Shoulder, Elbow, Wrist, Hand Flashcards
Acromioclavicular Joint-AC Joint
- Convex lateral end of clavicle on Concave acromion
- Acromioclavicular and Coracolavicular Ligaments attach acromion to lateral end of clavicle
Sternoclavicular Joint - SC Joint
-Medial end of clavicle is both convex: Superior/INF
—> Concave ant/post
-
Motion of Clavical
moves as a result of scapular elevation, depression, protraction and retraction
-rotates posteriorly when scap is upwardly rotated
Only bone attachment to axial skeleton
Scapulothoracic Joint
scap along thorax
1. Stability: achieved through the balanced forces of upper trap, levator scap, pec minor, rhomboids and serratus
What is Scaption?
30 degrees anterior to frontal plane
-functional position with less tension on the glenohumeral joint capsule
** Always look at spine of scap to decide if its an upward or downward rotation
glenohumeral joint
- convex head of humerus with concave glenoid fossa of scapular
- glenoid labrum increases joint congruence –> increase contact of head of humerus and glenoid
- labrum serves as an attachment for the joint capsule of the shoulder
Open pack position of Glenohumeral Joint
55 abduction
30 horizontal adduction
Closed pack of Glenohumeral Joint
full abduction and external rotation
Arthrokinematic motion of shoulder
CONVEX humeral head moving on CONCAVE glenoid fossa
what direction is the glide with the shoulder joint?
glide is in the opposite direction
Glide motions for Shoulder:
- extension
- flexion
- abduction
- ER
- IR
ext-ant glide
flex-post glide
abd-inf glide
ER- ant glide
IR- post. glide
2 glenohumeral ligaments
coracohumeral- coracoid process to greater tubercle
glenohumeral- covers ant. capsule
scapulohumeral rhythm
scap rotates 1 degree upward for every 2 degrees of total humeral movement
Starts at :
30 degrees of shoulder abd
60 degrees of shoulder flex
Neer’s impingement sign
GOAL: identify inflammation in subacromial space
POS: if there is pain
HOW:
pt. arm is passively forcibly flexed above head which decreases space btw. head of humerus and acromion process
Hawkins-Kennedy Impingement Test
GOAL: identify supraspinatus tendonitis
+ with pain
How:
pt. arm passively abducted 90 degrees and then forced into IR by therapist
Painful Arc
G: inflammation in subacromial space
+ pt has pain btw. 60-120 degrees of abd
H: pt. actively abducts against gravity
Speeds Test
G: bicep tendonitis
+ pain at bicipital groove
H: pt. forearm is supinated with elbow fully extended
Yergason’s Test
G: tendonitis of long head of bicep
+pain in bicipital groove
H: pt supinates forearm and ER shoulder against therapists resistance
Apprehension for Anterior Dislocation test
G: anterior glenohumeral joint instability
+ pt. demonstrates apprehension and prevents further movement of UE
H: pt. supine-> therapist passively abducts and ER shoulder
apprehension for posterior dislocation test
G: posterior glenohumeral joint instability
+ pt. demonstrates apprehension and prevents further movement of UE
How: pt. in supine and therapist passively flexes UE to 90 degrees and elbow to 90 degrees
-therapist passively IR UE and applies a posterior force to pt. elbow
Drop Arm Test
G: identify torn rotator cuff
+ unable to slowly lower arm or experiences pain
H: therapist passively abducts UE to 90 degrees and asks pt. to slowly lower arm
Empty Can Test
G: identifies supraspintatus tendon tear
+ patient has pain or weakness
H: pt. UE positioned horizontally @ 30 degrees ant. to the frontal plane with IR .
