Management of Injuries of the Wrist and Hand Flashcards
how many bones are there in the hand?
27
what bones make up the proximal carpal row?
scaphoid
lunate
triquetrum
pisiform
what bones make up the distal carpal row?
trapezium
trapezoid
capitate
hamate
what bones articulate with the radius?
scaphoid and lunate
what structure allows more congruency on the medial side of the wrist?
the triangular fibrocartilanenous complex (TFCC) bw the ulna and carpals
what is positive ulnar variance?
longer ulna
what is negative ulnar variance?
shorter ulna
what is an easily injured structure in the wrist due to its location?
the TFCC
what is the carpometacarpal jt line?
the articulation bw the distal carpal row and the metacarpal bases
what is the midcarpal jt line?
the articulation bw the proximal and distal row of carpal bones
what is the radiocarpal jt line?
the articulation bw the radius and proximal row of carpal bones
what are the 2 axes of the wrist?
AP and ML
what is the axis point of the 2 axes of the wrist?
the capitate (some variances)
what is the convex surface of the radiocarpal jt?
proximal carpal row
what is the concave surface of the radiocarpal jt?
radius, ulna, and TFCC
what are the arthrokinematics of wrist extension? (ask OD for clarification)
posterior roll
anterior glide
what are the arthrokinematics of wrist flexion (ask OD for clarification)
anterior roll
posterior glide
what are the arthrokinematics of radial deviation?
radial roll
ulnar glide
what are the arthrokinematics of ulnar deviation?
ulnar roll
radial glide
what are the arthrokinematics of flexion at the CMC jt?
volar (palmar) roll and glide
what are the arthrokinematics of extension at the CMC jt?
dorsal roll and glide
when the wrist goes into extension, what is the first part of the hand to move?
distal row of carpal bones and metacarpals (CMC jt)
after the distal carpals and metatarsals initiate wrist extension to neutral, what bones move?
the capitate and scaphoid are drawn in CPP and start to extend to 45 deg
after the capitate and scaphoid move into extension to 45 deg, what bones move?
at 45 deg, the lunate and triquetrum start to go into CPP and move into ext
after the lunate and triquetrum go into ext at 45 deg, what bones move?
the proximal and distal carpals move together until end range
t/f: movement in the hand/wrist into flexion is the opposite order of extension
true
what is the order of bones moving into extension?
CMC–>capitate and scaphoid–> lunate and triquetrum–> proximal and distal carpal rows
what systems should we focus on for the wrist and hand?
NS, circulation, endocrine, integ, CVP, and MSK
why is the NS important in the wrist/hand?
there can be ulnar and median nerve injuries
how can we look at perfusion in the hand?
Allen test where the radial and ulnar arteries are occluded and pt pumps hand about 10 times then they are released to see reperfusion rate and pattern
why is the endocrine system important in the wrist/hand?
DM may affect sensation although not as much as the LE bc it is easier to see and is closer to the trunk
what CVP things may we want to observe/screen with the wrist/hand?
edema, clubbing, oxygenation, Baeu’s lines
what are some red flags that may point us towards a fracture in the wrist/hand?
recent fall/hx of direct trauma
exquisite pain, tenderness, edema, ecchymosis
chronic steroid use (bone demineralization)
hx of bone demineralization
what are some red flags that may point us towards a grade 1/2 tendon rupture in the wrist/hand?
pain with motion and passive stretch
edema
tenderness
what are some red flags that may point us towards a grade 3 tendon rupture in the wrist/hand?
total loss of motion
palpable defect
edema
tenderness
what are some red flags that may point us towards an infection in the wrist/hand?
hx of recent open surgery
presence of an abscess
signs of edema
chills, fever, malaise
what are some red flags that may point us towards complex regional pain syndrome (CRPS) in the wrist/hand?
hx of traumatic event
hypersensitivity
pitting edema
trophic changes including brittle nails, course hair growth, and errythema
poor response to analgesics
what are trophic changes?
changes in the growth of things
what is a common treatment for CRPS?
desensitization and compression
what are some red flags that may point us towards Raynaud’s phenomenon?
blanching and redness in response to cold
pain and paresthesia to cold
hx of RA, vascular disease, use of beta blockers, tobacco use
if there is a HPI of stiffness with inactivity, what things should we look at?
