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DPT 616 : MSK > Management of Injuries of the Wrist and Hand > Flashcards

Management of Injuries of the Wrist and Hand Flashcards

1
Q

how many bones are there in the hand?

A

27

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2
Q

what bones make up the proximal carpal row?

A

scaphoid

lunate

triquetrum

pisiform

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3
Q

what bones make up the distal carpal row?

A

trapezium

trapezoid

capitate

hamate

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4
Q

what bones articulate with the radius?

A

scaphoid and lunate

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5
Q

what structure allows more congruency on the medial side of the wrist?

A

the triangular fibrocartilanenous complex (TFCC) bw the ulna and carpals

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6
Q

what is positive ulnar variance?

A

longer ulna

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7
Q

what is negative ulnar variance?

A

shorter ulna

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8
Q

what is an easily injured structure in the wrist due to its location?

A

the TFCC

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9
Q

what is the carpometacarpal jt line?

A

the articulation bw the distal carpal row and the metacarpal bases

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10
Q

what is the midcarpal jt line?

A

the articulation bw the proximal and distal row of carpal bones

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11
Q

what is the radiocarpal jt line?

A

the articulation bw the radius and proximal row of carpal bones

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12
Q

what are the 2 axes of the wrist?

A

AP and ML

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13
Q

what is the axis point of the 2 axes of the wrist?

A

the capitate (some variances)

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14
Q

what is the convex surface of the radiocarpal jt?

A

proximal carpal row

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15
Q

what is the concave surface of the radiocarpal jt?

A

radius, ulna, and TFCC

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16
Q

what are the arthrokinematics of wrist extension? (ask OD for clarification)

A

posterior roll

anterior glide

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17
Q

what are the arthrokinematics of wrist flexion (ask OD for clarification)

A

anterior roll

posterior glide

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18
Q

what are the arthrokinematics of radial deviation?

A

radial roll

ulnar glide

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19
Q

what are the arthrokinematics of ulnar deviation?

A

ulnar roll

radial glide

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20
Q

what are the arthrokinematics of flexion at the CMC jt?

A

volar (palmar) roll and glide

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21
Q

what are the arthrokinematics of extension at the CMC jt?

A

dorsal roll and glide

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22
Q

when the wrist goes into extension, what is the first part of the hand to move?

A

distal row of carpal bones and metacarpals (CMC jt)

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23
Q

after the distal carpals and metatarsals initiate wrist extension to neutral, what bones move?

A

the capitate and scaphoid are drawn in CPP and start to extend to 45 deg

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24
Q

after the capitate and scaphoid move into extension to 45 deg, what bones move?

A

at 45 deg, the lunate and triquetrum start to go into CPP and move into ext

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25
Q

after the lunate and triquetrum go into ext at 45 deg, what bones move?

A

the proximal and distal carpals move together until end range

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26
Q

t/f: movement in the hand/wrist into flexion is the opposite order of extension

A

true

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27
Q

what is the order of bones moving into extension?

A

CMC–>capitate and scaphoid–> lunate and triquetrum–> proximal and distal carpal rows

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28
Q

what systems should we focus on for the wrist and hand?

A

NS, circulation, endocrine, integ, CVP, and MSK

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29
Q

why is the NS important in the wrist/hand?

A

there can be ulnar and median nerve injuries

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30
Q

how can we look at perfusion in the hand?

A

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

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31
Q

why is the endocrine system important in the wrist/hand?

A

DM may affect sensation although not as much as the LE bc it is easier to see and is closer to the trunk

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32
Q

what CVP things may we want to observe/screen with the wrist/hand?

A

edema, clubbing, oxygenation, Baeu’s lines

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33
Q

what are some red flags that may point us towards a fracture in the wrist/hand?

A

recent fall/hx of direct trauma

exquisite pain, tenderness, edema, ecchymosis

chronic steroid use (bone demineralization)

hx of bone demineralization

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34
Q

what are some red flags that may point us towards a grade 1/2 tendon rupture in the wrist/hand?

A

pain with motion and passive stretch

edema

tenderness

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35
Q

what are some red flags that may point us towards a grade 3 tendon rupture in the wrist/hand?

A

total loss of motion

palpable defect

edema

tenderness

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36
Q

what are some red flags that may point us towards an infection in the wrist/hand?

A

hx of recent open surgery

presence of an abscess

signs of edema

chills, fever, malaise

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37
Q

what are some red flags that may point us towards complex regional pain syndrome (CRPS) in the wrist/hand?

A

hx of traumatic event

hypersensitivity

pitting edema

trophic changes including brittle nails, course hair growth, and errythema

poor response to analgesics

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38
Q

what are trophic changes?

