Lecture 15: Wrist & Hand Conditions Flashcards
Colles fracture
- fracture of distal end of radius with dorsal displacement
- +/- ulnar fracture
Etiology of Colles fracture
- older adults
- female > male
- FOOSH (Fall on outstretched hand)
Colles fracture and lunate
- lunate acts as a wedge to sheer the distal 2cm of the radius
- body momentum causes the fragment to displace radially and posteriorly
Colles Fracture Exam findings
- general loss of A/PROM from immobilization; capsular pattern (equal limitations in flexion and extension)
- may lose some shoulder ROM
- rarely heals without some malalignment – loss of full ROM (flexion, UD, pronation)
Ulnar variance
relative lengths of the distal articular surfaces of the radius on the ulna
Positive ulnar variance
“longer” ulna
Negative Ulnar variance
“shorter” ulna
Colles Fracture - Rx implications
- consider ROM goals - inquire about alignment
- ROM/accessory motion restrictions - 2deg immobilization
- strengthening
- functional activities
- look for median nerve compression, vascular disturbances, or other complications
smith fracture
-distal radial fracture with volar/palmar displacement of fragment
Rx implications of smith fracture
similar to colles fracture
Scaphoid fractures/lunate dislocations etiology
- similar mechanism to colles fracture
- 20-30y.o male
If the radius is strong, a fall tends to fracture the: s
scaphoid or dislocate the lunate
What to note for a scaphoid fracture
-poor blood supply to the scaphoid
Common presenting symptoms for scaphoid fracture
- pain
- localized tenderness in anatomical snuff box
- loss of thumb function
- palpation changes of lunate
- mm spasm with PROM
Treat implications for scaphoid fracture
- Rx swelling agressively
- watch for healing regularly
- A/PROM (after immobilization)
Hand Fractures
- Bennett’s Fracture (2deg ABD)
- Boxer’s fracture (metacarpal fracture of 4th metacarpal)
Ulnar collateraal ligament tear AKA
- Skier’s thumb
2. Gamekeeper’s thumb
Other ligamentous injuries of the hand
PIP and DIP collateral ligaments
Ligamentous injury treatment considerations
- joint protection/rest (splinting/buddy taping)
- minimize stress to tissues
- Progress Rx through stages of healing as appropriate
Tendinopathy etiology
- repetitive use or eccentric strain of wrist/forearm mm
- results in micro-damange, usually at musculo-tendon junction
- tissue response to stress/fatigue
common tendinopathy impairments
- pain when involved mm is stretched or contracted v resistance
- increased pain after exercise activity of wrist/hand
- decreased strength, endurance
- decreased grip strength
- tenderness to palpation
DeQuervain’s syndrome Tenosynovitis etiology
inflammation and swelling of the synovial lining of the common sheath of the APL and the EPB in the first dorsal compartment
often insidious; may be due to trauma or reptitive irritation
DeQuervain’s syndrome presenting symptoms
- tenderness over radial styloid
- pain with thumb movements (grasping, writing)
DeQuervain’s syndrome pertinent exam findings
- pain with resisted thumb extension and abduction
- mild swelling
- tenderness over anatomical snuff box
- (+) Finkelstein’s
DeQuervain’s syndrome Treatment implications
- conservative vs. surgical
- splinting
- AROM - gentle resisted motion
Pronator teres syndrome
- compression of the median nerve between heads of the pronator teres (or fib. arch of FDS)
- wrist/finger flexor weakness
- hand symptoms (CTS)
Carpal tunnel syndrome pertinent exam findings
(+) Tinel's Sign (+) Phalens (+) EMG Median. N tension sign Thenar mm. atrophy Lumbrical weakness
carpal tunnel etiology
-increased pressure in the tunnel
carpal tunnel etiology
- increased pressure in the tunnel
- trauma
- pregnancy
- unknown causes
- collagen disease
- Hereditary
Carpal tunnel syndrome common presenting findings
- pain/numbness radial sign of hand
- sensory changes with prolonged use
- worse at night (position)
- decreased prehension/clumsiness
Ulnar nerve compression
-compression of the ulnar nerve within Guyon’s tunnel
-parasthesia of ulnar 1 1/2 fingers
-weakness of muscles innervated by ulnar nerve
-may lead to deformities of the hand in chronic cases
Rx: similar to CTS
Osteoarthritis onset
later decades
Osteoarthritis symptoms
- pain with nodular swelling of distal fingers (H nodes)
- joint instability
Most common place for osteoarthritis
1st CMC. DIPs
Rheumatoid Arthritis etiology
age 20-40
female> male
+RA factor
