Hands and finger 2 Flashcards
phalangeal #
- unstable if shaft or transverse fracture
1. Distal phal. fractures = usually involve crush injuries w/ lots of pain & swelling
2. Boxer’s Fracture = metacarpal head fracture - most common fracture in the hand after the scaphoid
•punch to a wall rather than to a person
Mx - conservative
• Best to treat conservatively and w/out surgery to prevent interrupting soft tissue
• Immobilise for 4 weeks with hand based POSI splint/POP
• Splint involved digit AND adjacent digit
o Splint to immobilise the joints proximal and distal to the fracture
- Oedema control = coban
Conservative • reduction o Boxer’s: splint to facilitate reduction and to prevent MCP extension stiffness and prevent ulnar collateral ligament from tightening ♣ Malunion can lead to extensor lag • splinting
o distal phalanx fracture
♣ 3 weeks
MT
• AROM depending on stability
Surgical
• indicated if reduction is not successful or if there is rotation present (pictured)
• If ORIF, early active movement is often allowed
o In this case, use the POSI splint further protect the ORIF (remove for exercises)
Stable fracture Mx • resting extension splint • active motion as stability improves • buddy strap • oedema control
DUPUYTREN’S DISEASE
- inherited proliferative connective tissue disorder of palmar fascia (which becomes hyperplastic)
- scarring causes finger contractures
- more common in caucasians, males, 40+ y/o
Ax:
able to flx but not extend fingers. Aching and possible itching
Observe:
• Observation: Puckering, nodules in the palm, distortion of the skin, Curled fingers, Presence of knuckle pads
• Movement exam - Palmar fascia plays a vital role in gripping - dec. grip
• Positive tests: Table top test if bigger than 1/2cm
Mx:
Early stages
• Radiation therapy
• Then needle aponeurotomy, collagenase Injection (Xiaflex)
Sx
• if have fixed flx deformity
• If people aged 30-40 have surgery, it will come back again
• Not optimal because the contracture will return and be BIGGER
• Post-operation often require pressure garments or splints
o Tendency for fingers to go back into flexion
Post-operative physiotherapy • Maintain finger extension o Static or dynamic splints o Tendon gliding? o CPM or gentle passive ROM o Reduce swelling to prevent post operative stiffness
Prognosis
Has a high recurrence rate
FLX TENDON SYNOVITIS
Inflammationof thefluid-filled sheath (synovium) that surrounds a tendon.
- genetic, repeated hand-tool uses, RA
• Complains of
o Pain, swelling and difficulty moving the particular joint where the inflammation occurs
o Fingers are ‘stuck’ in a flexed position
Ax
• Palpation: Doughy swelling over tendon sheath
• Movement exam: Impaired active flexion
- Passive flexion > active flexion (Active insufficiency)
Mx
Decrease pain -NSAIDs, ice
Early active mobilisation
1. 0-6 weeks: dorsal blocking splint
- Wrist in 0-10 degrees flexion, MCPs 70-90 degrees flexion and PIP/DIP at 0 degrees extension
• Week 1: (in the splint) hourly x 10 reps of passive finger flexion and the active extension to the splint & 10x active gentle1/3 fist hourly
• Week 2: as above plus 10x gentle half fist hourly
• Week 3: as above and 10 x gentle ¾ fist hourly
• Week 4: as above and 10x gentle full fist hourly
• Week 6: commence splint wean
- Rubber bands pull fingers into flexion passively preventing active flexion to allow tendon repair
o RARELY DONE now in QLD**
DRUJ fractures
- Predominantly females aged 60-70 from a FOOSH
- also high energy injury in younger people (fall from a height)
- Compression (axial loading) however rare
• Eponyms
o Colles’ fracture: = dorsal/anterior and radial displacement of the wrist and hand.
o Smith’s fracture: reverse Colle’s with a volar displacement
o Barton’s fracture: a displaced, unstable articular fracture subluxation with carpus following
Ax
Observation: Possible deformity, Swelling
• Palpation: Extremely tender on palpation
o Loss of wrist motion (mainly due to pain)
* xray confirmation
DRUJ fractures Mx
Surgical
• Obtain a good reduction maintain a good reduction (while loading) early motion as fracture stability allows
Conservative
• Immobilisation for non-displaced fractures
• Ligamentotaxis: closed reduction pins and plaster external fixation
• Percutaneous pinning: haywires holding it in place
• ORIF +/- bone grafting
Rehabilitation: early therapy 1. Oedema control o Compression and elevation o Hand ROM o Shoulder and elbow ROM o Wrist mobilisation as soon as fracture healing allows o Splint to support and rest fracture
Possible complications • Significant malunion = Stiffness, OA, pain • Carpal tunnel syndrome • TFCC tears • EPL rupture • Complex regional pain syndrome type 1
Therapy (mobilisation) • Active wrist ROM o Check # stability and type of movement required - esp wrist ext w/ fingers in grip position o Independent wrist extension o Supination ROM • Passive wrist ROM o Passive stretches o Manual therapy techniques o CPM: continuous passive motion (machine that moves you)
Complex Regional Pain Syndrome
- A sympathetic vasomotor dysfunction characterised by very severe pain, swelling, stiffness and discolouration
• Allodynia
• Three stages
- Acute: pain, swelling, red, sweating, heat, stiffness
- Subacute: continued pain and stiffness, organised oedema, decreased redness
- Chronic: very stiff, reduced pain.
• 2 types
more common in Women, Prior mobilisation in a tight cast, or followig radial fracture (22%-39%)
Patient history: Sensory motor and autonomic abnormalities
Complex Regional Pain Syndrome Ax
Physical examination
No objective findings - hard to diagnose
Diagnostic tools: Budapest criteria
♣ Patient fulfils at least 2 signs (sensory, vasomotor, edema) and ¾ symptom categories (sensory, vasomotor, oedema, motor/trophics)
• What is seen in the three stages
o Acute: pain, swelling, red, sweating, heat, stiffness
o Subacute: continued pain and stiffness, organised oedema, decreased redness
o Chronic: very stiff, reduced pain.
Complex Regional Pain Syndrome Management
Management Aims - Reduce pain and swelling (DO NOT INCREASE) - Improve function - Improve mobility, ‘well body’, stress management - Requires multidisciplinary team - Improve patient’s QOL Be hands on!
Therapy • Laterality cards • Mirror therapy • Gentle active exercise • NO PASSIVE EXERCISE - Will only increase pain and swelling • Contrast bathing • Functional use of hand • Shoulder and elbow ROM • TENS • Splinting? – protective
Complex Regional Pain Syndrome Management pt 2
Graded motor imagery
• Involves 3 stages. 1st = distinguish between left and right. 2nd = imagined hand movements. 3rd = is mirror therapy. (Lv.1&2 evidences)
Pharmacological approach
• antidepressants, anticonvulsants and capsaicin
Multidisciplinary approach
• physiotherapy
• advice and education
• cognitive behavioural therapy
Invasive Mx
• spinal cord stimulation, sympathectomy
Prognosis:
• CRPS patients respond well to conservative treatment, 74% CRPS I cases would resolve
• Smokers have poor prognosis in comparison to those who doesn’t smoke