-therapist applies downward pressure
What is rotator cuff impingement
tendons compressed or pinched under coracoacromial arch
- mechanical compression=primary
- secondary= glenohumeral instability, weak muscles
clinical signs of rotator cuff impingement
+ hawkins-kennedy, painful Arc and Neers test
- pain& tenderness at supraspinatus tendon
- pain and weakness with abduction, flexion and ER
- traction to GH joint may decrease pain
pt. c/o:
- pain at night
- pain with overhead activities
Non-surgical Rotator Cuff Phase 1
- decrease pain
- decrease inflammation
- pt. education to avoid overhead movements-80 degrees or more
- restore normal arthokinematics-mobs and sleeper stretch
- scapular muscle strengthening
- closed chain-low load
- wall push-ups
- progress to open chain only as symptoms allow
- initiate rotator cuff resistance exercises
Phase 2 Non surgical Rotator Cuff
advanced stabilization and strengthening
- simple motions to more complex
- re-education to avoid re-injury
- exercises mimic desired activity
Sub acromial decompression/ acromioplasty
reshaping the acromion with detachment of the coracoacromial ligament and possible distal clavicle resection
-rotator cuff not torn
clinical signs of rotator cuff torn
+Drop Arm Test
+Empty can Test
- pain/weakness with abduction,flexion,ER
- may be unable to abduct arm
pt. C/O:
- pain in shoulder which can radiate to deltoid
- sometimes pt. has no pain
Phase 1 of Surgical repair of RTC
- 3-4 weeks*
- modalities
- shoulder support as supraspinatus heals-sling w/abduction support
- pain free ROM
- pendulums
- PROM w/o gravity
- active exercises of tri/bi, elbow, wrist & hand
- slowly progress to AA exercises
- gentle strengthening MD
- multiangle isometrics
- support UE to decrease tension on repair
Phase 2 of Surgical Repair of RTC
- avoid repeated abduction or motions near 90 degress of shoulder ABD,FLEX
- *5-12 weeks **
- short arc exercises between 60-120 degrees
- ROM & Flexibility of shoulder girdle
- shoulder girdle and shoulder muscle stability, endurance & function
- incorporate short-arc ex
- rotator cuff strengthening MD
- proceed very cautiously with ER if supraspinatus and infraspinatus was repaired
Biciptal Tendonitis
overuse, glenohumeral instability and impingement
-RTC weakness
Biciptal Tendonitis S&S
+speed tests
+ Yergason’s test
c/o:
- pain at tendon of long head of biceps
- resistance of shoulder flexion
- w/ overhead activities
bicep tendonitis treatment
*CONTROL INFLAMMATION & PROMOTE HEALING
-modification of tasks to prevent overuse
-strengthen RTC muscles
-strengthen scapular muscles
may include:
* surgical intervention-scraping of tendon to eliminate adhesion’s/scar tissue or widening of subacromial space
shoulder instability/subluxation/dislocation
cause:
- can be chronic from hypermobility
- often result of trauma
anterior dislocation
force/position:
-arm abducted. extended and ER
* Most common
anterior aprrehension test
anterior dislocation signs
humeral head sits anterior in glenoid fossa
pt. c/o pain or catching with movement
pain sleeping on affected side
posterior dislocation
force/position
-ARM ABDUCTED, FLEX, IR
+posterior apprehension test
immediate need for closed reduction of dislocation
phase 1 treatment for anterior shoulder instability
4-6 WEEKS
- manage pain and swelling
- AROM
- strenghten of elbow, forearm, wrist in pronation that protect shoulder
- NO SHOULDER ABDUCTION, ER OR EXT
- submax isometric exercises to RTC, deltoid in positions that protect shoulder
Recovery phase of anterior instability
- provide continued protection
- increase shoulder mobility
- mobs except anterior
- increase RTC and scap muscle strength
- isometrics
- partial WB and stabilization
- *external rotators need to regain strength to stabilize the humeral head against atn. translating forces
- *IR&ADD need to regain strength to support ant. capsule
adhesive capsulitis/frozen shoulder
-capsule inflammation, fibrosis and adhesions with resultant pain and ROM loss
primary cause-most common, occurs spontaneously, from unknown cause
secondary cause-after trauma or immobilization
clinical signs of frozen shoulder
capsular patter ROM loss
muscle weakness
guarded shoulder motions with scapular subsititutions
severe decrease in functional use of arm
pt c/o pain with motion, rest and sleeping
capsular patter of shoulder
ER
ABDUCTION
