The Hand Flashcards
1
Q
What must be asked during a patient interview of a hand problem?
A
Mechanism, force, duration of injury
time interval between injury and treatmet
medical/surgical management
structures damaged, repaired and technique
location, intensity and type of symptoms
behaviour of symptoms
hand dominance, occupation/social issues
2
Q
What structures could be injured in the hand.?
A
Integument Bony Ligamentous Muscle/tendon Nerve Vascular
3
Q
What injury could occur in the integument of the skin?
A
Acute/ trauma:
wound/friction burn
Insidious/Overuse
callous
4
Q
what bony injuries could occur in the hand?
A
Acute/ trauma:
fracture
Insidious/Overuse?
stress fracture
5
Q
What ligamentous injuries could occur in the hand
A
Acute/ trauma:
dislocation +/- fracture
Insidious/Overuse
instability/laxity
6
Q
What muscle/tendon injuries could occur in the hand?
A
Acute/ trauma:
rupture/tears
Insidious/Overuse
itis
opathy
osis
7
Q
What nerve/vascular injuries can occur in the hand?
A
Acute/ trauma:
tear/compression
Insidious/Overuse
compression
8
Q
What is involved in the physical assessment of a hand?
A
Look at Xrays -fractures/instabilities/non-union/bone necrosis Observation Oedema Sensation ROM Muscle Testing
9
Q
What does a lateral xray view of the hand show.
A
Distal radius, scaphoid, lunate and capitate
10
Q
What xray view assesses the Distal radius, scaphoid, lunate and capitate?
A
lateral
11
Q
How can SC instability be seen on hand xray?
A
PA with clenched fist, >3mm gap indicates ligament injury.
12
Q
What must be observed on a PA hand Xray?
A
arcs should be a smooth line, note size of scapholunate gap
13
Q
What can ultrasonography detect in the had?
A
Tendon injury
synovial thickening
ganglions
synovial cysts
14
Q
what observations should be made during the physical examination of the hand
A
- upper limb and general posture screen
- wounds/scars/lacerations
- skin condition & colour-red/shiny or dry
- oedema
- deformity,wasting
15
Q
When examining a hand, what types o wound could be observed?
A
tidy
untid
tissue loss +/- soft tissue coverage e.g flap
infected
16
Q
What are some general observations when examining a wound?
A
Type of closure Primary Delayed primary Secondary intention Closure: sutures, staples, steri-strips etc Inflammatory response- normal/abnormal Exudate - colour, amount,odour
17
Q
What should be included in an oedema assessment?
A
Location ad type
- pitting or hard brawny oedema
- any associated infection signs
Measurement:
-circumferential - tape measure
volumetric
18
Q
What should be examined for when palpating the had?
A
- skin temp, sweating
- scar tethering
- hypersensitivity- presence and location
- muscle spasm
- tenderness over tendons, tendon sheaths, joints
19
Q
What is the error of hand goniometer?
A
5 degree inter-tester error
20
Q
How does the American society for hand therapists record ROM?
A
+ to record hyperextenson
- to indicate inability to fully extend
21
Q
what is the differential diagnosis for hand ROM
A
intrinsic vs extrinsic muscle tightness
intrinsic muscle tightness
22
Q
How does MCP flexion affect PIP and DIPjoints?
A
They can passively fully flex an extend
They cannot fully flex if the wrist is in neutral
23
Q
How does MCP extension affect PIP and DIP joints?
A
They cannot fully flex or extend
24
Q
What happens if the wrist is passively extend wth MCP and IP extension ?
A
The fingers are pulled into flexion
25
What nerve supplies abductor pollicus brevis?
Median nerve
26
What nerve supplies abd dig minimi and what sign is associated with it?
ulnar nerve
| Frornent's sign
27
What is pure PIN palsy?
attempted wrist extension causes radial deviation of the wrist because o the preservation of ECRL and brachioradialis. ECU lost
28
What does the radial nerve supply?
ECRB, sup, ECU, ext dig minimi, ext dig coommunis, APL, EPL, EPB, extensor indicis.
29
What does the median nerve supply?
all of the flexors of the forearm except FCU and FDP t little and ring fingers (ulnar nerves)
Hand: LOAF
1st and 2nd (L)umbricals
Muscles of the thenar eminence (O)ppens pollicis, (A)bductor Pollicis Brevis, (F)lexor pollicis brevis)
30
What could be observed on the palm of someone with median nerve injury?
