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PHTY3120 > L23: Wrist & Hand Anatomy, Examination & Management Principles > Flashcards

L23: Wrist & Hand Anatomy, Examination & Management Principles Flashcards

1
Q

What are the 5 arthrology features of Wrist & Hand?

A
  1. 1st CMC joint is mobile for opposition
    • Mobile joints are more likely to wear out (arthritis) - 1st CMC joint
  2. 2nd & 3rd CMC joints are stable
  3. 4th & 5th CMC joints are mobile for grips
  4. Wrist used to be ball & socket joints. Evolution broke it up to 8 carpals for dexterity.
  5. Brachiation: Forearm pronation supination
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2
Q

What are the 4 nomenclature features of Wrist & Hand?

A
  1. Digit: Thumb (Th), index finger (IF), middle finger (MF), ring finger (RF), little finger (LF)
  2. Joints: CMC, MP, PIP, DIP
  3. Total active motion (TAM)
  4. Total passive motion (TPM)
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3
Q

What are the muscles of the wrist and hand?

A
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4
Q

What are the 3 tendons of the wrist and hand?

A
  1. Central slip
  2. Lateral slip joined with intrinsics
  3. Terminal slip
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5
Q

What are the 4 flexor tendon anatomy for the hand and wrist?

A
  1. FDS
  2. FDP
  3. Retinacular sheath
  4. Vincula brevis & longus
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6
Q

What are the 3 tendon excursion?

A
  1. FDP 32mm, FDS 24mm
  2. At DIP 1 mm excursion = 10° ROM
  3. At PIP 1.3 mm excursion = 10° ROM
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7
Q

What are the nerves of the wrist and hand?

A
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8
Q

What are 3 subjective examinations of the wrist and hand?

A

Majority of hand patients are traumatic/post-surgical. Some are overuse.

  1. Know the structures involved
  2. Know the healing timeframe
  3. Know how to assist healing
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9
Q

What are the 3 history of current injury in the subjective examination of the wrist and hand?

A
  1. Mechanism, force & duration of injury
  2. Time interval between injury and treatment
    • Early treatment is easier to manage
    • Late treatment has secondary issues
  3. Medical/surgical management
    • Structures damaged, repaired and technique
    • Good communication between surgeon and therapist
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10
Q

What are the 4 history of primary complaint in the subjective examination of the wrist and hand? What are the 3 outcome measures?

A
  1. Location, intensity & type of symptoms
  2. Behaviour of symptoms
  3. Hand dominance
  4. Occupation, social issues
  5. General health questions

Outcome measures: DASH, PRWE, VAS

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11
Q

What are 5 observations in the objective examination of the wrist and hand?

A
  1. UL & general posture screen
  2. Wounds, scars, lacerations
  3. Skin condition & colour: Red, shiny, dry
  4. Oedema
  5. Deformity, wasting

Reassure them if they are anxious to let you see the hand

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12
Q

What are 6 wound assessments in the objective examination of the wrist and hand?

A
  1. Location & size of wound
  2. Wound classification
  3. Types of wound
  4. Type of closure
  5. Inflammatory response
  6. Exudate
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13
Q

What are 4 wound classification in the objective examination of the wrist and hand?

A
  1. Black = Necrotic tissue
  2. Yellow = sloughy tissue
  3. Red = Granulation tissue
  4. Pink = Epithelial tissue
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14
Q

What are 2 types of wounds in the objective examination of the wrist and hand?

A
  1. Tidy: e.g. Clean surgical incision
  2. Untidy: e.g. Tissue loss +/- soft tissue coverage
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15
Q

What are 4 types of closure in the objective examination of the wrist and hand?

A
  1. Primary
  2. Delayed primary
  3. Secondary intention
  4. Closure: Sutures, staples, steri-strips etc.
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16
Q

What is the inflammatory response in the objective examination of the wrist and hand?

A

Normal or abnormal

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17
Q

What is the exudate in the objective examination of the wrist and hand?

A

Colour, amount, odour

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18
Q

What are 3 oedema assessments in the objective examination of the wrist and hand?

A
  1. No normal standards
  2. Location & type of oedema
    • Pitting or hard brawny oedema
    • Signs of infection
  3. Measurements
    • Circumferential measure around MCP, PIP etc.
    • Volumetric measure: Put hand in a jar of water, measure volume of water displaced (volume of hand) - uncommon
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19
Q

What are 5 palpation assessments in the objective examination of the wrist and hand?