FLEXION
frozen shoulder treatment goals
control pain, edema and muscle guarding modalities -mobs 1-2 pain free ROM progressively increase joint and soft tissue mobility -mob grades 3-4 correct faulty glenohumeral and scapulothoracic rhythm -strengthen scap and RTC muscles correct faulty posture and movement -closed kinetic chain exercises -progress to functional activities
reflex sympathetic dystrophy
an excessive, abnormal response of the sympathetic nerve system in response to trauma
underlying mechanism unclear
clinical signs of RSD
burning pain and hypersensitivity
edema in arm
discoloration of arm
3 stages of RSD
- edem, ROM loss
- 2-6 months: shiny/tough skin changes, joint stiffness
- 6 months and beyond-muscle atrophy, bone loss and joint ankylosis
treatment for RSD
respect pain that accompanies RSD
work within pt. levels while attempting to maintain ROM, strengthen& increase function, desensitize painful area
sprengel’s deformity
smaller scap
rotated medially
scap did not descend during last trimester of gestation
limitation of scap movement limits and glenohumeral movement
scap muscles may be poorly developed & replaced by fibrous bands
therapy goals for sprengels deformity
strengthen scap muscles
improve mobility
improve functional movement of shoulder girdle and shoulder
what does the bicep do for the RTC
pulls the head of the humerus into correct alignment with the glenoid fossa
-depresses head of humerus as arm elevates, keeping head of humerus from impinging on subacromial space
open pack position of shoulder
55 ABDUCTION
30 HORZ ADDUCTION
long axis traction
sustained glide or oscillaton
purpose: pain relief, general mobility
stabilize: scap in supine, scap stabilized by pts. BW on table
mobilize: humerus from glenoid fossa
distraction
P: pain relief, general mobility
s-scapula
m-proximal humerus in an inferior direction
**use web grip
inferior/caudal glide
p-increase abduction
s-scapula
m-proximal humerus in an inferior direction
posterior glide
p-increase IR and flex
s-scapula
m-proximal humerus in posterior direction
anterior glide
p-increase ER and ext
s-scapula
m-proximal humerus in an anterior direction
**if elbow comes up-> humerus is shifting forward =need to stop
Humeroulnar Joint
movement-elbow flex/ext
concave ulna on convex distal humerus
- elbow flexion-ulna glides ant
- elbow ext - ulna glides post
open pack of elbow
70 DEGREES FLEX
10 DEGREES SUPINATION
humeroradial joint
movement- elbow flex/ext
supination and pronation
- Concave radial head on convex distal humerus
elbow flex-radius glides ant
elbow ext-radius glides post
pronation/sup-radial head spins on humerus capitulum
proximal radioulnar joint
forearm pronation and supination
open pack:
70 flexion
35 supination
- forearm pron/sup= radial head rolls within ulnar’s radial notch
- pronation= radial head glides dorsally(post)
- supination=radial head glides volarly(ant)
elbow carrying angle
full elbow ext-valgus
full elbow flex-varus
Ulnar Medial collateral ligament
very thick
**ulnar side considered medial side*
thick triangular ligament that connects distal humerus to the proximal ulna
*tommy john surgery
Valgus Stress Test
assesses integrity of medial collateral ligament
elbow bent to 20-30 degrees
therapist applies a valgus stress
+if pain or increased laxity
radial lateral collateral ligament
connects the distal humerus to the proximal ulna near the radial notch
it is also connected to the annular ligament
provides support against varus stress
Varus Stress Test
assesses integrity of lateral collateral ligament
therpist applies a varus stress
+ if pain or increased laxity
annular ligament
surrounds the proximal radius and keeps the radius within the radial notch of ulna
distal radioulnar joint
movement: forearm pronation and supination
concave radius within convex ulna
pronation: radius moves ant
supination: radius moves post
elbow flexion
biceps bradhii, brachialis and brachioradialis
elbow extension
triceps
forearm supination
supinator and biceps brachii
forearm pronation
pronator teres and pronator quadratus
causes of elbow hypomobility
trauma
fractures
degenerative joint disease
subluxations
dislocations
capsular pattern of the elbow
flexion>ext
pushed elbow
proximal subluxation of ulna
occurs form FOOSH
clinical signs of pushed elbow
decrease:
-elbow flex or ext
-forearm pronation
wrist flex
