S2L3: Wrist and Hand Flashcards
1
Q
Type of prehension pattern where the thumb is not necessarily active
A
Hook grasp
2
Q
Synergistic actions of the wrist muscles are noted in the following
A
When the thumb is extended, the ECU contracts to prevent radial abduction of the wrist by the abductor pollicis longus
3
Q
Which of the following is not considered precision handling? (Note: Precision handling involves the thumb)
a. Lateral prehension
b. Pad-to-pad prehension
c. Tip-to-tip prehension
d. Pad-to-side prehension
A
a. Lateral prehension
4
Q
Which of the following carpal bones does not form part of the radiocarpal joint?
a. Trapezoid
b. Scaphoid
c. Lunate
d. Triquetrum
A
a. Trapezoid
5
Q
The flexor digitorum profundus muscles insert into
A
Base of distal phalanges
6
Q
Purpose of tendon zones
A
For anatomists to communicate where the
a ffected fingers, tendons, and soft tissues are
Knowing the a ected zones leads us to know the
possible consequences and complications
7
Q
Divisions in the palmar & dorsal aspects of the hand
A
Tendon zones
8
Q
Flexor Tendon: Zone I
A
Distal phalanx to neck of middle phalanx
9
Q
Insertion of FDP and FDS
A
Distal phalanx to neck of middle phalanx
10
Q
Flexor Tendon: Zone II
A
Neck of middle phalanx to neck of metacarpals
11
Q
Flexor Tendon: Zone III
A
Neck of metacarpals to distal border of the carpal ligament (palmar aspect)
12
Q
Flexor Tendon: Zone IV
A
Carpal tunnel
13
Q
Flexor Tendon: Zone V
A
Proximal border of carpal ligament to the forearm
14
Q
Flexor Tendon: TI
A
Insertion of FPL (distal phalanx) to neck of proximal phalanx
15
Q
Flexor Tendon: TIII
A
Neck of 1st MC to boundary of carpal ligament
16
Q
Flexor Tendon: TII
A
Neck of proximal phalanx to neck of 1st MC
17
Q
Extensor Tendon: Odd numbers represent what
A
Joints
18
Q
Extensor Tendon: Zone I
A
DIP joints
19
Q
Extensor Tendon: Zone II
A
Middle phalanx
20
Q
Extensor Tendon: Zone III
A
PIP joints
21
Q
Extensor Tendon: Zone IV
A
Proximal phalanx
22
Q
Extensor Tendon: Zone V
A
MCP joints (knuckles)
23
Q
Extensor Tendon: Zone VI
A
Metacarpals
24
Q
Extensor Tendon: Zone VII
A
Midcarpal joints
25
Extensor Tendon: TI
IP joint
26
Extensor Tendon: TII
Proximal phalanx
27
Extensor Tendon: TIII
MCP joint
28
Extensor Tendon: TIV
Metacarpal
29
Flexor Tendon Laceration: Anatomical and morphological differences
Usually return to full activity by 12 weeks p surgery (esp if primary repair)
30
Extensor Tendon Laceration: Anatomical and morphological differences
More common than flexor; extensors are more superficial & flat
More di fficult to return to function d/t multiple attachments and possible formation of adhesions
31
Flexor Tendon Laceration: Condition of the tendon after the rupture
Flexor tendons retract* when ruptured; require surgical intervention most often
*Retract: gap formation, umaatras yung proximal part
32
Extensor Tendon Laceration: Condition of the tendon after the rupture
Less likely to retract d/t numerous soft tissue attachments (interossei & lumbricals); more prone to adhesions
33
Extensor Tendon Laceration: Most di ffcult to treat zones
Zone III and VII
34
Flexor Tendon Laceration: Most diffcult to treat zones
Zone II (No Man’s Land: laceration in this area is problematic d/t limited vascularity and confined space)
35
Rupture or avulsion of the flexor digitorum profundus
Unable to flex DIP during closed fist position
Zone I injury
Jersey Finger
36
Zone I injury to the extensor tendon
mechanism at or near the
DIP joint
Unable to extend DIP
Mallet Finger
37
Direct repair
Tendons are simply sutured together
Indicated for clean wounds
38
Tendon graft
Indicated for separated tendons/segments
Palmaris longus tendon: usually used for grafts
39
A repair done within the first 24 hours after surgery
Immediate primary repair
