Hand & Wrist Treatment Approaches (Lecture #5) Flashcards
What normally causes hypomobility? (4)
RA
OA
Trauma (Fx / Sprain)
Post operative/post immobilization
KNOW: W/ joint hypomobility in the hand we hvae functional limitations in:
* Activities involving prehension, pinch or grippping / grasping
* Pain and/or weakness can also be a factor (these can lead to deficits in dexterity (find motor coordination)
A pt comes in w/ joint hypomobility. Explain early stage treatment:
Start w/ joint protection
* Pateint education - say they cant grasp smaller objects - can we make the objects that they need bigger so they arent tensioning those hypomobile joints (put some kind of cover over pencile so they dont have to grasp something quite as small)
* Pain management (manual, medication, modalitites) - if highly irritable we need to try and reduce the pain as much as possible which will allow them to progress through interventions we do in the future
- think parafin / iontophoresis / ultrasound
* Orthoses - say were constantly stressing an area which led to the hypomobility - maybe having some kind of splint / orthoesis to keep us from going into that pain pattern over and over again would be helpful
* Activity modification: Balance activity and rest (relative rest = were resting the painful activity / avoiding it so that its not painful - however, you want to keep them as active as possible - so figure out a way to use affected side in a non-painful way) | Avoid prolonged periods of stress / strain on affected tissues (split up dishes if thats whats bringing on pain to avoid that prolonged period of stress) | Avoid painful resisted activities
* Patient to be as independent as possible w/ minimal pain and stress to joints - in the beginning we really want to calm down that area
* Respect pain
* Eventaully start moving into strengthen / ROM (remebering to respect pain) - we want to do this in a pain free way - we don’t want to exaserbate a highly irritable pt
The goal of this stage is to do pain management and maintaing as much function as possible
KNOW: We often want to avoid going into the painful movement all the time w/ hypomobility OA / RA
* So we need things to are bigger to help us not go into that full finger flexion all the time
KNOW: Joint hypomobility intial loading and mobility:
PROM –> AAROM –> AROM
Tendon gliding: Think about flexior digitorum profundus etc… They go through tendon sheaths and the slide forward and back through them. In someone who is hypomobile if they continue to not move through that full ROM they can develop adhesions between the tendons and the tendonsheaths which can lead to more painful hypomobility in the future. The idea with this is just to get it moving within its sheath so those adheasions dont form.
We can also use multiangle isometrics. This is doing isometrics at different points in that ROM. (next page)
TEndon gliding that hits all tendons in hand
The picture below is a multiangle isometric. She would progress into flexion from that fully exended position hitting it from multiple angles. This is a good way to prepare the joints for full AROM. Can do these w/ mcp joints or really and joints in the hand
A joint is hypomobile. What is proably the BEST manual therapy approach here?
Joint mobilizations (glides / slides)
Movement w/ mobilization is also utilized to allow them to work into that movement is a distrated / glided state (helps improve those hypomobile pts)
Who would be contraindicated for joint mobilizations?
RA pts in inflammatory phases
* The tissue can easily be torn here
* Theres a lot of tissue breakdown at this time before it “heals”
I already know how to do this!
Metacarpal arch = distal transverse arch
* This arch can become stiff over time
What kind of glide is this?
* What is it used for?
Dorsal concave mobilization of the metacarpal arch
* Makes sense - the dorsal side of the hand is making a cave (and named “dorsal” to dilinate what side it is)
Improves gross extension (makes sense were extending the 2 fingers were mobilizing)
What kind of glide is this?
* What is it used for?
Dorsal convex metacarpal arch mobilization
for improved gross hand grasp
* Primarly spherical grasp (makes sense - lookse like were holding a sphere w/ this grip) - when were really trying to get around something
NOTE: We don’t just have to do metacarpal arch mobilizations - we can do mobilizations of each individual metacarpal
KNOW:
This is mobilizing each individual metacarpal near the carpal bones
Proximal intermetacarpa mobilizations can be palmar or dorsal (both shown below)
They are both used to improve hand mobility w/ a variety of grips (so we would use it on our hypomobile pts, like those w/ OA / RA in a NON FLARED PHASE to avoid stressing that already very pathological capsular tissue)
KNOW: We can perform traction at CMC joints like this (note we can also perform traction at the PIP / MCP / DIP joints as well if those areas are pathologic)
* good for pts to have that mid hand pain (typically linked to arthritis - aka distraction helps)
* Its also used to improve general mobility of the CMC joint
PAIN IN MIDDLE PORTION OF HAND ARE THE PTS WE PERFORM THIS ON
What glide of the thumb is this? What motion does it improve?
This is a radial glide of the thumb
It improves extension
What glide of the thumb is this?
* What motion does it improve?
Ulnar glide of the thumb
Improves thumb flexion
This is 1st CMC distraction - used often for those OA pts (intracapsular pathology = traction pairs well w/)
Thumb arthro
* note this is a saddle joint so the glide and slide are “interesting”
A dorsal glide of the thumb improves what motion?
Improves abduction of the thumb
A palmar glide of the thumb improves what motion?
Improves adduction
Radiocarpal slide and glide in opposite directions
* Convex on concave
I don’t think the ulna interacts w/ the carpal bones
Radiocarpal distraction
What glide is this?
* What does it help with? Why?