resting position of the hand
knuckle size
scars
SWELLING
t/f: we should ask further questions based on the HPI
true
t/f: we should ask questions that lead us towards the answer we want
false, we should ask unbiased questions
t/f: wrist/hand injuries can be cumulative trauma disorders (CTD) or single traumatic events (ie FOOSH)
true
if we suspect CTD may be the issue, what question might we want to ask?
what they do for work
what should we inspect at the wrist/hand?
general posture
presence of hand arches
bony deformities
signs of RA/OA
signs of peripheral nerve entrapment or palsy
MCP, PIP, or DIP deformity
presence of nodes and contractures
presence of trophic changes
nail appearance
is there greater flexion on the ulnar or radial side of the wrist?
on the ulnar side
what is MCP, PIP, or DIP deformity associated with?
tendon rupture/jt instability
t/f: a Smith’s fx is the opposite direction of a Colle’s fx
true
what is a Colles fx? (ask OD for clarification)
distal radial fx w/dorsal angulation (dinner fork deformity) often resulting from a FOOSH
if there is a loss of hand arches, what could this indicate?
neurologic damage
what are some ways we may see a loss of hand arches?
ape hand
hand of benediction
claw hand
instrinsic weakness
what do bony deformities in the wrist/hand suggest?
fx
what is Dupuytren’s contracture?
overgrowth of fascia restriction that usually starts on the ulnar side of the palm
Dupuytren’s contracture tends to be related to what?
alcohol abuse
if we see puckering of the ulnar palm, what may this be?
Dupuytren’s contracture
why is Dupuytren’s contracture difficult to treat?
bc it is a chronic progressive condition
what may trophic changes on the thenar and hypothenar eminences suggest?
nerve issues
what is a Mallet finger?
damage to the central tendon causes the DIP to drop bc it can’t extend
what is a Boutoniere’s deformity?
PIP flexion
DIP hyperextension
what is a swan neck deformity?
PIP hyperextension
DIP flexion
what causes a claw hand?
median and ulnar nerve injury
what is a claw hand?
no IP extension
intrinsic minus
what is an ape hand caused by?
median nerve injury
what is an ape hand?
when the thumb falls in the same plane as the hand bc of loss of thenar muscles
what is a hand of benediction (closing dysfxn)?
can’t flex digits 2 and 3
what is a hand of benediction (opening dysfxn)?
can’t extend IPs of digits 4 and 5 but can extend the MCP and digits 2 and 3
what are Heberdens nodes?
hyperplasia of the DIPs
what are Bouchards nodes?
hyperplasia of the PIPs
what is ulnar drift?
when the fingers drift to the ulnar side of the hands from MCP breakdown and tendon pulling that way from RA
what is ulnar drift often associated with?
RA
what things should we consider in the examination of mobility of the wrist/hand?
passive and active insufficiency
fist motions (straight, hook, roof)
use of overpressure and counterpressure
end feel and capsular pattern
increased mobility on the ulnar side (ulnar variance)
wrist motion w/the axis at the capitate
MCP triplanar motion
is MCP motion primarily sagittal, transverse, or frontal?
sagittal
where does the median nerve innervate?
the radial side of the palm
what muscles of the wrist/hand are innervated by the median nerve?
flexor carpi radialis
palmaris longus
flexor digitorum superficialis
where does the ulnar nerve innervate?
the ulnar side of the palm
what muscle is innervated by the ulnar nerve?
flexor carpi ulnaris
where does the radial nerve innervate?
the dorsal side of the hand
what muscles are innervated by the radial nerve?
extensor carpi radialis
extensor carpi ulnaris
what muscles are innervated by the posterior interosseous nerve?
extensor digitorum
extensor digiti minimi
extensor pollicis longus
abductor pollicis
where do the wrist extensors originate?
at the lateral epicondyle
where do the wrist flexors originate?
at the medial epicondyle
wrist extension is largely innervated by what nerve?
the radial nerve
what nerve innervates the adductor pollicus?
the ulnar nerve
what are the 2 intrinsic muscles groups?