40
A repair performed up to 10 days after injury
Delayed primary repair
41
A repair done 10 days to 3 weeks after injury
Secondary repair
42
Surgery performed well beyond 3-4 weeks
Late reconstruction
43
Multiple separate surgeries performed over a period of weeks or months
Staged reconstruction
44
Guidelines for delayed motion
Unreliable patients
■ Children 7-10 years of age
● Over activeness
● Inc apprehensive behavior
■ Patients with impaired cognitive capacity
● Dementia, psychotic problems
● Unable to understand exercise program
Patients who are unlikely to adhere to the program
■ Unmotivated or overzealous patients
Primary Intervention scenario: Compensatory
○ Promotes patient independence while waiting for the operated part to stabilize
Secondary Intervention Scenario: Restorative
○ Facilitate healing while in splints
45
Used when controlled immobilization extends for 3-4 weeks
Delayed motion
46
Position of immobilization: Flexor zones I, II, III
10-45 deg wrist flexion
40-70 deg MCP flexion
PIP and DIP extension
47
Position of immobilization: Flexor zone IV
70 deg MCP flexion
Neutral wrist
48
Position of immobilization: Extensor zone III, IV
PIP and DIP extension
49
Position of immobilization: Extensor zones V, VI
30 deg wrist extension
30-45 deg MCP flexion
50
Prevents excessive extension & keep tendon approximated to promote healing
Dorsal blocking splint
51
Guidelines for early controlled motion
Decreases edema
Maintains tendon-gliding; decreases adhesion
formation
Increases synovial fluid di ffusion; faster healing rate d/t increased nourishment and blood flow
Increases wound maturation and tensile strength of the tendons (collagen alignment)
Decreases gap formation
Primary Intervention Scenario (minimum
protection phase): Restorative
○ Expect more challenging exercises to be
provided for pt to return to work
52
Early ACTIVE controlled motion approach
More recommended than passive
Use of minimum active tension (MAT) of repaired tendons within the first 24-48 hours
○ Isometrics within allowable/pain free ranges
Recommended for primary tendon repairs
53
Done after a short period of immobilization: only 1-3 days
Maximum Protection Phase
54
Passive motion of individual joints within the allowable limits (pain-free range)
Di fferential gliding of FDS & FDP
○ Flexion of PIP & DIP separately
○ Perform flexion at 1 joint while stabilizing the other joint (flexing the PIP and DIP separately, not combined)
Place and hold exercises
○ Move joint, maintain position, & hold for 6 sec
Maximum Protection Phase
55
1-5 weeks post-op
Maximum Protection Phase
56
Moderate Protection Phase weeks post-op
4-8
57
Place and hold exercises
Active flexion of IP joint in dynamic splint
Tendon gliding and blocking exercises
○ Tendon Blocking: prevent accessory or compensatory motions to isolate desired movement
Moderate Protection Phase
58
In which phase:
No splint, healed injuries
Dexterity exercises
Minimum Protection Phase
59
Low-load resistive exercises
○ Light-resistance ex (manual, rubber bands, spiderweb)
Sustained grasp exercises
○ Hold plastic cup w/o crushing
○ Progress by filling w/ water (half-full)
Practice of transfers from table ↔ mouth
○ Progress by filling cup w/ water completely
Avoid spilling water during motion
○ Progress by using mugs or heavier cups
Full functional use
Minimum Protection Phase
60
Flexor tendon gliding exercises in order (5)
Straight hand
Hook or claw fist
Full fist
Table top or intrinsic plus
Straight fist
61
Flexion of the DIP and PIP joints while maintaining MP extension
Maximum gliding occurs between the profundus and superficialis tendons and between the profundus tendon and the bone
Hook or claw fist
62
Flexion of all the MP and IP joints simultaneously
Maximum gliding of the profundus tendon with