A

changes in the growth of things

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39
Q

what is a common treatment for CRPS?

A

desensitization and compression

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40
Q

what are some red flags that may point us towards Raynaud’s phenomenon?

A

blanching and redness in response to cold

pain and paresthesia to cold

hx of RA, vascular disease, use of beta blockers, tobacco use

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41
Q

if there is a HPI of stiffness with inactivity, what things should we look at?

A

resting position of the hand

knuckle size

scars

SWELLING

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42
Q

t/f: we should ask further questions based on the HPI

A

true

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43
Q

t/f: we should ask questions that lead us towards the answer we want

A

false, we should ask unbiased questions

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44
Q

t/f: wrist/hand injuries can be cumulative trauma disorders (CTD) or single traumatic events (ie FOOSH)

A

true

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45
Q

if we suspect CTD may be the issue, what question might we want to ask?

A

what they do for work

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46
Q

what should we inspect at the wrist/hand?

A

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

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47
Q

is there greater flexion on the ulnar or radial side of the wrist?

A

on the ulnar side

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48
Q

what is MCP, PIP, or DIP deformity associated with?

A

tendon rupture/jt instability

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49
Q

t/f: a Smith’s fx is the opposite direction of a Colle’s fx

A

true

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50
Q

what is a Colles fx? (ask OD for clarification)

A

distal radial fx w/dorsal angulation (dinner fork deformity) often resulting from a FOOSH

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51
Q

if there is a loss of hand arches, what could this indicate?

A

neurologic damage

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52
Q

what are some ways we may see a loss of hand arches?

A

ape hand

hand of benediction

claw hand

instrinsic weakness

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53
Q

what do bony deformities in the wrist/hand suggest?

A

fx

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54
Q

what is Dupuytren’s contracture?

A

overgrowth of fascia restriction that usually starts on the ulnar side of the palm

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55
Q

Dupuytren’s contracture tends to be related to what?

A

alcohol abuse

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56
Q

if we see puckering of the ulnar palm, what may this be?

A

Dupuytren’s contracture

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57
Q

why is Dupuytren’s contracture difficult to treat?

A

bc it is a chronic progressive condition

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58
Q

what may trophic changes on the thenar and hypothenar eminences suggest?

A

nerve issues

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59
Q

what is a Mallet finger?

A

damage to the central tendon causes the DIP to drop bc it can’t extend

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60
Q

what is a Boutoniere’s deformity?

A

PIP flexion

DIP hyperextension

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61
Q

what is a swan neck deformity?

A

PIP hyperextension

DIP flexion

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62
Q

what causes a claw hand?

A

median and ulnar nerve injury

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63
Q

what is a claw hand?

A

no IP extension

intrinsic minus

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64
Q

what is an ape hand caused by?

A

median nerve injury

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65
Q

what is an ape hand?

A

when the thumb falls in the same plane as the hand bc of loss of thenar muscles

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66
Q

what is a hand of benediction (closing dysfxn)?

A

can’t flex digits 2 and 3

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67
Q

what is a hand of benediction (opening dysfxn)?

A

can’t extend IPs of digits 4 and 5 but can extend the MCP and digits 2 and 3

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68
Q

what are Heberdens nodes?

A

hyperplasia of the DIPs

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69
Q

what are Bouchards nodes?

A

hyperplasia of the PIPs

70
Q

what is ulnar drift?

A

when the fingers drift to the ulnar side of the hands from MCP breakdown and tendon pulling that way from RA

71
Q

what is ulnar drift often associated with?

A

RA

72
Q

what things should we consider in the examination of mobility of the wrist/hand?

A

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

73
Q

is MCP motion primarily sagittal, transverse, or frontal?

A

sagittal

74
Q

where does the median nerve innervate?

A

the radial side of the palm

75
Q

what muscles of the wrist/hand are innervated by the median nerve?

A

flexor carpi radialis

palmaris longus

flexor digitorum superficialis

76
Q

where does the ulnar nerve innervate?

A

the ulnar side of the palm

77
Q

what muscle is innervated by the ulnar nerve?

A

flexor carpi ulnaris

78
Q

where does the radial nerve innervate?

A

the dorsal side of the hand

79
Q

what muscles are innervated by the radial nerve?

A

extensor carpi radialis

extensor carpi ulnaris

80
Q

what muscles are innervated by the posterior interosseous nerve?

A

extensor digitorum

extensor digiti minimi

extensor pollicis longus

abductor pollicis

81
Q

where do the wrist extensors originate?

A

at the lateral epicondyle

82
Q

where do the wrist flexors originate?