A
  1. Skin temperature, sweating
    • Hand hot, sweating, shiny - SNS overdrive
  2. Scar tethering
  3. Hypersensitivity: Presence & location
  4. Muscle spasm
  5. Tenderness over tendons, tendon sheaths, joints
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20
Q

What are 5 ROM assessments in the objective examination of the wrist and hand?

A
  1. Measure AROM then PROM
  2. Hand goniometer dorsal placement
    • 5° inter-tester error
  3. American Society for Hand Therapists uses E/F
    1. Plus (+) to indicate hyperE
    2. Minus (-) to indicate loss of full E
    3. e.g. +15/110 means 15° hyperE. -15/110 means 15° loss of E
  4. If hand is stiff and cannot make a fist, then measure tip to distal palmar crease.
  5. Tenodesis effect: Wrist position affects finger tendons contraction
    • Wrist F + finger E
    • Wrist E + finger F
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21
Q

What are 3 tightness assessments in the objective examination of the wrist and hand?

A
  1. Intrinsic muscle tightness
  2. Extrinsic flexor tightness (FDP, FDS, FPL)
  3. Extrinsic extensor tightness (EDC, EI, EPL)
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22
Q

What are 2 intrinsic muscle tightness assessments in the objective examination of the wrist and hand?

A
  1. With MCP joint F, PIP and DIP can passively full F
  2. With MCP joint E, PIP and DIP cannot fully F
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23
Q

What are 3 extrinsic flexor tightness (FDP, FDS, FPL) assessments in the objective examination of the wrist and hand?

A
  1. With MCP joint F, PIP and DIP can passively E
  2. With MCP joint E, PIP and DIP cannot fully E
  3. With fingers E, then passive wrist E, the fingers will be pulled into F.
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24
Q

What are 3 extrinsic extensor tightness (EDC, EI, EPL) assessments in the objective examination of the wrist and hand?

A
  1. With MCP joint E, PIP and DIP can passively F
  2. With MCP joint F, PIP and DIP cannot fully F
  3. With fingers F, then passively wrist F flex the wrist, the fingers will be pulled into E.
25
Q

What are 3 muscle testing assessments in the objective examination of the wrist and hand?

A
  1. FDP quadriga effect: Each tendon of FDP is conjoined with each other. If one tendon is cut, it will affect the other tendons of FDP.
  2. FDS little finger: A separate FDS tendon to little finger allows isolated little finger PIP F. Conjoined FDS tendons do not a llow isolated little finger PIP F.
  3. Extensors: 6 compartments dorsally
    • First - AbPL, EPB •
26
Q

What are 3 peripheral nerves muscle testing assessments in the objective examination of the wrist and hand?

A
  1. Know the location of irritation/compression/injury of nerves
  2. Test 1 proximally and 1 distally innervated muscle for each nerve.
27
Q

What are the proximally and distally innervated muscles of the median nerve in the objective examination of the wrist and hand?

A

PROXIMAL: FCR

DISTAL: Abductor pollicis brevis

28
Q

What are the proximally and distally innervated muscles of the ulnar nerve in the objective examination of the wrist and hand?

A

PROXIMAL: FCU

DISTAL: Abductor digiti minimi: Abd both little fingers against each other. If one side collapses, it means weakness.

29
Q

What are the proximally and distally innervated muscles of the radial nerve in the objective examination of the wrist and hand?

A

PROXIMAL: ECRL

DISTAL: EPL

30
Q

What are 6 sensation testing assessments in the objective examination of the wrist and hand?

A
  1. Temperature recognition
  2. Tinel’s sign: Tap from distal to proximal - predict level of reinnervation distal to repair/injury.
  3. Pressure threshold test: Semmes Weinstein Monofilaments - determine light touch/deep pressure.
  4. Static two-point discrimination: Assess tactile gnosis
    • 2-4mm is normal
  5. Moving two-point discrimination: Greater ability to assess tactile gnosis
  6. Moberg’s pick up test: Pick up everyday objects with EO & EC, time taken measured.
31
Q

What are 4 purpose of sensation testing assessments in the objective examination of the wrist and hand?

