pain distal to the ulna, increased with end-range forearm pronation/supination and forced gripping
Painful click during wrist motions
Tenderness localized distal to ulnar head
TFCC Lesion Intervention
Joint distraction, wrist strengthening
Long arm cast or splint 6 weeks
Primary Osteoarthritis
Commonly involves 1st CMC joint or scaphotrapeziotrapezoid joint
Secondary Osteroarthritis
Old trauma or infection
1st CMC Osteoarthritis
Women > men >45 years old Joint pain at the base of thumb which increases with use Restricted ROM in capsular pattern Joint crepitus
Osteroarthritis Intervention
Splinting
Thermal modalities
Education
Dupuytren Contracture
Active cellular process in the fascia of the hand, characterized by nodules in palmar and digital fascia Tendon-like cords Contractures at MCP and PIP Little finger in 70% Usually bilateral
Dupuytren Contracture Examination
Caucasian men, later in life
Higher incidence with alcoholic, diabetic, epileptic, tobacco
Inability to straighten fingers, primarily 4th/5th
Dupuytren Contracture Intervention
Stretching initially
Surgery
Postoperative scar management and splinting
UCL sprain of the thumb
Gamekeeper’s or skier’s thumb
Injury to MCP of the thumb
Most common ligament injury
UCL sprain of the thumb Examination
Pain/tenderness on ulnar aspect of MCP
Direct force causing hyperextension and abduction of MCP joint or repeated trauma
UCL sprain of the thumb Intervention
Splinting
Strengthening
Taping
Ganglia
Thin-walled cysts containing hyaluronic acid that develop spontaneously over a joint capsule or tendon sheath
Common sites: anterior or posterior surfaces of the wrist and fingers
Ganglia Examination
May not cause pain
As grows: aching increased with flexion/extension
Tender with applied pressure
Ganglia Intervention
Needle aspiration or surgical excision
Tendonitis
Inflammation of the tendon or tendon-muscle attachment
Overuse
Abductor pollicis longus
Extensor pollicis brevis
Tenosynovitis
Inflammation of the tendon sheath
Rheumatic disease, DM, hypothyroid
DeQuervain Disease
Progressive tenosynovitis involving sheaths of first posterior compartment of wrist (APL and EPB)
Thickening of extensor retinaculum, stenosing of fibro-osseus canal and eventual entrapment and compression of tendons
DeQuervain Disease Examination
Gradual and insidious onset
Dull ache over radial aspect of the wrist
“Creak” in wrist as tendons move
Severe pain with wrist ulnar deviation and thumb flexion/adduction
Localized swelling and tenderness in region of radial styloid process
Loss of abduction of CMC joint
DeQuervain Disease Intervention
Rest Activity modification Splinting NSAIDs Manual therapy
Trigger Finger
Painful snapping/triggering of the fingers due to disproportion between the flexor tendon and its tendon sheath
More common in thumb, ring and middle fingers
Most common in diabetics, young children, menopausal women, RA
Trigger Finger Examination
Limited finger motion (esp PIP)
Crepitus or moving nodular mass near A1 pulley with finger movement
Swelling
Trigger Finger Intervention
Splinting, immobilization MCP joint
Activity modifications
Steroid injections or surgical release
Tendon rupture
Common flexor pollicis longus and flexor digitorum profundus to index finger
Tendon rupture with repair postoperative
Early protected mobilization
Know number of strands of suturing used: 2 strands-may be limited to PROM; 4-6 strands-may be able to work tendons actively
Prevent adhesions that limit excursion
Mallet Finger Deformity
Traumatic disruption of the terminal tendon from DIP
Mallet Finger Deformity Examination
Loss of active extension of the DIP joint, can be extended passively
Flexion deformity of DIP
Mallet Finger Deformity Intervention
Immobilization/splinting of DIP in extension
Allow PIP movement
Unrestricted use after 12 weeks
Carpal Tunnel Syndrome
Ischemic compression of the median nerve at the wrist as it passes through the carpal tunnel
Compounded by increase in synovial fluid pressure and tendon tension
Carpal Tunnel Syndrome Examination
Intermittent pain and paresthesia in median nerve distribution of hand, progressively becomes more persistent
Symptoms typically worse at night
Phalen tests and Tinel sign
Carpal Tunnel Syndrome Intervention
Splints, ergonomics
Activity modification
Diuretics and NSAIDs
Isolated tendon excursion exercises and nerve glides
Radial Nerve Entrapment Examination
Weak wrist and finger extension
Hand grip weakened as a result: decreased stabilization
Wartenberg Syndrome
Compression of the superficial sensory radial nerve
Pain, paresthesias, numbness on radial aspects of hand and wrist
Radial Nerve Entrapment Intervention
Activity modification
Manual therapy
Chronic Regional Pain Syndrome Examination
Reflex sympathetic dystrophy (RSD)
Past event of trauma Persistent pain Edema: pitting or nonpitting Stiffness Skin temperature changes, sweating Hyperalgesia Allodynia
Chronic Regional Pain Syndrome Intervention
Reflex sympathetic dystrophy (RSD)
Team approach
Minimize pain while doing PT
Slow/gentle progression of strengthening, AAROM, AROM, weight-bearing exercises
Mirror therapy
Colles Fracture
Complete fracture of distal radius with posterior displacement of the distal fragment
FOOSH
Smith Fracture
Complete fracture of distal radius with anterior displacement of the distal fragment
Fall on back of a flexed hand
Scaphoid Fracture
Most commonly fractured carpal bone
FOOSH with wrist pronated
Scaphoid Fracture Examination
Posterior radial-sided wrist pain
Tenderness over anatomic snuffbox
Swelling in anatomic snuffbox
All wrist pain with swelling and pain in the snuffbox should be treated as ___ until ruled out because __.
Scaphoid fracture
Delayed diagnosis can result in long-term pain, loss of mobility and/or loss of function
Kienbock Disease
Aseptic necrosis or osteonecrosis of lunate
Pain over lunate
FOOSH
Decreased grip strength
Surgery vs immobilization with splint followed by exercise
Lunate Dislocation
Dislocation of the lunate volarly FOOSH or hit by outside force Pain over lunate Deformity Inability to move wrist Median neuropathy
Lunate Dislocation Intervention
Reduction
Immobilization
No extension for 5-6 weeks
Raynaud’s Phenomenon
Vasospasm of the distal vessels of the hands and toes
Decreased circulation distal UE
Diffuse pain in hand
Pale fingers
Cold may trigger
Allen’s test (+)
Blanching of fingers followed by reddening
Boxer’s Fracture
Fracture of the 5th metacarpal
Hook Grip Innervation
Median N
Ulnar N
Power Grip Innervation
Ulnar N
Maybe median N
Lateral Pinch Innervation
Ulnar N
Precision Pinch Innervation
Median N
Cylindrical Grip Innervation
Radial N
Median N