respect to the sheath and bone as well as over the superficialis tendon
Full fist
63
MCP flexion, PIP and DIP extension
Maximum gliding of the superficialis tendon occurs with respect to the flexor sheath and bone
Table top or intrinsic plus
64
Straight fist
From the table-top position to the straight fist position by flexing the PIP joints while maintaining the DIP joints in extension
Maximum gliding of the flexor pollicis longus
65
Flexor tendon gliding exercise Initial position for prescription
hook fist or straight hand
66
Flexor Tendon Blocking Exercises goal
Isolate motion, prevent compensatory motions
67
Tendon blocking: Isolated MCP flexion of one digit
Lumbricals and palmar interossei
68
Tendon blocking: Isolated PIP flexion of one digit
FDS
69
Tendon blocking: Isolated DIP flexion of one digit
FDP
70
T/F: Pt should be able to make a full fist when full independent tendon-gliding is available
True: Full fist tendon blocking exercise
71
Decrease in mobility and range of motion
Hypomobility
72
Causes of hypomobility
RA, OA, Acute joint trauma, Immobilization
73
Begins 15-50 y.o.
RA
74
Begins after 40 y.o.
OA
75
Progression is sudden, instantaneous with flare ups (weeks/months)
RA
76
Progression of OA
Gradual, wear and tear (years)
77
Manifestations of RA
Inflammatory synovitis
○ Redness
○ Swelling
○ Warmth
Irreversible structural cartilage & bone damage
○ Chronic conditions
78
Manifestations of OA
Cartilage degeneration
● Altered joint architecture
● Osteophyte formation
Formation of small bones within the joint as a result of bone to bone contact
79
Joint involvement of RA
Bilateral
Common in hands
● PIP, MCP, wrist, elbow, shoulder
80
Joint involvement of OA
Unilateral
○May progress to (B)
Weight bearing joints (hip, knee)
● UE: DIP, PIP,1st CMC
81
T/F: Systemic signs are present in OA and not in RA
False: Present in RA, none in OA
82
OA or RA:
Typical s/sx of inflammation
Morning stiff ness (at least 1 hour)
Increased pain c activity
RA
83
OA or RA:
Morning sti ness (<30 minutes)
Increased pain c WB and strenuous activity
Crepitus
LOM
OA
84
Advanced stage of RA joint signs
Joint capsule weakening
Cartilage destruction
Bone erosion
Tendon rupture*
Muscle imbalances*
Subluxations*
Deformities*
with *: occurs over time d/t malalignment
85
Advanced stage of OA joint signs
Capsular laxity leading to hypermobility or instability
Contractures and limited motion develop
General weakness & poor endurance
86
RA & OA MANAGEMENT: Protection Phase Primary Intervention
Restorative
○Address the pain
87
RA & OA MANAGEMENT: Protection Phase Secondary Intervention
Compensatory
○ OA: use the other hand
○ Use of splints or adaptive equipment
88
RA & OA MANAGEMENT: Control pain and protect joints (4)
Patient education
■ Explain mechanism and pathology
■ Inform patient of the activities that are advocated and should be avoided
Pain management
■ Medications
■ Physical modalities: PWB, US
Splinting/Orthosis
Activity modification
■ Breakdown one complex activity into simpler components
89
RA & OA MANAGEMENT: Maintain joint & tendon mobility, muscle integrity (4)
ROM exercises
■ Start with passive if there is inflammation
Multiple-angle muscle sets
Gentle isometrics
Tendon gliding
■ Choose a combination; do not pressure patient to perform all
90
RA & OA MANAGEMENT: Controlled Motion and Return to Function Phase Primary Intervention
Restorative
○Restore function as soon as possible
91
RA & OA MANAGEMENT: Controlled Motion and Return to Function Phase (3)
Increase joint play and accessory motions ○ Joint mobilization
■ Do not apply too much force since the joints are just small
Improve joint tracking and pain-free motion ○ MWM for the wrist and digits
■ Lateral glide during wrist extension
■ Lateral glide during finger flex-ex