A
  1. Aids in diagnosis - which nerve is involved
  2. Determines degree of denervation
  3. Prognostic hand function
  4. Determine appropriate rehab
32
Q

What are 5 grip and pinch strength testing assessments in the objective examination of the wrist and hand?

A

Grip strength

  1. Standard assessment
  2. Jamar dynamometer
  3. Second handle position
  4. Shoulder add, elbow F 90°, forearm & wrist neutral
  5. Average of 3 trials, compare with other side

Pinch strength

33
Q

What are 2 functional assessments in the objective examination of the wrist and hand?

A
  1. ROM, strength, sensation tests do not always correlate with functional abilities.
  2. Hand function has 4 usage patterns
34
Q

What are 3 “ROM, strength, sensation tests do not always correlate with functional abilities” assessments in the objective examination of the wrist and hand?

A
  1. Questionnaires: e.g. DASH
  2. Observation
  3. Functional tests: e.g. Nine hole test
35
Q

What are 4 “usage patterns of hand functional” assessments in the objective examination of the wrist and hand?

A
  1. Finger-thumb prehension: Tips, lateral, 3-point
  2. Full hand prehension: Power, cylinderical
  3. Non-prehension: Pushing objects
  4. Bilateral prehension: Using both palms
36
Q

What are 3 characteristics in the Healing Timeframes in the management of wrist and hand?

A
  1. Vital for clinical reasoning
  2. Know the healing timeframes for bone, tendon, nerve etc.
  3. Majority of wrist & hand injuries are traumatic/post-surgical.
37
Q

What are the 4 healing stages?

A
38
Q

What is the timeframe, cellular process (2) and management of inflammation in the management of the wrist and hand?

A

TIMEFRAME:

  • 0-48 hours

CELLULAR PROCESS

  • Vascular response, phagocytosis
  • Negligible wound strength

MANAGEMENT:

  • Rest, elevation, oedema control
39
Q

What is the timeframe, cellular process and management of proliferation in the management of the wrist and hand?

A

TIMEFRAME:

  • 12 hours - 10 days

CELLULAR PROCESS:

  • Migrate & bridge wound edges

MANAGEMENT:

  • Rest, elevation, oedema, light exercise
40
Q

What is the timeframe, cellular process and management of fibroplasia in the management of the wrist and hand?

A

TIMEFRAME:

  • 4-28 days

CELLULAR PROCESS:

  • Collagen deposition

REMODELLING:

  • Exercise, oedema control, function
41
Q

What is the timeframe, cellular process and management of remodelling in the management of the wrist and hand?

A

TIMEFRAME:

  • 1 month - 2 years

CELLULAR PROCESS:

  • Scar maturation, reshaping and reforming

MANAGEMENT:

  • Exercise, manual techniques, function
42
Q

What are 4 wound management of the wrist and hand?

A
  1. Appropriate wound dressing post-op
    • Minimal bulk
    • Moist environment
    • Many types of dressings available, important to know the appropriate dressing for different wounds
    • e.g. Alginate dressings for bleeding wounds
    • e.g. Silver dressings have anti-microbial properties
  2. Prevent & control infection
  3. Minimise mechanical influences
    • Oedema, tension, necrotic tissue
  4. Scar management
43
Q

What are 4 positions of safe immbolisation (POSI) in the management of the wrist and hand?

A
  1. Wrist F 30° + MCP joints F 60° + IP joints max E + Thumb abd
    • MCP collateral ligaments are lengthened (taut) in F and shortened (lax) in E, so we want to immobilise in MCP F.
    • PIP volar plates are tightened in F, so we want to immobliise in PIP E.
  2. Place hand in POSI to minimise hand contracture & tightness.
  3. May immobilise the whole hand, or just some fingers
  4. POSI unless contraindicated: e.g. After nerve or tendon repair
44
Q

What are 2 oedema management of the wrist and hand?

A
  1. Oedema management ensures maximal healing and return to function.
  2. Excessive oedema can limit wound healing and develop stiffness.
45
Q

What are 6 preventions of odema in the management of wrist and hand?

A
  1. Gentle decline in elevation from hand to shoulder
  2. Early AROM and tendon gliding exercises
  3. Cold packs
  4. Compression
  5. Manual oedema mobilisation (effleurage)
  6. Contrast bathing: 1 minute in warm water, 1 minute in cold water - vasodilation & vasoconstriction (limited evidence)
46
Q

What are 7 types of compression techniques to prevent oedema in the management of the wrist and hand?