pulled elbow or nursemaids elbow
radial head is pulled out of annular ligament
forceful pull on hand - pick up heavy object or jerking motion
common in young children
clinical signs of pulled elbow
supination is restricted
person holds forearm in pronation
treatment of pulled elbow
restore alignment of radial head within annular ligament performed by appropriate medical provider
phase 1 for elbow hypomobility
minimize adverse impacts on immobilization
reduce inflammation
maintain joint and soft tissue mobility
maintain intergrity and function of related areas
goals of phase 2 elbow hypomobility
increase soft tissue and joint mobility
- joint mob 3+4
- manual stretching
- self-stretching and hep
- self mobilization with movment
improve muscle performance and strength
-open and then closed chain
initiate functional activities
phase 3 goals for elbow hypo-mobility
increase muscle performance/ strength
- isokinetic ex
- plyometric ex if appropriate
restore full functional mobility of joints and soft tissue
promote joint protection
progress to independence
JOINT MOB 3-4
criteria for phase 2 of elbow hypomobility
no swelling, minimal pain and tolerates ROM activities
criteria for phase 3 of elbow hypomobility
no pain, almost full AROM, strength 4/5
total elbow arthroplasty
significant pan and decrease of function
follow MD protocol
over-use/repetitive stress injuries
excessive use causes micro-trauma and parital tearing of muscle tissue
inflammation can become chronic with continue irritation
new scar tissue if repeatedly over stressed before it is mature
lateral epicondylitis
tennis elbow
inflammation at wrist extensor tendons
can become chronic with fibrosis-epicondylosis
more common
repeated wrist extensor activities
signs of lateral epicondylitis
general increase pain at lateral epicondyle
pain with palpitation on lat epicondyle
pain w. resisted wrist ext w/ elbow ext
pain with passive wrist flexion and elbow extended and forearm pronated —-stretches the wrist extenors
medial epicondylitis
inflammation at wrist flexor tendons and pronator teres
can become chronic with fibrosis of area
GOLFERS ELBOW
signs of medial epicondylitis
general increased pain at medical epicondyle
pain with palpation on medial epicondyle
pain with resisted wrist flexion with elbow ext
pain with passive wrist ext w/ elbow extended and forearm supinated —-stretches wrist flexors
medial ulnar collateral ligament-valgus stress overload
acceleration phase and deceleration forces apply high valgus stress loads on ulnar collateral ligament
clinical signs of medial valgus stress overload
pain along medial aspect of elbow joint
+valgus stress test-pain and laxity of ulnar collateral ligament
–if sprain is significant may require tommy john’s surgery =grade 3
medial collateral ligament rehab with no surgery
rehabilitation is similar to overuse injuries
- stretch/strength-no valgus stress
- monitory full extension
exercises for medial collateral ligament with no surgery
emphasize eccentric control of bicep ROM Low load stretching HEP controls speed of movement PNF patterns try to prevent elbow flexion contractures
Tommy John Surgery Rehab
limited ROM 3-4 weeks: 110 ROM elbow flex, submax isometric
full ROM 406 weeks:0-130 elbow flexion= con,ecc contraction
Functional training 2-4 months-> begin throwing, 2 hands then 1 hand
resume sports 10-12 months
immobilization is important
olecranon fractures
usually fall on the point of the elbow
forceful contraction of triceps
-no active tricep contraction until fully healed
supracondylar fractures
can be due to FOOSH =distal humerus goes posteriorly
direct trauma to posterior elbow=distal humerus displaces anteriorly
intercondylar fractures
-T or Y fracture to distal humerus which goes through the condyles
-can be due to fall on elbow
direct trauma to posterior elbow
Radial Head and/or proximal ulna fractures
usually due to FOOSH
possible fracture complications
nondisplaced
displaced
comminuted
Volkmann ischemic contracture
severe swelling at elbow due to fracture creates pressure on blood vessels and nerves
- brachial artery
- median nerve
increased varus or valgus deformity
gunstock deformity=cubitus varus-radial head and neck fracture
valgus deformity=cubitus valgus- prox. radius and ulnar fracture—> very tight joint and wont fully extend
what do you stretch for the lateral epicondyle?