Palmar glide
The radiocarpal joint is convex on concave
So, during extension we have a dorsal roll and a palmar glide
* This palmar glide portion is what happens during extension - so doing a palmar glides helps w/ extension
Its named for the way you’re pushing
What kind of glide is this? (Note the palm is up)
* What movement does this help w/? Why?
Pushing toward dorsal side so its a dorsal glide (named for the way were pushing)
The radiocarpal joint is convex on concave. During flexion its a palmar roll and a dorsal glide
* So this being a dorsal glide helps w/ flexion
This is how radial / ulnar deviation works
* NOTE: were mostly focused on the proximal carpal bones on the radius
What kind of glide is this? What movement does it help w/? Why?
Radial glide
Radiocarpal joint is convex on concave (opposite)
Roll = radial
Slide = ulnar
Helps w/ Ulnar deviation
What kind of glide is this? What movement does it help w/? Why?
Ulnar glide
Radiovarpal joint is convex on concave (opposite roll and slide)
Roll = ulnar (duh)
Glide = radial (because they have to be opposites)
The elbow has a pathology that makes supination / pronation very painful. Originally you do a glide at the proximal radioulnar joint (primary place in the elbow for supination / proantion) and realize that its highly irritable and doesnt tolerate this movement well. What is the next joint you should move to to try and and improve supination / pronation?
Distal radioulnar joint
When doing a distal radioulnar mobilization an anterior glide of the radius is perofrmed. Does this promote supination or pronation?
improves pronation (do it yourself)
When doing a distal radioulnar mobilization a posterior glide of the radius is perofrmed. Does this promote supination or pronation?
Supination
KNOW: The radius is better to mobilize than the radius at the distal radioulnar joint because its bigger and performs most of the movement
KNOW: We still progressively load a hypomobile joint
* Yes, we obivously do need to adress the mobility deficits as well
* However, if someone cannot move a muscle through its correct ROM - they most likely are loading it incorrectly
* we want to get their muscles balanced correctly (we want things like finger flexion vs extension to be correctly balanced to where it should be comparitvely)
* we can work on opposition
* Grip types
* encourage pt to return to conditionoing / aerobic EX
* Potentially activity modificaiton
Whats stronger finger flexion or finger extension?
Finger flexion
KNOW: Post surgery pts will often have hypomobility
There are some hand surgeries that dont fuse anything but have a period of immobilization post op.
* maybe we do some partial ROM but we don’t want to stress it at all - we need to let it heal
* Because this immobilization adhesions can form between the tendons and the sheath (sticking together) or maybe we have scar tissue formation that can block movement or even potentaily a contracture
These are reasons we might have hypomobility post OP w/o a fusion
What is a synovectomy?
* Why is it used?
When synovial sheaths of tendons are removed of tendons in the hand
We would do this if the sheaths were chronically inflammaed (chronic tenosynovitits)
What is an arthroplasty in the hand?
* whats it used for?
Can really be done at any joint. Its used to relaive pain but not actually fuse the joint
What is a arthrodesis?
* whats it used for?
Fusion of a joint
Used to provide stability to a joint
This actualy spans multiple joints (very hypomobile)
What kind of repair was likely done here?
Extensor tendon repair
What is this surgery?
Carpal tunnel release
* NOTE: bad outcomes due to double crush syndrome likely being the cause OR neural health is so bad already that getting the pressure off didnt really help
What kind of repair was likely done?
Flexor tendon repair
This is how you should progress from post OP
Dont forget you can load prox and distal to the problematic area
Tendinopathies in the hand can occur because of:
* Repetitive use w/o opportunity to adapt (most common)
* RA (note RA is worse in distal extremitties so it really causes issues in the hand)
* Overloaded stress (traumatic) - think being in a situation that involves a lot more stress than most activites you need to do (think someone training for a marathon by doing short jogs then doing one traumatic massive run)
* Changes in tendon sheath - these can become inflamed and lead to a tendonpathy
There are lots of ligaments in the wrist - HOWEVER, they are named where its super easy to figure out based on their names
KNOW: W/ a wrist sprain ROM was taken to the extreme and the ligments were stress / torn
* In a non operature wrist sprain the tare is very minor or there is no tear at all
Typically w/ wrist sprains they’re going to have pain w/ stressing the involved ligament
* For example - if the triquetrocapitiate ligament was sprained there would be pain when i press / move the capiatete or the pisiform
* We would also likely see laxity (hypermobile) - espeically fi there is a tare or a rupture
KNOW: Whenever you have a flexor tendon pathology it is labled in a “zone” which will allow us to know what possible tendons were affected
For example if we stay “zone 1” we know that flexor digitorum superficialis is not affected (because it doesnt cross the DIP joint)
What bones are in zone 3?
Metacarpals
Which two zones are at risk for adhesions
zone 2/4
due to how close the tendons are packed together
Which zone is considered “no mans land” and has poor vascularization?
Zone 2
very poor healing time due to poor vascularization
This is a direct tendon repair or “end to end repair”
It is typically done when the tendon quality is good and there is a straight tear across
This is a tendon graft
Used when the tendon quality is poor or if the tare isnt straight across / frayed
* they cutt off all the frayeed ends before attaching
We typically use an autograft from the palmaris longus (makes sense its got the biggest amount of fascia at the end)
After a flexor tendon repair the wrist is allowed to go into about 30 degrees of extension but not full extension. but can do full wrist flexion
* we don’t want to stretch out the flexor tendons during extension