Wasting of the thenar eminence
31
How can q median nerve lesion be assessed in the
Ring or OK sign - FPL and index FDP working so anterior interosseu branch of the median nerve is okay.
If injury to AIN, fingers make a square instead of circle
32
What does the ulnar nerve innervate?
FCU, FDP ( ring and little fingers), 4 dorsal inteossei, palmar inteossei 2/3/4, lumbrcals 3 and 4, add pol, muscles of the hypothenar eminence - abd digiti minimi, opens digiti minimi and flex dig minimi
33
What test assesses ulnar nerve injury in the hand?
Froment's sign
grip paper- thumb remains flat, flexion if positive
34
What can cause ulna nerve pathology in the hand?
Hook of Hamate fracture can compress the nerve in Guyon'sCanal
Wrist prolonged compression- cyclist
Hypothenar and interosseus atrophy (dorsal guttering)
35
What are the sensibility tests in the hand?
1. temperature
2. tinel's sign
3. pressure threshold test - semmes Weinstein monofilaments
4. static two point discrimination
5. Moving two point discrimination
6. mobrg's pick up test
- pick up everyday objects with eyed opened and closed while being timed
36
What is the standard for a grip strength test?
Second handle positon
shlder abd, elbow fl 90 degree, forearm and wrist in neutral
average of 3,compare with other side.
37
What are the 4 ways that the hand can be evaluated?
ROM
Strength
Sensibility
Hand function usage patterns
38
What are the functional usage patterns of the hand?
1. finger-thumb prehension
2. full hand prehension
3. non prehension
4. bilateral prehension
39
What are the types of finger-thumb prehension?
tip
lateral
3 point
40
What are the types of full hand prehension?
power
| cylindrical
41
What is nonprehension?
pushing objects
42
What is bilateral prehension?
using palmer surfaces of both hands
43
What are the treatment prinicples for the hand?
1. wound healing principles
2. oedema control
3. therapeutic exercise/ manua therapy
4.splintage
. scar management
6. sensory re-education
7.functional intergration
44
How long does inflammation phase last?
0-48 hrs
45
What happens during inflammation phase?
Vascular response, phagocytosis
| negligible wound strength
46
What is the management during inflammation phase?
rest, elevation, oedema control
47
When in healing does proliferation of fibroplasts occur?
12-hr-10 days
48
What happens during proliferation of fibroplast
Migrate and bridge wound edges
49
What is the management during proliferation of fibroplasts?
rest, elevation, oedema, light exercise
50
What are the phases of wound healing?
Inflammation
| Poroliferation of fibroplasts
51
What is the role of therapy in wound healing?
Appropriate dressing
- minimal bulk
- moist environment
Prevent and control infection
Minimise mechanical inluences
- oedema tensions at site necrotic tise
Scar management
52
What is the position for safe immobilisation of the hand?
wrist : 25-30 extension
MCP flexed to 60
IP joints max extension
Thumb: palmar abduction
53
What are the ways to control oedema?
```
Elevation
Compression
- coban bandage
- lycra finger stall
isotoner gloves
pressure garments
```
Retrograde massage
contrast bathing
appropriate exercise
54
Why I management of scars important?
Scar can significantly impede gliding and function of a hand
55
What are techniques to manage a scar?
massage (from 21+ days)
Thermal agents
Electrotherapy
Silicone products
56
What treatment is used for hypersensitivity?
Desensitization
57
How would desensitization be used for hyperalgesia?
Identify stimuli that provoke a response (texture/immersion particles/maintained pressure/temperature changes)
Apply 5-10 minutes, 3-4 times day
58
What is the definition of sensory re-education
Method by which patient learns to interpret patter of abnormal sensory impulses after interruption in the peripheral nervs system
59
What are the aims of splinting?
1. protect healing tissues/prmotehealing
2. maintain optimal anatomic position
3. restrict/control motion
4. promote/improve rom
5. PROMOTE FUNCTION
60
How can splinting be used to stretch?
provides low load, constant stretch and allow for adaptive changes in the scar matrix and remodelling
61
What three kinds of pathologies occur in the hand?