A

at the medial epicondyle

83
Q

wrist extension is largely innervated by what nerve?

A

the radial nerve

84
Q

what nerve innervates the adductor pollicus?

A

the ulnar nerve

85
Q

what are the 2 intrinsic muscles groups?

A

PAD and DAB

86
Q

t/f: the extensor mechanism plays into the lumbricals’ ability to extend the fingers and contributes to mallet finger, Boutoniere’s deformity

A

true

87
Q

where is the A1 pulley located?

A

distal metacarpal

88
Q

where is the A2 pulley located?

A

proximal at the proximal phalanx

89
Q

where is the A3 pulley located?

A

distal at the proximal phalanx

90
Q

where is the A4 pulley located?

A

middle phalanx

91
Q

where is the A5 pulley located?

A

distal phalanx

92
Q

what does “A” pulley mean?

A

annular pulleys

93
Q

what are the “c” pulleys?

A

collateral pulleys

94
Q

the A and C pulleys are on what side of the hand?

A

volar side

95
Q

what are the extrinsic flexor muscles of the wrist and hand?

A

flexor carpi radialis (FCR)

palmaris longus (PL)

flexor digitorum superficialis (FDS)

flexor digitorum profundus (FDP)

flexor carpi ulnaris (FCU)

96
Q

what is the insertion of the FDS? what does it do?

A

it inserts on the middle phalanx

it does PIP flexion

97
Q

what is the insertion of the FDP? what does it do?

A

it inserts on the distal phalanx

it does DIP flexion

98
Q

what are the extrinsic extensors of the wrist and hand?

A

extensor carpi radialis Longus (ECRL)

extensor carpi radialis brevis (ECRB)

extensor digitorum (ED)

extensor carpi ulnaris (ECU)

99
Q

what does the ED (extensor digitorum) do?

A

MCP extension w/IP flexion

100
Q

what muscle makes up the hood mechanism

A

ED (extensor digitorum)

101
Q

what does the FPL do?

A

thumb IP flexion

102
Q

what does the APL do?

A

thumb CMC extension>abduction

103
Q

what does the EPB do?

A

thumb MCP extension

104
Q

what does the EPL do?

A

thumb extension and CMC thumb adduction

105
Q

what tendons are affected by DeQuervain’s tenosynovitis?

A

EPB and APL

106
Q

what are the instrinsic muscles of the wrist and hand?

A

APB

FPB

OP

ADM (adductor digiti minimi)

ODM (opponens digiti minimi)

DI - abd (DAB)

PI-add (PAD)

lumbricals

107
Q

what do the lumbricals do?

A

MCP flexion

IP extension

108
Q

how do we examine grip, pinch, and coordination at the hand and wrist?

A

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

109
Q

how do we perform the 5 position grip test?

A

do 3 trials at each position BL

110
Q

what are we looking for with the results from the 5 position grip test?

A

a bell curve with the strongest being at position 2/3

111
Q

if there is a ___% difference bw BL grip strength, one side needs to be strengthened

A

10

112
Q

what are the fine motor tests?

A

Purdue peg board

9 hole peg test

113
Q

what is the gross motor test?

A

Minnesota rate of manipulation test

114
Q

where is Lister’s tubercle?

A

on the top of the distal radius

115
Q

what tendons make up the anatomical snuff box?

A

extensor pollicus brevis

extensor pollicus longus

abductor pollicus longus

116
Q

what runs through the carpal tunnel?

A

9 tendons and the median nerve

117
Q

what does a space occupying lesion in the carpal tunnel result in?

A

inflammation of the flexor tendons

118
Q

what weaker structure gets affected by a space occupying lesion in the carpal tunnel?

A

the median nerve

119
Q

thenar eminence atrophy may result from what?

A

median nerve injury in carpel tunnel syndrome

120
Q

what are the tests for carpal tunnel syndrome?

A

Phalen test

reverse phalen test

carpal compression test

tinel sign

121
Q

how is the phalen test performed?

A

BL wrist flexion with backs of hands against each other for 60 sec

122
Q

what is the sensitivity and specificity of the phalen test?

A

sn=34-88%

sp=40-100%

123
Q

what is a (+) phalen test?

A

reproduction of pain/paresthesia in the median nerve distribution

124
Q

how should we ask about symptoms with the phalen test?

A

“what do you feel?”

125
Q

how do we perform the reverse phalen test?

A

BL wrist extension with the palms together held for 60 sec

126
Q

what is the sensitivity and specificity of the reverse phalen test?

A

sn=88%

sp=93%

127
Q

t/f: the reverse phalen test is often a treatment to stretch the wrist but not if it causes pain

A

true

128
Q

how is the carpal compression test performed?