Improve mobility, strength, and function
○ Neuromuscular control and strength
■ Grip strength c proper form/posture
○ Functional activities
■ Incorporate pt’s lifestyle, occupation
○ Conditioning exercises
○ Joint protection
92
Joint Protection Principles: Respect
Respect pain
● Educate the pt to stop activity when pain is
felt
● Continuing the activity might aggravate
the pain
● Ensure that the exercises do not cause pain
93
Joint Protection Principles: Maintain
Maintain functional ROM, strength, endurance
● For OA and RA pts, functional ROM is
targeted rather than full ROM
● Goal: Enough ROM, strength, and
endurance to perform activities independently c the least amount of di culty and assistance provided
94
Joint Protection Principles: Balance
Balance activity level and rest
● Breakdown complex activities into smaller
components
● Add break times in between
95
Joint Protection Principles: Use
Use stronger, larger muscles whenever possible
● e.g. Using the forearm to lift instead of the
fingers
Use appropriate adaptive equipment
96
Joint Protection Principles: Avoid
Avoid deforming postures
● e.g. For someone with Z-deformity (ulnar
deviation of the digits), opening a water bottle towards ulnar deviation is not recommended. Instead, the water bottle can be opened towards radial deviation or using the palms of both hands.
● Proper body mechanics: Better to push than to pull
97
Fracture of the distal end of the radius resulting to dinner fork deformity
Colle's fx
98
An avulsion fracture of the distal end of the radial styloid process
Chauffeur's fx
99
Fracture at the neck of the 5th metacarpal bone
Boxer’s Fracture
100
Fracture of the distal end of the radius involving the intraarticular joint of the radius and its adjoining carpal bones
Barton’s Fracture
101
Fracture of the distal end of the radius accompanied by fracture of the ulnar styloid process
Smith’s Fracture
102
Management for fx: post-injury
Operative
103
Management for fx: post-operation
Conservative
104
Post-Op Protection Phase Weeks
0-6
105
Post-Op Protection Phase: Primary Intervention
Restorative
106
Post-Op Protection Phase: Secondary Intervention
Compensatory, Preventive
107
Post-Op Protection Phase: Control swelling (3)
Elevation of the hand above heart level (use pillow)
Encourage active mobilization
○ Movement hastens the reabsorption of excess fluids (muscle pumping action)
Compression stockings, tapes
108
Post-Op Protection Phase: Limit stiffness (2)
Aggressive AROM and PROM of the digits
Scar massage (cross-fiber massage)
109
Rehabilitation goals for post-op protection phase (2)
Control swelling, limit stiffness (0-6 weeks)
110
Post-Op Controlled Motion Phase Weeks
6-8 weeks
111
Post-Op Controlled Motion Phase Goal
Maximize mobility
112
Post-Op Controlled Motion Phase: Maximize mobility (3)
Fixations are removed
Active-assisted forearm and wrist mobilizations, esp supination
May still use dynamic splint
113
Post-Op Return-to-Function Phase Weeks
8-12
114
Post-Op Return-to-Function Phase Goal
Improve mobility, strength, and function
115
Post-Op Return-to-Function Phase: Improve mobility, strength, and function (2)
Continue active-assisted mobilization
Strengthening exercises, digits, theraputty, small weights
116
Joint surgeries (4)
Wrist arthroplasty
MCP arthroplasty
PIP/DIP arthroplasty
1st CMC arthroplasty
117
Wrist arthroplasty phases (3)
Immobilization, maximum & moderate protection, minimum protection
118
Wrist arthroplasty: Immobilization
Neutral position from several days to 2 weeks
Then, in 10-15 degrees of extension for 1-4 weeks
○ Functional position of the wrist (extension)
119
Wrist arthroplasty: Maximum and Moderate Protection Phases (2)
Maintain → improve mobility of unoperated joints