wrist extensors
what do you stretch for the medial epicondyle
wrist flexors
joint distraction of humeroulnar joint
p-pain control, general mobility to increase elbow flex/ext
s-humerus using a belt
m-ulna
**mobilize ulna at 45 degree angle to the shaft using both hands
open pack position of humeroulnar joint
70 degrees of elbow flexion
10 degrees supination
distal glide of elbow
p: increase elbow flexion
S:humerus
m: ulna
**Perform scooping motion toward your body
joint distraction of humeroradial joint
p: pain control, general joint mobility
s: distal humers
M: distal radius
*pull radius distally
Dorsal Radial Glide
p: increase elbow extension
S: distal humerus
M: proximal radius in a dorsal direction–posterior
*radial head toward floor with palm
Volar Radial Glide
p: increase elbow flexion
S: distal humerus
M: proximal radius in a volar direction-anterior
* radial head towards ceiling with fingers underneath
open pack of proximal radioulnar joint
70 degrees of elbow flexion
35 degrees of supination
dorsal glide of proximal radioulnar joint
p: increase pronation
s:proximal ulna
M: proximal radius in dorsal direction
**Posterior direction
Volar Glide of proximal radioulnar joint
P: to increase supination
S: proximal ulna
M:proximal radius in a volar or anterior direction
**grasp underneath and mobilize toward palm
Distal Radioulnar Joint Dorsal Glide
P: increase supination
S: distal Ulna
M: distal radius in a dorsal direction
**pt. is seated-> elbow flexed 70 degrees and supinated 10 degrees
Olecranon bursitis - students elbow
Edema in bursa along posterior elbow
causes: repeated leaning or crawling using elbows
or repeated throwing overhead
arthritis
treatment considerations
elbow pad with resting activities
anti-inflam supportive techniques
elbow overuse/repetitive phase 1 treatment
ICE-superficial injury
supportive techniques and taping
alter activities-give pt. other things to do to avoid doing activity that caused injury
soft tissue/joint mobs
pt. education
deep friction massage
stretching-be careful at beginning of treatment to not damage origin of muscles
muscle setting-elbow initially flexed, pain free ROM
phase 2 of elbow overuse treatment
criteria: no signs of inflammation
restore full ROM
strengthen muscles
initiate functional activities
start w/ eccentric -> less stress and helps w/ collagen realignment
supportive straps -> cause muscle to think the origin is where the strap is and takes load off muscle
elbow overuse phase 3
criteria: full pain-free ROM
activity modification
-help retrain muscle into proper alignment
functional training
* if they start to have pain-> they will begin to substitute —need to stop exercise so they do not do compensate
distal radial ulnar joint
forearm prontation/supintation
concave ulnar notch of radius on distal convex ulna
radiocarpal joint
radius connects to: scaphoid, lunate, triquetrum
-only the radius is part of the joint
MOVEMENT: wrist radial and ulnar deviation & wrist flex/ext
prox. row of carpal bones are convex and move on concave distal radius
what does that annular disc provide at the radiocarpal joint?
it helps evenly transfer force along the radius
midcarpal joint
joint btw. 2 rows of carpals
movement: wrist radial/ulna deviation
wrist flex/ext
midcarpal joint is a plane joint
glide on each other
what is the arrangement of carpal bones?
trapezium, trapezoid, capitate, hamate = convex(distal)
scaphoid, lunate, triquetrum, pisiform=concave(prox)
carpometacarpal joint CMC 2-5
2nd metacarpals w/ trapezoid
3rd with capitate
4th w/ hamate
- allows cupping of hand
- allows extension which improves release objects
CONCAVE=METACARPAL
CONVEX=CARPAL
carpometacarpal joint CMC 1
1st metal carpal w/ trapezium=saddle joint
movement:
flex/ext
abd/add
opposition
1st MTC concave on convex trapezium=flex/ext
1st MTC convex on concave trapezium=abd/add
metacarpophalangeal MCP 2-5
condyloid joints
MCP flex/ext
MCP abd/add
concave prox phalanx w/ convex metacarpal
interphalangeal: IP, PIP, DIP
movement:
IP flex/ext
PIP flex/ext
DIP flex/ext
wrist extension muscles
extensor carpi radialis brevis and longus
extensor carpi ulnaris
**lateral epicondyle
wrist flexion muscles
flexor carpi radialis
flexor carpi ulnaris
**medial epicondyle
finger extension
extensor digitorum
*extensor hood ligament= wraps around distal MTC/ prox phalanx and continues distally
extensor indices
extensor digiti minimi
finger flexion
flexor digitorum profundus
flexor digitorum superficialis
lumbricals
finger abduction
dorsal interossi- ulnar