Traumatic
Degenerative
Systeic - inflammatory/auto-immune disease
62
What are common traumatic conditions in the hnd?
Fractures ( distal radial #, carpal # (especially scaphoid) metacarpal and phalangeal #)
Ligament Injuries (carpal instability, skier's thumb, inter phalangeal)
Nerve lacerations
Tendon lacerations
63
What are common degenerative/overuse conditions in the hand?
OA
De Quervain's Tenosynovitis
Carpal Tunnel Syndrome
Dupuytren's Disease
64
What common inflammatory/auto-immune condition occurs in the hand?
RA
65
How common are distal radius fractures (DRF)?
15% of all fractures
66
Who is prone to a DRF?
predominantly 60-70 age groups from FOOSH
High energy injury in younger people
67
What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint?
Colles' fracture
68
What is a Colles' fracture?
What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint
69
What is a smith's racture?
"reverse colles" with volar (palm side) diplace
70
What is barton's fracture?
displaced, unstable articular fracture subluxation with carpus ollowing
71
What are the steps to a medical management of DRF?
1. obtain a good reduction
2. maintain a good reduction
3. early motion as fracture estability allows
72
What are the treatment options for DRF?
immobilisation - non displaced fractures
cloed reduction
external fexation
ORIF +/- bone grafting
73
Early therapy fr DRF
Oedema control: elevation and compression
Finger ROM
Shoulder, neck, elbow ROM
74
Rehab for DRF once cast removed
writ mobilstions/exs as soon as fracture healing allows
75
HINT***
| Complications of DRF?
```
Significant malunion
Stiffness, OA, pain
Carpal tunnel syndrome
TFCC tears
EPL rupture
Complex regional pain syndrome type 1
```
76
What could cause a hook of Hamate fracture?
cycling, golf, fall
77
When could a lunate fracture occur?
Rare, necrosis more common -Kienbock's disase
78
When should wrist problems be referred on?
Most wrist problems present late - send for xray tor rule ut #
If in any doubt, send for second xray
79
How isscaphoid # diagnosed?
snuff box tenderness/swelling
xray
4 daybone scan 100% sensitive
MRI 72 hrs 100% senstive
80
What should be done if a scaphoid fracture is suspected?
splint
81
What is done for fracture of scaphoid tubrcle
not usually displaced
| rx: immobilisation
82
How often is waist of scaphoid fractured and management
70-80%
increased displacement
increased ned for Sx
83
What is important to note about fracture of proximal pole of scaphoid?
increased risk arterial compromise
| high chance of Sx
84
What are contraindications for closed treatment of scaphoid fracture?
proximal pole
delayed union
comminution (breaking skin)
85
Dx o scapholunate ligament tea
MOI - FOOSH
dorsal central pain/swelling, possible clicking.
scaphoid shift test - Watson's test
86
Tx grade 1 scapholunate ligament tear
immobilise (splint), therapy
Limit gripping, pushing
progressive wrist strengthening - co contraction, proprioception, ADLs
87
Tx grade 2 scapholunate ligament tear
possibly surgical ? pinning, ? repair
88
Tx grade 3 scapholunate ligament tear
open repar, fusion - permanent oss of wrist ROM
89
Where is the triangular fibrocartilage complex
lies between ulna and carpals
| majo stabilier of distal radioulnar joint
90
What can damage the triangular fibrocartilage complex?
compressive loadswith ulnar deviation
| distal radio-ulnar fracture/trauma
91
Sign of TFCC?
clicking sensation onwrs movement
| reduced grip strength
92
Special tests for TFCC
TFCC grind test, supination lift test
93
Treatment of TFCC twear
Bracing
strengthening whenable
arthroscopic repair
94
What is De-Quervain's tenosynovitis?
Thickening & stenosis 1s ext compartment - ABd PL and EPL
95
What is DDx De-Quervain's tenosynovitis?
OA + instability
96
Who is more likely to have De-Quervain's tenosynovitis?
females > males (3-10 x
- pregnancy onet
More common 30-55 yrs
Chronic trauma: movement patterns - thumb abd & ext, RD and UD of wrist
Uaccustomed use
Sporting - racquet sports, rowing, ocupational
97
S&S De-Quervain's
Pain (possible swelling) base of thumb
possibly catching or crepitus
Provocative test: finklestein's
98
TxDe-Quervain's tenosynovitis?
conservative Mx
| rest, EPA, ADL modification, splinting, gentle active ROM exercises, corico-steroid injection
99
When and how is splinting used in De-Quervain's tenosynovitis?
