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PHTY3120 > L24: Wrist and hand pain, injury and pathology > Flashcards

L24: Wrist and hand pain, injury and pathology Flashcards

1
Q

What are the 5 zones of the flexor tendons (flexor tendon injuries)?

A
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2
Q

What are the 3 repairs of the tendon in the wrist and hand?

A
  1. Primary repair: Sew two ends of tendon together
    1. Done within a few days of injury
  2. Delayed repair
  3. Secondary repair: Two-stage surgery
    1. Tendon graft

Minimum 4 strands of suture

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3
Q

What are the 6 strengths of tendon repair in the wrist and hand?

A
  1. 1-20 days: Dependent of suture material and type of repair
  2. 1-10 days: Strength decreases, minimum at 5 days
  3. 3-6 weeks: Strength increases
  4. 12 weeks: Full strength
  5. Strength is proportional to number of suture strands that cross repair site.
    • e.g. 2 strand = 1800 g. 6 strand = 5400 g.
  6. Every tendon heals differently
    • e.g. Rotator cuff tendon tolerates no load till 12 weeks because it needs to heal to bone.
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4
Q

What are the 2 types of healing in the wrist and hand?

A
  1. Extrinsic healing
  2. Intrinsic healing
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5
Q

What are 3 features of extrinsic healing in the wrist and hand?

A
  1. Ingrowth of fibroblasts
  2. Scars with tendon sheath & surrounding structures (e.g. Fascia, skin etc.)
  3. Increased adhesions, decreased mobility
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6
Q

What are 2 features of intrinsic healing in the wrist and hand?

A
  1. Intratendinous blood supply
  2. End to end tendon fibroplastic activity
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7
Q

What are 4 things that healing motions lead to in the wrist and hand?

A
  1. Faster recovery of strength
  2. Less adhesions
  3. Improved tendon excursion
  4. We want motion, but must be careful!
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8
Q

What are 7 factors that postoperative management depends on for flexor tendon injury for the wrist and hand?

A
  1. MOI: Clean, jagged
  2. Surgeon’s preference
  3. Type & position (zone) of repair
  4. Condition of tendon: Amount of tension on repair
  5. Other tissues involved: e.g. Digital nerve, artery?
  6. Rate and quality of scar formation
  7. Patient age, general health, social influences
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9
Q

What are 4 goals of postoperative management for flexor tendon injury in the wrist and hand?

A
  1. Restore maximal active flexor tendon gliding by preventing
    • Tendon rupture
    • Scarring with adhesions
  2. Prevent flexion contractures
  3. Maintain F ROM of all uninvolved joints
  4. Return to previous level of function
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10
Q

What are 3 main postoperative management approaches for flexor tendon injury in the wrist and hand?

A
  1. Immobilisation - rare
  2. Early passive mobilisation
  3. Early active mobilisation
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11
Q

What are are 4 characteristics of the splint for postoperative management approaches (Early Passive Mobilisation) for flexor tendon injury in the wrist and hand?

A

Splint (0-6 weeks) applied to fingertips to hold the fingers in passive F

  1. Dorsal thermoplastic
  2. Wrist 10-25° F
  3. MCP 45-60° F
  4. +/- Rubber band traction
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12
Q

What are the timeframes (Wk1-4, 3-4, 6, 8-12) of the early passive regime (example protocol) for postoperative management approaches for flexor tendon injury in the wrist and hand?

A
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13
Q

What are is the postoperative management approaches (Early Active Mobilisation) for flexor tendon injury in the wrist and hand?

A

Active contraction of the involved flexor with caution and within prescribed limits

  • Controlled Active Motion (CAM) program
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14
Q

What are the 3 features that the Controlled Active Motion (CAM) program is depended on for postoperative management approaches (Early Active Mobilisation) for flexor tendon injury in the wrist and hand?

A
  1. Good repair - minimum 4 strands
  2. Early referral to therapy
  3. High patient compliance
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15
Q

What are the 5 features of the splint to prevent stretching tendons for postoperative management approaches (Early Active Mobilisation) for flexor tendon injury in the wrist and hand?

A
  1. Dorsal thermoplastic
  2. Wrist neutral
  3. MCP 60° F
  4. IP full E
  5. +/- Protective bar
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16
Q

What are the 3 tendon gliding exercises for postoperative management approaches (Early Active Mobilisation) for flexor tendon injury in the wrist and hand?

A
  1. Fist: Max FDP excursion
  2. Straight fist: Max FDS excursion
  3. Hook: Max differential glide, much more FDP than FDS
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17
Q

What are the timeframes (Wk1, 2, 3-4, 5-6, 7, 8, 12) of the early active regime (example protocol) for postoperative management approaches for flexor tendon injury in the wrist and hand?