finger adduction
palmer interossi-ulnar
radial nerve
- posterior hand*
sensation: dorsal hand 1- medial side of 4th finger, medial thumb - *fingers 1-3 on dorsal side but not finger tips
motor: wrist & finger extension, thumb extension
nerve compression/injury:
- drop wrist deformity
- extensor muscles are paralyzed
median nerve
sensation:
fingers 1-3-on voral side or palm side and finger tips
medial side of 4th finger
motor:
finger flexion
thumb opposition
flexion
nerve compression:
thenar eminence atrophy-starts to flatten
can be due to carpal tunnel syndrome
ulnar nerve
sensation:
dorsal and palmer of 5th and lateral side of the 4th finger
motor: PIP and DIP of 4/5 finger ext. flexion of little finger MCP finger abduction thumb adduction DIP/ PIP adduction
nerve compression:
hypothenar eminence atrophy
hand of benediction
narrowing of gunyon’s canal can compress ulnar nerve
Tinel’s Sign test
therapist taps over carpal tunnel of wrist
+pt. reports parathesia distal to wrist
identifies carpal tunnel syndrome
Phalen’s Test
pt. maximally flexes wrists and holds the back of the hands together for 1 minute
+ pt. reports paresthesia, tingling, numbness in median nerve distribution
identifies carpal tunnel syndrome
Reverse Phalen Test
pt. maximally extends wrists and holds the palms together for 1 minute
- prayer stretch
+ pt. reports parathesia, tingling, numbness in median nerve
identifies carpal tunnel
Finkelstein’s Test
pt. makes a fist while holding thumb inside fingers
therapist performs ulnar deviation to wrist
+pain in snuffbox
identifies de Quervian’s Syndrome
acute phase goal for wrist
control pain
maintain joint mobility and muscle flexibility
maintain function of surrounding uninvolved areas
therapeutic management in acute phase for wrist
well joint motion
splinting/bracing
modalities to control pain and inflammation
pain free ROM
multi-angle isometrics
sub acute phase for wrist/hand
CRITERIA
-resolving edema
minimal to no pain with ROM and isometrics
GOALS:
progressively restore joint mobility-mobs
progressively restore muscle flexibility -gain full ROM
progressively strengthen involved area
return to functional activities w/ protection
wrist/hand return to function phase
criteria:
pain free ROM
strength testing
*limitations in functional use of the involved area due to losses of ROM and muscle weakness
how to achieve main goals of: return to function phase of wrist/hand
specificity of exercises increase complexity increase speed of movement perform close chained ex increase joint mobility reduce risk of re-injury
Rheumatoid arthritis
most common inflammation in MCP, PIP and wrist joints, extrinsic tendon and sheaths
joint capsule weakening, cartilage destruction, bone erosion and tendon rupture
clinical signs of RA
flexion at wrist joint
radial deviation of wrist
rupture/stretching of collateral ligaments of MCP joint
–ulnar drift of fingers, volar sublux of prox phalanx
swan neck deformity of fingers 2-5
boutonniere of thumb
Swan Neck
hyper ext. of PIP
flexion of DIP
Boutonniere deformitiy
PIP flex
DIP ext
*extensor hood mechanism breaks off
DJD/OA
chronic degenerative disease which affects articular cartilage
can cause bony overgrowths/spurs
signs of OA
restricted/painful ROM
joint capsule limitations
possible abnormal hard end feels due to bone spurs
muscle weakness
joint enlargement
most common in trapezoiscaphoid articulation
CMC, DIP
heberdon nodes
DIP enlargement
bouchard nodes
PIP enlargement
RA/OA acute phase
increase rest during flare-ups alternate activities to avoid fatigue use frequent but short episodes ofe x pain free AROM ex avoid prolonged static positions during the day
what to be aware of with RA
ligaments,tendons and capsule will be weakened due to the diseases process and the use of steroids
person experiences low-grade fever and fatigue during acute phase
active ex not tolerated with pain use gentle PROM
grade 1-2 mobs can be used but not recommended
avoid/alter strong grasping activities which further deform wrist and hand
avoid twisting motions
subacute and chronic phase treatment of RA/OA
use appropriate adaptive equipment to decrease stress on joints
pain free resistance ex within tolerance of joint
very gentle pain-free stretching within tolerance
encourage nonimpact or low impact conditioning ex
HEP of AROM and gentle stretching
Colle’s fracture
distal radius is fracture
distal radius then displaces in dorsal direction
dinner fork deformity
FOOSH
RADIUS MOVES POSTERIORLY
Smith Fracture
reverse colles fracture