A

apply compression to the CT for 30 sec

129
Q

what is the sensitivity and specificity of the carpal compression test?

A

sn=42-75%
sp=84-95%

130
Q

what is a (+) reverse phalen test?

A

reproduction of pain/paresthesia in the median nerve distribution

131
Q

how do we perform the tinel sign at the wrist?

A

tap on the CT and tunnel of guyon (from pisiform to radial side of the wrist)

132
Q

what is a (+) tinel test at the wrist?

A

tingling/pain into the 2-3 digits for the median nerve or into the 4-5th digits (dorsal) for ulnar nerve

133
Q

t/f: upper limb neurodynamic tests/mobilizations are location specific and the area of pain tells us the area of compression

A

false

134
Q

how do we perform median nerve upper limb neurodynamic testing?

A

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

135
Q

t/f: upper limb neurodynamic testing is not a prolonged stretch

A

true

136
Q

what is the intervention for upper limb neurodynamic testing?

A

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

137
Q

what is the flossing maneuver for the median nerve?

A

with the arm in shoulder abduction and elbow extension, flex the wrist and SB away, then extend the wrist and SB towards them

138
Q

how do we perform ulnar nerve upper limb neurodynamic testing?

A

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

139
Q

how do we perform radial nerve upper limb neurodynamic testing?

A

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

140
Q

how do we perform the froment sign?

A

grasp paper with the webbed space while the PT tries to pull it away

141
Q

what is a (+) Froment sign?

A

if the paper gets pulled out or there is IP flexion

142
Q

what does a (+) Froment sign indicate?

A

weak adductor pollicus from ulnar nerve palsy

143
Q

how do we perform the Wartenburg sign?

A

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

144
Q

what does a (+) Wartenburg sign indicate?

A

ulnar nerve palsy

weak palmar interossei

145
Q

what are the special tests for TFCC syndrome?

A

TFCC load test

TFCC press test

gripping rotatory impaction test (GRIT)

146
Q

how do we perform the TFCC load test?

A

UD with long axis compression through the ulna

147
Q

what is a (+) TFCC load test?

A

pain

148
Q

what is the sensitivity and specificity of the TFCC load test?

A

sn=100%
sp=NA

149
Q

how do we perform the TFCC press test?

A

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

150
Q

what is a (+) TFCC press test?

A

pain

151
Q

is paresthesia a (+) test for the TFCC press test or TFCC load test?

A

no

152
Q

how do we perform the gripping rotatory impaction test (GRIT)?

A

measure grip strength with a dynamometer in pronation vs supination

153
Q

what is a (+) GRIT?

A

grip sup>pro

154
Q

t/f: the GRIT is not testing the strength of the pronators and supinators?

A

true

155
Q

how do we perform the Watson scaphoid instability test?

A

UD and ext then RD and flex the wrist while applying pressure to the scaphoid to assess for intercarpal instability

156
Q

what is a (+) Watson scaphoid instability test?

A

subluxation or pain

157
Q

what is the sensitivity and specificity of the watson scaphoid instability test?

A

sn=69%
sp=64-68%

158
Q

what is the axial loading test for?

A

scaphoid fx

159
Q

how do we perform the axial loading test?

A

apply axial compression through the 1st CMC

160
Q

what is a (+) axial loading test?

A

pain

161
Q

what is the sensitivity and specificity of the axial loading test?

A

sn=89%
sp=98%

162
Q

what is the Murphy sign?

A

observing alignment of the MCPs with the hand in a fist

163
Q

what is a (+) Murphy sign?

A

if the 3rd digit MCP is level with the other digits or is depressed

164
Q

what does a (+) Murphy sign indicate?

A

lunate dislocation

165
Q

how do we perform the Bunnel-Littler test?

A

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

166
Q

if there is no change in motion with MCP ext vs flex with the Bunnel-Littler test, what may this indicate?

A

capsular tightness of the PIP

167
Q

if the finger is tighter with MCP flexion in the Bunnel-Littler test, what may this indicate?

A

intrinsic tightness

168
Q

what is the special tests for DeQuervain’s tenosynovitis?

A

Finkelstein test

169
Q

how do we perform the Finkelstein test?

A

make a fist w/the thumb tucked and carefully UD

170
Q

what is a (+) Finkelstein test?

A

pain

171
Q

what is the sensitivity and specificity of the Finkelstein test?

A

sn=81-100%
sp=50-100%

172
Q

what is a common treatment for DQ?

A

spica splint (a wrist based brace to control UD and prevent and and ext of the thumb)

DPT 616 : MSK (23 decks)

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