PAD and DAB
t/f: the extensor mechanism plays into the lumbricals’ ability to extend the fingers and contributes to mallet finger, Boutoniere’s deformity
true
where is the A1 pulley located?
distal metacarpal
where is the A2 pulley located?
proximal at the proximal phalanx
where is the A3 pulley located?
distal at the proximal phalanx
where is the A4 pulley located?
middle phalanx
where is the A5 pulley located?
distal phalanx
what does “A” pulley mean?
annular pulleys
what are the “c” pulleys?
collateral pulleys
the A and C pulleys are on what side of the hand?
volar side
what are the extrinsic flexor muscles of the wrist and hand?
flexor carpi radialis (FCR)
palmaris longus (PL)
flexor digitorum superficialis (FDS)
flexor digitorum profundus (FDP)
flexor carpi ulnaris (FCU)
what is the insertion of the FDS? what does it do?
it inserts on the middle phalanx
it does PIP flexion
what is the insertion of the FDP? what does it do?
it inserts on the distal phalanx
it does DIP flexion
what are the extrinsic extensors of the wrist and hand?
extensor carpi radialis Longus (ECRL)
extensor carpi radialis brevis (ECRB)
extensor digitorum (ED)
extensor carpi ulnaris (ECU)
what does the ED (extensor digitorum) do?
MCP extension w/IP flexion
what muscle makes up the hood mechanism
ED (extensor digitorum)
what does the FPL do?
thumb IP flexion
what does the APL do?
thumb CMC extension>abduction
what does the EPB do?
thumb MCP extension
what does the EPL do?
thumb extension and CMC thumb adduction
what tendons are affected by DeQuervain’s tenosynovitis?
EPB and APL
what are the instrinsic muscles of the wrist and hand?
APB
FPB
OP
ADM (adductor digiti minimi)
ODM (opponens digiti minimi)
DI - abd (DAB)
PI-add (PAD)
lumbricals
what do the lumbricals do?
MCP flexion
IP extension
how do we examine grip, pinch, and coordination at the hand and wrist?
5 position grip
rapid grip exchange
lateral pinch
tip to tip pinch
3 jaw chuck pinch
Purdue peg board
9 hole peg test
Minnesota rate of manipulation test
how do we perform the 5 position grip test?
do 3 trials at each position BL
what are we looking for with the results from the 5 position grip test?
a bell curve with the strongest being at position 2/3
if there is a ___% difference bw BL grip strength, one side needs to be strengthened
10
what are the fine motor tests?
Purdue peg board
9 hole peg test
what is the gross motor test?
Minnesota rate of manipulation test
where is Lister’s tubercle?
on the top of the distal radius
what tendons make up the anatomical snuff box?
extensor pollicus brevis
extensor pollicus longus
abductor pollicus longus
what runs through the carpal tunnel?
9 tendons and the median nerve
what does a space occupying lesion in the carpal tunnel result in?
inflammation of the flexor tendons
what weaker structure gets affected by a space occupying lesion in the carpal tunnel?
the median nerve
thenar eminence atrophy may result from what?
median nerve injury in carpel tunnel syndrome
what are the tests for carpal tunnel syndrome?
Phalen test
reverse phalen test
carpal compression test
tinel sign
how is the phalen test performed?
BL wrist flexion with backs of hands against each other for 60 sec
what is the sensitivity and specificity of the phalen test?
sn=34-88%
sp=40-100%
what is a (+) phalen test?
reproduction of pain/paresthesia in the median nerve distribution
how should we ask about symptoms with the phalen test?
“what do you feel?”
how do we perform the reverse phalen test?
BL wrist extension with the palms together held for 60 sec
what is the sensitivity and specificity of the reverse phalen test?
sn=88%
sp=93%
t/f: the reverse phalen test is often a treatment to stretch the wrist but not if it causes pain
true
how is the carpal compression test performed?
apply compression to the CT for 30 sec
what is the sensitivity and specificity of the carpal compression test?
sn=42-75%
sp=84-95%
what is a (+) reverse phalen test?
reproduction of pain/paresthesia in the median nerve distribution
how do we perform the tinel sign at the wrist?
tap on the CT and tunnel of guyon (from pisiform to radial side of the wrist)
what is a (+) tinel test at the wrist?