A
  1. Short stretch bandages
  2. Tubular elastic bandages
  3. Coban bandage sticks to itself, elastic
  4. Lycra finger stall
  5. Isotoner gloves
  6. Pressure garments
  7. Chip bags for brawny oedema: Bags filled with little foam balls - undulating pressure promotes lymphatic flow.
47
Q

What are 3 ways to make a fist in the management of the wrist and hand?

A
  1. Flexor dominant - IP F
  2. Intrinsic dominant - lumbricals + long finger flexors
  3. Both - MCP & IP F
48
Q

What are 5 therapeutic exercises in the management of the wrist and hand?

A
  1. The hand is a like sponge - squeeze and tap the oedema out of hand
  2. Tenodesis effect: Wrist E is easier to make a fist.
  3. Encourage and reassure patients that making a fist is safe and beneficial
  4. Care with passive exercise! Do not force movements as it can lead to pain, swelling and more stiffness.
    • Gradually improve movements with passive holding
  5. Exercise is contraindicated with fractures
49
Q

What are 5 common hand exercises in the management of wrist and hand?

A
  1. Extensors
  2. Lumbricals - table top
  3. Claw
  4. Long fist FDS
  5. Tight fist FDP
50
Q

What are 4 manual therapy techniques in the management of wrist and hand?

A
  1. Manual therapy is for stiffness rather than pain
  2. Care with passive mobilisation
  3. Must not cause post-treatment pain or swelling
  4. Must consider wrist & hand anatomy & biomechanics
51
Q

What are 4 scar management techniques in the management of wrist and hand?

A

Scar can significantly impede gliding and function of hands due to pain and reduced ROM.

  1. Scar massage (from >21 days): Circular motions facilitate movement of tissue under scar
    1. 5 minutes, 4-5x a day
  2. Thermal agents for comfort
  3. Electrotherapy - rarely
  4. Silicone products prevent hypertrophic scarring by hydrating the scar and applying light pressure: e.g. Cica care, otoform
52
Q

What are 2 desensitisation techniques in the management of wrist and hand?

A
  1. Any scar can become hypersensitive, especially in hands.
  2. Desensitisation aims to gradually increase the tolerance to tactile stimulation in areas of hypersensitivity
53
Q

What are the 5 features in the desensitisation progream in the management of wrist and hand?

A

Find a tolerable stimulus that provokes hypersensitivity. Apply stimuli 5 -10 minutes, 3-4x a day.

  1. Textures
  2. Immersion particles
  3. Maintained pressure
  4. Temperature changes
  5. e.g. Immerse hand in raw rice > peas > pasta shells
54
Q

What is sensory re-education in the management of wrist and hand?

A

Sensory re-education is to learn to interpret the pattern of abnormal sensory impulses generated after an interruption in PNS.

55
Q

What are 5 sensory re-education if patient cannot feel touch (no protective sensation) in the management of wrist and hand?

A
  1. Maintain cortical representation
    • Remember what it was like to touch
    • Mental imagery
    • Describe touch
    • Look at touch
    • Mirror box
  2. Avoid heat (smoking), cold, sharp objects, excessive force
  3. Change tools frequently
  4. Observe skin for signs of stress
  5. Skin care: Soaking, oil, care for blisters etc.
56
Q

What are 4 sensory re-education if patient can feel touch in the management of wrist and hand?

A
  1. Discriminate various textures
  2. Discriminate various sized objects
  3. Find objects in bowl of rice, sand etc.
  4. Do with EO, EC, EO
57
Q

What are the 5 purposes of splinting in the management of wrist and hand?

A
  1. Protect and promote healing
  2. Maintain optimal anatomic position.
  3. Restrict/control motion.
  4. Improve ROM
  5. Promote function
58
Q

What are 3 features when making splints in the management of wrist and hand?

A
  1. Splints are made of thermoplastic materials
  2. Immerse it in water, it softens, shape and mould it to hand
  3. Expensive
59
Q

What are 3 features of functional integration in the management of wrist and hand?

A
  1. A&E to promote ADLs - start simple then progress
  2. Provide aids & appliances
  3. Facilitate RTW and SDP for work injuries
  4. Organise work site visit, suitable duty plan recommendations

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