displaced fracture of radius in palmar direction-anterior
fall on dorsum of hand
ulna fracture
usually occur together w/ radial fracture
scaphoid fracture
result of FOOS with hyperextended and ulnar devation
avascular necrosis due to disruption of blood supply possible
management: proximal portion of scaphoid no direct circulation w/ 12-24 weeks of immobilization
clinical signs of scaphoid fracture
pain and swelling in anatomical snuffbox
pain with wrist extension
decreased grip strength
MCP fractures
- boxers fracture-neck of 4/5 MTC
2. bennett fracture-palmar base of proximal 1st metacarpal
phalanx fracture
treatment depends on type and displacement
TFCC-triangular fibrocartilage complex
injury to articular disc and ligaments on the ulnar side of wrist
Cause:
-force applied to pronated hand: FOOSH; drill “catching” arm and rotating
Treatment for TFCC
nonsurgical -splint
surgical-arthroscopic or open surgical repair
SKier’s Thumb
acute sprain of collateral ligament of thumb
cause of skier’s thumb
valgus stress and hyper extension of thumb
treatment of skier’s thumb
spint or surgery
DeQuervains tenosynovitis
swelling thickening and narrowing of sheath’s tunnel for abductor pollicis longus and extensor pollicus brevis tendon
causes of DeQuervain’s
forceful repeated thumb abduction and extension usually with radial deviation
Clinical signs of DeQuervain’s
pain on radial side of wrist aggravated by use of thumb
pain increased by ulnar deviation of wrist
+ flinkelstein test
Trigger Finger
inflammation or thickened tendon/flexor sheath
causes of trigger finger
idiopathic or repetitive tasks requiring prolonged grasp
clinical signs of trigger finger
sticking/catching of tendon with finger flexion
Boutonniere Deformity
rupture or stretched extensor tendon at pip
clinical signs of Boutonniere deformity
PIP flexion
DIP hyper extension
Mallet finger
avulsion fracture or tendon rupture at distal phalanx
signs of mallet finger
DIP flexion cant actively extend DIP
Transverse Carpal ligament
formed by carpal bones and transverse carpal ligament
contains median nerve and 9 flexor tendons
carpal tunnel syndrome
median nerve entrapment
cause of CTS
arthritis fracture cysts swelling from trauma aging pregnancy occupational factors vibration repeated motion of wrist
signs of CTS
numbness and tingling of thumb and radial digits
pain worsens at night
atrophy of thenar muscles
swelling in hand and forearm
tests for CTS
Tinnel’s
Phalen’s
Reverse Phalen’s
Possible rehabilitative management options
altering lifestyle avoid extreme wrist flex/ext tendon gliding ex supportive modalities cock-up splint: 0-20 ext surgery
types of grips 4
- Hook- holding on to monkey bars ex
- cylinder-obj. btw finger and thumb–holding water bottle
- holding on to hammer
spherical-opening a jar w/ finger tips on top
full hand extension glide
MCP PIP DIP
hook/claw glide
MCP ext, PIP DIP flex
Full fist glide
full flexion of MCP PIP DIP
lumbricals
MCP Flexion
DIP PIP extension
Straight Fist
MCP Flex
PIP flex
DIP ext
how to strengthening lumbricals
MCP joint flexion with IP ext
interossei and thumb abductor brevis and longus strengthening
MCP abduction
ex: rubberband around fingers and have pt. open hands
Oppones pollicis strengthening
thumb opposition: pinching, tripod and tip to tip
3 precautions with stretching fingers
fingers should always be stretched individually
lengthen the muscle over one joint while stabilizing the other joints
careful not to cause hypermobility
Radiocarpal joint traction
p: pain control and general mobility
S: distal radius and ulna
M: proximal row of carpals
position: pt. seated with forearm pronated
grasp: styloid processes and fixate the radius and ulna against table
mobilize the distal direction
radiocarpal dorsal glide
p: Increase wrist flexion
s: distal radius and ulna
M: proximal row of carpals in a dorsal direction-posterior/back of hand
**have arm pronated and towel under wrist
radiocarpal joint volar glide
p: increase wrist extension
s: distal radius and ulna
M: proximal row of carpals in a volar direction–towards palm of hand
**pt. hand is pronated
radiocarpal joint ulnar glide
P:increase radial deviation
s: distal radius and ulna
M: proximal row of carpals in ulnar direction
- *pt. forearm in neutral with ulna supported on treatment table
- *move towards ulna–> towards floor
radiocarpal joint radial glide
p: increase ulnar deviation
s: distal radius and ulna
m: proximal row of carpals in an radial direction
**neutral hand and move towards radius –>towards ceiling