tingling/pain into the 2-3 digits for the median nerve or into the 4-5th digits (dorsal) for ulnar nerve
t/f: upper limb neurodynamic tests/mobilizations are location specific and the area of pain tells us the area of compression
false
how do we perform median nerve upper limb neurodynamic testing?
pt in supine
use one hand to block and depress the scap from on top of the shoulder
use the other hand to bring the arm into shoulder abduction–> elbow extension–>wrist flexion
can add cervical SB
t/f: upper limb neurodynamic testing is not a prolonged stretch
true
what is the intervention for upper limb neurodynamic testing?
stretch the limb into the position that symptoms occur in then back of and do this a few times
10-12 reps 2-3x/day
what is the flossing maneuver for the median nerve?
with the arm in shoulder abduction and elbow extension, flex the wrist and SB away, then extend the wrist and SB towards them
how do we perform ulnar nerve upper limb neurodynamic testing?
pt in supine
use one hand to block and depress the scap from on top of the shoulder
abduct the shoulder–> pronate –> extend the wrist–> flex the elbow
how do we perform radial nerve upper limb neurodynamic testing?
pt in supine
use one hand to block and depress the scap from on top of the shoulder
go into full pronation–>elbow extension–>wrist flexion–> shoulder abduction
how do we perform the froment sign?
grasp paper with the webbed space while the PT tries to pull it away
what is a (+) Froment sign?
if the paper gets pulled out or there is IP flexion
what does a (+) Froment sign indicate?
weak adductor pollicus from ulnar nerve palsy
how do we perform the Wartenburg sign?
resist 5th metacarpal add
place the fingers in abduction and try to move the pinky into adduction
have pt rest hand in finger adduction - see if pinky drifts into abduction
what does a (+) Wartenburg sign indicate?
ulnar nerve palsy
weak palmar interossei
what are the special tests for TFCC syndrome?
TFCC load test
TFCC press test
gripping rotatory impaction test (GRIT)
how do we perform the TFCC load test?
UD with long axis compression through the ulna
what is a (+) TFCC load test?
pain
what is the sensitivity and specificity of the TFCC load test?
sn=100%
sp=NA
how do we perform the TFCC press test?
have the pt in a chair with armrests and have them push themselves up with their hands on the armrests to create self axial compression and UD
what is a (+) TFCC press test?
pain
is paresthesia a (+) test for the TFCC press test or TFCC load test?
no
how do we perform the gripping rotatory impaction test (GRIT)?
measure grip strength with a dynamometer in pronation vs supination
what is a (+) GRIT?
grip sup>pro
t/f: the GRIT is not testing the strength of the pronators and supinators?
true
how do we perform the Watson scaphoid instability test?
UD and ext then RD and flex the wrist while applying pressure to the scaphoid to assess for intercarpal instability
what is a (+) Watson scaphoid instability test?
subluxation or pain
what is the sensitivity and specificity of the watson scaphoid instability test?
sn=69%
sp=64-68%
what is the axial loading test for?
scaphoid fx
how do we perform the axial loading test?
apply axial compression through the 1st CMC
what is a (+) axial loading test?
pain
what is the sensitivity and specificity of the axial loading test?
sn=89%
sp=98%
what is the Murphy sign?
observing alignment of the MCPs with the hand in a fist
what is a (+) Murphy sign?
if the 3rd digit MCP is level with the other digits or is depressed
what does a (+) Murphy sign indicate?
lunate dislocation
how do we perform the Bunnel-Littler test?
hold the MCP in ext while passively flexing the PIP, noting the available ROM
then hold the MCP in flexion while passively flexing the PIP, noting available ROM
if there is no change in motion with MCP ext vs flex with the Bunnel-Littler test, what may this indicate?
capsular tightness of the PIP
if the finger is tighter with MCP flexion in the Bunnel-Littler test, what may this indicate?
intrinsic tightness
what is the special tests for DeQuervain’s tenosynovitis?
Finkelstein test
how do we perform the Finkelstein test?
make a fist w/the thumb tucked and carefully UD
what is a (+) Finkelstein test?
pain
what is the sensitivity and specificity of the Finkelstein test?
sn=81-100%
sp=50-100%
what is a common treatment for DQ?
spica splint (a wrist based brace to control UD and prevent and and ext of the thumb)