RA presentation
- involvement of synovial membrane
- multiple joints with exacerbations and remissions
- deformities 2deg instability and muscle imbalance
RA classic hand signs
- ulnar deviation
- Boutonniere deformity
- Swan Neck deformity
- Z shaped thumb
- MCP subluxation
Common sites for RA
- MCP
- PIP
- wrist
Bacterial Arthritis
occurs after bites, wounds, septicemia
- pain exacerbated by movement
- local pain and swelling
bacterial arthritis RX
- antibiotics
- joint aspirations
Raynaud’s Disease
- idiopathic vascular disorder
- intermittment pallor or cyanosis
- cold, mottled, painful hand
- dont tolerate temp changes
Raynaud’s disease implications
- don’t rx with cold
- check vascularization (allen’s test)
- facilitate increased blood flow with muscle pumping exercises
complex regional pain syndrome (CRPS)
Reflex Sympathetic Dystrophy (RSD)
Etiology
- exact mechanism is poorly understood
- usually a preceding event like a: fracture, trauma to nerve, prolonged edema, and immobilization
- alteration cutaneous innervation following injury
- peripheral - increased substance P and bradykinin
- central - increased substance P, bradykinin, glutamate in SC
- females > males (2-4:1)
- all ages, peak 50-70
CRPS (Stamp)
- sensory: allodynia, hypo/hyperalgesia, hypo-hyperesthesis
- trophic: hair, nails, skin changes
- autonomic: swelling, sweating, edema
- motor: weakaness, contractures, atrophy
- Pain
CRPS characteristics
- usually starts distally and spreads proximally
- intense prolonged pain
- disproprtionate to inciting event
- vasomotor disturbances (bluish skin color or shiny red discoloration)
CRPS treatment implications
- whatever it takes (trial and error)
- distraction and weight bearing
- desensitization (rubbing affected limb gently with cloth)
- early active mobilization
- functional and fine motor exercises
- adapt to severity of disease
- below pain threshold
sympathetic block
spinal cord stimulator
medications: steroid, pain patch, opioids
Ganglion cysts
- after trauma to wrist joint capsule, the synovium may herniate to form a ganglion cyst
- greatest pain with extension
- tenderness over scapho-lunate intervala
Swan-neck deformity
- hyper-extension of the PIP
- flexion of the DIP
- 2deg contraction of intrinsic muscles & laxity of PIP joint
- common with RA or after trauma
Boutonniere Deformity
- MCP and DIP extension
- PIP flexion
- rupture of the central tendinous slip of extensor hood
- common with RA
Claw fingers/hand
- MCPs are hyperextended and PIP/DIP are flexed
- loss of intrinsic muscle action (ulnar nerve)
Ape hand deformity
-thumb falls back in line with fingers
Pt unable to flex thumb
wasting of thenar eminence 2deg median and ulnar nerve palsy
Ulnar drift
- ulnar deviation of the digits due to weakening of the capsular/ligamentous structures of the MCP joints
- common with RA
Mallet finger
- ruptrue or avulsion of the extensor tendon where it inserts in the distal phalynx
- distal phalanx rests in flexion
splint in extension
Trigger finger
- thickening of tendon flexor sheath causes “sticking” of tendon as pt. attempts to flex finger
- usually occurs in 2nd adn 3rd digits
Dupuytren’s Contracture
-contracture of palmar fascia
-flexion of MCP and PIP joint
-usually ring or middle finger
-men>women
-40/70 yo
-increased in ppl with epilepsy alcholism or gout
painless
Flexion
(Capitate and Hamate)
(Trapezium & Trapezoid)
(Capitate and Hamate): dorsal
(Trapezium & Trapezoid): volar
Extension
(Capitate and Hamate)
(Trapezium & Trapezoid)
(Capitate and Hamate): volar
(Trapezium & Trapezoid): dorsal
Radial Deviation
(Capitate and Hamate)
(Trapezium & Trapezoid)
(Capitate and Hamate): ulnar
(Trapezium & Trapezoid): dorsal
Ulnar deviation
(Capitate and Hamate)
(Trapezium & Trapezoid)
(Capitate and Hamate): radial
(Trapezium & Trapezoid): volar
treat the capitate and hamte as
convex (gliding on concave surfaces of portions of the scaphoid, lunate, and triquetrum)
Treat trapezium & trapezoid as
concave (gliding on convex distal surface of scaphoid)
Distal radioular dorsal glide
supination
distal radioulnar volar glide
pronation
radiocarpal dorsal glide
flexion
radiocarpal volar glide
extension
radiocarpal ulnar glide
radial deviation
radiocarpal radial glide
ulnar deviation
1st cmc dorsal glide
abduction
1st cmc volar glide
adduction
1st cmc ulnar glide
flexion
1st cmc radial glide
extension
MCP, PIP, DIP dorsal glide
extension
MCP, PIP, DIP volar glide
flexion