○ ROM and light resistive exercises for joints above & below
Restore control and mobility of the wrist
○ Active wrist extension > flexion
■ For functional use
■ Wrist extension increases grip strength
○ Tendon gliding with wrist in neutral
○ Postpone radial/ulnar deviation, flexion c ulnar deviation (avoid lateral motions initially)
○ Regain use of wrist, finger, & thumb musculature
■ Muscle sets
■ Isometrics
■ Manual and light resistance
120
Wrist arthroplasty: Minimum Protection Phase (2)
Regain functional strength of the wrist and hand
○ Strengthening of extensors > flexors
Regain ROM of the wrist at functional level
○ At least 15 degrees of wrist extension
121
MCP ARTHROPLASTY Phases (3)
Immobilization, Maximum Protection Phase, Moderate and Minimum Protection Phases
122
MCP ARTHROPLASTY: Immobilization (4)
Wrist in neutral
MCP in extension, neutral, or slight radial deviation
IPs in slight flexion
Lateral motions are avoided
123
MCP ARTHROPLASTY: Maximum Protection Phase (2)
Active hand exercises in the dynamic splint
● Avoid lateral pressure of thumb on digits
124
MCP Arthroplasty: Moderate and Minimum Protection Phase (3)
Full active MCP extension
45-60 deg of flexion (index & middle fingers); or 70 deg of flexion (ring & little fingers)
-To facilitate locking of the grip
Active radial deviation of fingers
125
Dynamic extension splint with rubber bands function
Permits active MCP flexion
At rest, maintains the MCP joints in extension and sometimes slight radial deviation
126
PIP ARTHROPLASTY: Start of ROM for central-slip sparring
1-3 days post-op
127
PIP ARTHROPLASTY: Start of ROM for central-slip splitting
3-5 days post-op
128
Goal of PIP arthroplasty
Goal: 70 deg PIP flexion and full extension
Avoid lateral stresses to the operated joint
129
Positioning of post-op swan neck for immobilization
PIP flexion and DIP extension
130
Positioning of post-op boutonniere's for immobilization
PIP extension and DIP flexion
131
What to avoid in 1st CMC arthroplasty
Avoid opposing thumb to the little finger
Avoid excessive lateral movements
○ Eg. pad to pad grip motion
132
Force in stretching of 1st CMC post-op arthroplasty
In stretching, apply force on the 1st metacarpal and not on the phalanx
133
Primary intervention for overuse syndromes
Restorative
134
Restorative goals of overuse syndromes (4)
Control the pain
Reduce swelling
Limit adhesions causing the problems Restoration of function
135
Overuse syndromes: Protection Phase management (6)
Patient education
Physical modalities
Splinting
Cross-fiber massage
Muscle setting exercises
Tendon-gliding exercises (to reduce tendon block, to induce movement from one tendon to another)
136
Overuse syndromes: Controlled motion and return to function Phase management (4)
Stretching
Strengthening exercises
Endurance exercises
Prevention: self-monitoring and biomechanical
assessment
○ To avoid recurrence of injury
137
benign, can resolve in a few weeks
De Quervain's
138
often involves surgery; case to case basis because some surgeries trigger the
formation of more nodules
Trigger finger
139
Stenosing Tenovaginitis
De Quervain's Tenosynovitis
140
Tendons involved in De Quervain's
APL and EPB (anatomical snuffbox)
141
Symptoms of De Quervain's
Pain and swelling over the radial styloid process
(+) Finkelstein’s test
142
inflammation of the synovial membrane covering the tendon
Tenosynovitis
143
inflammation with thickening of a tendon sheath; presents c more pain
Tenovaginitis
144
Occurs as a result of nodule formation or thickening within the flexor tendon sheath
○ Di fficulty in tendon gliding d/t nodules on pulley systems
Trigger finger
145
T/F: Trigger finger - Finger locks in flexion; extension is not possible
True
146
Unlock by passive extension — snap
Trigger finger
147
Most common sites affected in trigger finger