A
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18
Q

What are the 7 extensor tendon zones in the postoperative management approaches for extensor tendon injuries in the wrist and hand?

A
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19
Q

What are the 4 characteristics of Mallet Finger (Zone 1-2) in the postoperative management approaches for extensor tendon injuries in the wrist and hand?

A
  1. Disruption of extensor tendon at DIP
  2. MOI: Forceful passive DIP F + resisted E
  3. S&S: Pain, swelling, drop in DIP, cannot actively DIP E
  4. Can involve bony fragment +/- surgery
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20
Q

What are 8 conservative management of Mallet Finger (Zone 1-2) in the postoperative management approaches for extensor tendon injuries in the wrist and hand?

A
  1. Effective ≤3 months post injury
  2. Immobilise DIP in 5-15° hyperE all the time for 6-8 weeks.
    • This tendon does not need to glide much - easier to treat
  3. Splint don & doff: Once a week doff, check skin, re-don
  4. Skin care
  5. ROM of other joints
  6. If swan neck deformity, may need to incorporate PIP joint
  7. At 6-8 weeks: Gentle active F, wean from splint
  8. If lag develops, re-splint and delay exercises for a few weeks
21
Q

What is the aim of microsurgery for nerve lacerations in the postoperative management approaches in the wrist and hand?

A

Microsurgery aims to sew the nerve sheath as accurately as possible

22
Q

What is the main healing timeframe for nerve lacerations in the postoperative management approaches in the wrist and hand?

A

Nerve sheath takes 3-4 weeks to gain sufficient strength to withstand stress

23
Q

What are 3 reasons for splinting for nerve lacerations in the postoperative management approaches in the wrist and hand?

A
24
Q

What are the management and exercise for healing timeframes (Wk 0-3-4, 3-4+) for nerve lacerations in the postoperative management approaches in the wrist and hand?

A
25
Q

What are 4 features of median nerve distal lesion (nerve lacerations) in the postoperative management approaches in the wrist and hand?

A
  1. Ape hand
  2. Loss of web space
  3. Muscles: FPB, OP, ABP, Lumbricals 1-2
    • Cannot oppose thumb
    • Loss of chuck pinch
    • Decreased power grip
  4. Sensation+++
26
Q

What are 3 features of ulnar nerve distal lesion (nerve lacerations) in the postoperative management approaches in the wrist and hand?

A
  1. Claw hand
  2. Flattened metacarpal arch
  3. Muscles: ADM, FDM, ODM, Interossei, Lumbricals 3-4, AP, FPB deep head
    • Loss of lateral pinch
    • Froment’s sign: Pinch paper between the thumb and index finger. Examiner pulls the paper out. Weakness of the adductor pollicis (ulnar nerve) will keep IP joint E. Adductor pollicis is compensated by FPL which cause IP joint hyperE.
    • Decreased power grip
27
Q

What are 4 muscles and 3 actions affected in a median nerve distal lesion (nerve lacerations) in the postoperative management approaches in the wrist and hand?

A

Muscles:

  1. FPB
  2. OP
  3. ABP
  4. Lumbricals 1-2

Actions:

  1. Cannot oppose thumb
  2. Loss of chuck pinch
  3. Decreased power grip
28
Q

What are 7 muscles and 3 actions affected in an ulnar nerve distal lesion (nerve lacerations) in the postoperative management approaches in the wrist and hand?

A

Muscles

  1. ADM
  2. FDM
  3. ODM
  4. Interossei
  5. Lumbricals 3-4
  6. AP
  7. FPB deep head

Actions

  1. Loss of lateral pinch
  2. Froment’s sign: Pinch paper between the thumb and index finger. Examiner pulls the paper out. Weakness of the adductor pollicis (ulnar nerve) will keep IP joint E. Adductor pollicis is compensated by FPL which cause IP joint hyperE.
  3. Decreased power grip
29
Q

What is the main complication of crush injuries in the postoperative management approaches in the wrist and hand?

A

gross oedema (due to burst cells).

30
Q

What are 2 features as a result of gross oedema of crush injuries in the postoperative management approaches in the wrist and hand?

A
  1. Cause fibrosis and adhesion formation
  2. Long time to rehab
31
Q

What are 4 crush injury postoperative managements approaches in the wrist and hand?

A
  1. Oedema control +++
  2. Pain: Ensure adequate analgesia
  3. Stiffness: Exercise, heat, splintage
  4. Gradual strength & endurance
32
Q

What are 8 features of amputations in postoperative managements approaches in the wrist and hand?