Acute:
forearm based thumb spic for 2/52
Rests AbPL, EPB.
Subacute:
thumboform- care with pressure
neoprene t rest EPB, AbPL
Taping - generally limited
100
What surgical and post op Mx for De-Quervain's tenosynovitis?
Decompression 1st dorsal compartment
wound/scar Mx
Gentle AROM
Strenghtening after 6/52
101
What is skier's thumb?
injury to ulnar collateral ligament of the thmb MP joint involving instability
102
MOI skier's thumb
forced abduction ad hypeextension e.g skier falling on outstretched hand that continues to hold ski pole
103
Investigation for skier's thumb
```
xray to exclude avulsion fracture
MOI
compare uninjured side
palpation
stability tests
```
104
How is skier's thumb stress test performed?
Stabilise metacarpal to prevent rotation that apply radial stress to te phalnx
105
Grading of skier's thumb
1. microscopic tearing, no loss of ligament continuity
2. partial tear
3. complete rupture
106
How are grade 1 & 2 managed?
Conservative.
thumb spica splint han based 6/52
Wk 3: Th flex/ext active ROM exercises out of splint 3-4 times a day.
Wk 6
Gentle passive ROM
lateral palmer pinch strengthening
107
How is grade 3 Skier's thumb managed?
Grade 3 or displaced avulsion # = surgery
Post op:
Hand based thumb spica 6/52
Week 2: thumb MP fl/ext AROM
Week 4: General thumb ROM and strengthening
Week6: modified splint for contact sports/manual work
108
What are the symptoms of carpal tunnel syndrome?
Pan, paraesthesia & numbness - media nerve distribution
Nocturnal symptoms (hand will drift into flexed position while sleeping
Weakness and loss dexterity in hnd
Sense of congestion or swelling in fingers
109
What can pathogenesis of carpal tunnel syndrome be?
1, decreased size of tunel
2. contents of tunnel
3. inlamatory
4. fluid balance
5. neuropathic
110
How can size of carpal tunnel decreas
bony abnormality
| thickened TCL
111
Examples contents of carpal tunnel that cause syndrome
Muscle bellies: lumbicals, FDS.
-mass: ganglia, lipoma
Haematoma
112
Inflammatory causes of carpal tunnel syndrom
RA, infection, Gout, overuse
113
How can fluid balance cause carpal tunne syndrome
pregnancy, hemodalysis, reynaud's, obesity, hypothyroidism
114
Neuropathic causes of carpal tunnel syndrome?
diabetes, alcohlism
115
Dx of CTS?
provocative tests: phalen's, Tnel's
sensibility tests - median nrve distribution
ABdPB muscle power
nerve conduction tests
116
CTS conservative Mx
```
Work/WDL modifications
Nocturnal splint holdingwrist in neutral
Electrotherapy
Oedema control
Assess Cx spine/central component
Weight loss, aerobic fitness,stop smoking
```
117
Surgical management and postop management of Carpal Tunnel.
```
endoscopic vs opn
wound management
early hand ROM
avoid heav lifting/pushing for 4/52
median nerve and tendon gliding exercise
scar managemen
```
118
How can splints help ulnar nerve compression?
change handlebar grip
119
What is wartenberg's syndrome
neuritis of superficial radial nerve - pin base/length thumn, radiodorsal wrist
120
What can cause wartenbeg's
tight jewellery, handcuffs, plaster cast
121
What is the aim of a nerve laceration repair
join as accurately as possible the connective tissue tubes of the peripheral nerve
122
How long does nerve surgery take to heal?
Nerve sheath takes 3-4 weeks to gin sufficient strength to withstand stress
Need to protect with splint until then
*** EDUCATON - particularly young people - high rerupture rate
123
0-3/4 weeks nerve repair
splinted in protected position - usuall flexion
| If no other issues involved - commenced active ROM exercise within splint
124
3/4+ weeks nerve repar
gradual active reginingf ROM
sensoryre-education
prevention o joint contracture - exercise splintage