middle and ring fingers
148
Symptoms of carpal tunnel
Sensory deficits are on the digits
○ Tingling sensation on the lateral 3 fingers
○ Intact sensation on the palmar area
Motor deficit on thenar muscles
○ Weak thumb reduces 80-90% of overall hand
function
149
Non-operative management of CTS
● Nerve protection with splinting
● Activity modification and patient education
● Mobility
● Muscle performance
● Sensory re-education
150
Intervention scenario for CTS
Primary Intervention Scenario: Restorative
○ Restore function of the median nerve
○ Reduce tingling and pins and needle sensations
○ Restore grip strength of thenar muscles
151
Mobility for CTS (3)
Joint mobilization
■ Possible restriction: limited motion of carpal bones
Tendon gliding exercises
■ There are also flexor tendons passing
through the carpal tunnel
■ Possible complication: confined space which
may cause impingement
Median nerve mobilization
■ ULTT 1
152
Activity modification for CTS
Biomechanical analysis of faulty motions
Ideal: neutral wrist while typing or playing the
piano
flexed/extended wrist can irritate median nerve
153
Muscle performance for CTS
Resistance & endurance exercises
■ Maintain thumb function, dexterity exercises
154
Sensory re-education for CTS
Apply sensory modalities on area for 5-10 minutes each (start c least irritating stimulus)
155
ULTT 1 position (median nerve stretch)
Shoulder girdle depression
Shoulder abduction
Elbow extension
Shoulder external rotation
Forearm supination
Wrist, finger, and thumb extension Contralateral cervical side flexion
156
Median nerve glides and mobilization (in order of progression)
Wrist neutral with fingers and thumb flexed
Wrist neutral with fingers and thumb extended
Wrist and fingers extended, thumb neutral
Wrist, fingers, and thumb extended
Wrist, fingers, and thumb extended, forearm supinated
Wrist, fingers, and thumb extended, forearm supinated, and thumb stretched into extension
157
Post-op management of CTS (3)
Immobilization
Maximum Protection Phase
Moderate and minimum protection phase
158
Days of immobilization for CTS
7-10 days; 1 week
159
Guidelines for CTS Immobilization (2)
Hand in splint
● Wrist in slight extension, fingers free to move
160
Guidelines for CTS Maximum Protection Phase (4)
Patient education
○ Inform patient not to bear weight on thenar area
Wound management, control edema and pain ○ To prevent infection & aggravation
Active tendon-gliding and nerve gliding exercises
○ Should be wrist in neutral
AROM exercises
○ Avoid active wrist flexion beyond neutral 10 days to 3 weeks post-op
161
Guidelines for CTS Moderate and minimum Protection Phase (5)
Scar tissue mobilization (cross-fiber massage)
Progressive stretching and joint mobilization of restricted tissues
Muscle performance
○ Isometrics: 4 weeks post-op
○ Grip and pinch exercises: 6 weeks post-op
Dexterity exercises
Sensory stimulation and discriminative sensory
re-education
162
Impingement of the ulnar nerve on the ligament passing through the pisiform and hook of hamate
Canal of Guyon syndrome
163
Sensory and motor affectation of canal of Guyon syndrome
Sensory & motor a ffectation on ulnar n. distribution
○ Medial 1 1⁄2 fingers (palmar aspect)
○ Weakness of hypothenar muscles
164
Non-operative management for CoG (4)
Modify the provoking activity
Avoid pressure to the base of the palm
Rest with cock-up splint
Ulnar nerve mobilization
165
Post-operative management for CoG (2)
Immobilization for 3-5 days
Gentle ROM of little finger
166
PREVENTIVE CARE AFTER NERVE INJURY (7)
Avoid handling hot, cold, sharp, or abrasive objects
Avoid sustained grasps
Change use of tools frequently
Build up size of handles to redistribute hand pressure
Wear protective gloves
Inspect skin regularly
Moisturize