A
  1. Wound management
  2. Oedema control and stump shaping
  3. Hand and finger ROM - begin early
  4. Scar management
  5. Desensitisation
  6. Functional use
  7. Psychological aspects
  8. Prosthesis for cosmetic reasons - not really functional
33
Q

What are 4 types of finger rheumatoid arthritis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. MP ulnar drift and palmar subluxation
  2. Boutonnière
  3. Swan neck
  4. Mallet finger
34
Q

What are 2 types of thummb rheumatoid arthritis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Boutonnière
  2. Swan neck
35
Q

What are 3 deformities of Boutonnière (RA) in postoperative managements approaches in the wrist and hand?

A
  1. PIP F
  2. DIP hyperE
  3. +/- MP hyperE
36
Q

What are 3 deformities of Swan neck (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Increased MP F
  2. PIP hyperE
  3. DIP F
37
Q

What are 4 causes of Boutonnière (RA) in postoperative managements approaches in the wrist and hand?

A
  1. PIP joint capsule becomes lax
  2. Central extensor tendon is stretched - PIP F
  3. Lateral bands move volar to PIP joint axis - DIP hyperE
  4. Oblique retinacular ligaments shorten
38
Q

What are 4 causes of Swan neck (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Flexor tenosynovitis
  2. PIP joint capsule, volar plate & collateral ligament become lax
  3. Lateral bands move dorsal to joint axis
  4. Oblique retinacular ligament lengthen
39
Q

What are 4 goals of rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Identify stage of RA: Acute, subacute, chronic?
  2. Reduce inflammation & pain
  3. Maintain stability & mobility
  4. Maintain or improve muscle-tendon function
40
Q

What are 6 managements for acute rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Rest
  2. Proper positioning to prevent contractures
  3. Gentle ROM exercise
  4. Cold therapy
  5. Education
  6. Oedema glove if required
41
Q

What are 8 managements for subacute rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Increase exercise and Activity as tolerated
  2. No resisted exercise if inflammation
  3. Isometrics in neutral position especially intrinsics
  4. Hand exercises
    • Wrist supination, neutral E
    • EDC action
    • Radial deviation of fingers
    • Thumb IP flexion
    • Independent FDS and FDP
    • Intrinsic muscle stretching
  5. Joint protection & energy conservation
  6. Splinting
  7. Oedema glove if required
  8. Heat
42
Q

What are 6 hand exercises for managements for subacute rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Wrist supination, neutral E
  2. EDC action
  3. Radial deviation of fingers
  4. Thumb IP flexion
  5. Independent FDS and FDP
  6. Intrinsic muscle stretching
43
Q

What are 4 managements for chronic rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Joint protection
  2. Exercises to increase strength & endurance
    • Isometric
    • Gentle progressive resistance
  3. Education
  4. Splintage
44
Q

What are 2 exercises to increase strength and endurance as management for chronic rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Isometric
  2. Gentle progressive resistance
45
Q

What are management for chronic rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Respect for pain
  2. Avoid deforming positions
  3. Use stronger larger joints when possible
  4. Avoid prolonged positions: e.g. Static grip
  5. Avoid repeated jarring of joints
  6. Distribute the load
  7. Use adaptive equipment: e.g. Larger handles
  8. Balance work and rest
46
Q

What is reflex sympathetic dystrophy (CRPS Type I) for rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A

is a sympathetic vasomotor dysfunction characterised by severe pain, swelling, stiffness and dis colouration

47
Q

What are the 3 stages of reflex sympathetic dystrophy (CRPS Type I) for rheumatoid arthristis (RA) in postoperative managements approaches in the wrist and hand?

A
  1. Acute: Pain, stiffness, swelling, red, sweating, heat 2.
  2. Subacute: Pain, stiffness, organised oedema, decreased redness
  3. Chronic: Severe stiffness, reduced pain
48
Q

What are 9 managements of reflex sympathetic dystrophy (CRPS Type I) in postoperative managements approaches in the wrist and hand?

A
  1. Laterality cards
  2. Mirror therapy
  3. Gentle active exercise
  4. No passive exercise as it will increase pain & swelling
  5. Contrast bathing?
  6. Functional use of hand +++
  7. Shoulder & elbow ROM
  8. TENS
  9. Splinting - protective
49
Q

What are 4 goals of managements of reflex sympathetic dystrophy (CRPS Type I) in postoperative managements approaches in the wrist and hand?

A
  1. Reduce pain & swelling
    • Ensure adequate pain relief
  2. Improve function
  3. Improve mobility
  4. Requires MDT

PHTY3120 (29 decks)

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