Week 8 Regional hand examination and intervention Flashcards
Palmar Hand Conditions
Trigger Finger
Causes: repetitive blunt trauma to __ pulley, fibrotic thickening, idiopathic
Symptoms:
Painful locking of involved finger in (flexion/extension)
Palpable nodule over __ pulley
Tenderness/pain over tendon sheath at __ pulley
An issue with the A1 pulley – fibrous reinforcements of the (flexor/extensor) tendon sheaths
Odd numbers go over the joints 2 and 4 – bowstringing for the tendons
Some say their finger gets locked down into (flexion/extension)
Some will have a little nodule that you can feel
A1; flexion; A1; A1; flexor; flexion
Trigger Finger
Conservative Management:
Steroid injection
Splinting MCP in (flexion/extension) - Sometimes able to do PIP
Surgical Management:
Release of A1 pulley
Rehab: Scar management Edema control A/PROM Avoid forceful composite fist
Complications: PIP joint (flexion/extension) contractures
Series of cortisone injections
Trying to avoid full composite fist because people will trigger. Try to block the MCP from (flexion/extension).
When flexing down the MCP will be blocked with the splinting – helps off load and not be in pain.
Can block the PIP to not flex the entire finger
First two weeks – all about the scar management and promote tendon gliding as the scar remodels. These structures are superficial so scar tissue will inhibit tendon gliding.
Avoid forceful composite fist – not gripping puddy.
Encourage extension (actively/passively) and eventually (actively/passively) to avoid PIP joint flexion contractures.
extension; flexion; flexion; actively; passively
Palmar Hand Conditions
Dupuytren’s Contracture
Benign fibromatosis of palmar and digital fascia in hand that develops in palmar ligaments - Primarily longitudinal ligaments
“Dupuytren’s contracture (also called Dupuytren’s disease) is an abnormal thickening of the skin in the palm of your hand at the base of your fingers.”
Palpable nodule/cord
+ _____ test
Can cause difficulty with hand hygiene and putting hand in pocket
Don’t have that big of a role in conservative management.
Pts will have problem with ADLs, putting hand in pocket, washing hands,
If pt can put their hand flat on the table, surgeon won’t do anything.
Picture: (+/-) table top test – ask them to put their hand flat on the table but they aren’t able
Table Top; +
Dupuytren’s contracture
Conservative Management
(Flexion/Extension) splinting
Maintain P/AROM as able
Surgical Management:
Open/closed fasciotomy
Palmar fasciectomy
Needle aponeurotomy
Post-Op Treatment: (Flexion/Extension) splinting Scar management Edema management Regain P/AROM of digits
Goal: improve hand function
Natural resting hand position is in (flexion/extension)
Pic – extension splint (can wear at night to maintain the extension they have but not interfere with ADLS)
Needle aponeurotomy – place the needle down, work their whole way up the cord to get them to release.
Have patient wear extension (part/full) time for a couple of weeks in pts post palmar fasciectomy/needle aponeurotomy
Extension; Extension; flexion; full;
Dupuytren’s Contracture
Patient at 2nd post-op visit (10 days) (s/P fasciectomy)
If doing nothing about the scar, it will tighten and contract and (flex/extend) down again. Chances of getting tendon to glide will be very (slim/large) if that is the case.
flex; slim
Joint injuries of the digits: general goals
Protect site of injury - don’t have to splint the entire finger. Still want to maintain the motion of the uninvolved joint. Depending on the stability may or may not be able to do controlled motion
Edema control Maintain ROM of uninvolved joints If injured joint is stable: Controlled ROM Pain-free and stable joint Restore previous level of function
Flexor tendons are right on top of each other and if they are unable to glide and clumping together, never gonna be able to make a fist.
Edema control – coband wrap (pic). The (smaller/larger) you spread it the more compression.
larger
Typical treatment for finger injuries
Interventions:
Protective splinting Patient education Edema management Controlled ROM Strengthening Return to functional activities
Complications:
Pain Edema Joint stiffness Intrinsic/Extrinsic tightness Loss of motion at adjacent joints
Intrinsic/extrinsic tightness –
If we have a pt with intrinsic tightness, but given extrinsic stretch won’t have affect we want to see.
(Intrinsic/Extrinsic) tightness – smaller muscles that originate in the hand. Ex -lumbricals. (Intrinsic/Extrinsic) tightness – larger muscles that start outside of the hand and work their way in .
Intrinsic; Extrinsic
Differentiating between intrinsic and extrinsic tightness
Check ROM of the PIP joint with the mcp extended and flexed.
If more motion of the PIP into flexion when the mcp is flexed, we have (intrinsic/extrinsic) tightness.
If the PIP flexion is greater when the MCP is extended than flexed, we have (intrinsic/extrinsic) tightness of the extensors.
If you have a pt who has decreased ROM of the PIP joint and the ROM is the same for both intrinsic/extrinsic they have a joint capsule tightness or a (flexion/extension) contracture
intrinsic; extrinsic; flexion
MCP joint anatomy
_____ is the thickening of the joint capsule
Sagittal band aka extensor hood . Coming off ____ plate and go into the (flexor/extensor) mechanism.
There is a radial and ulnar sagittal band and it maintains the EDC centrally across the joint when we move from flexion to extension.
Collateral ligaments help with valgus and varus stresses.
volar plate; volar; extensor;
MCP Joint Injuries
Collateral ligament injury
Forced ____/____stress at the MCP
Special Tests: ____/_____testing
Most common at the (thumb MCP/pinky MCP)
Test in both extension and flexion
Test in both flexion and extension because these ligaments are more tight in (flexion than extension/extension than flexion). Should have more stability in (flexion than extension/extension than flexion).
Tear of the radial carpal ligament in pic
valgus/varus; valgus/varus; thumb MCP; flexion than extension; flexion than extension
Collateral ligament injury to the MCP
Conservative Management
Partial tear or non-displaced bony avulsions - A bony avulsion is when a piece of bone is pulled off by the tendon or ligament.
Hand-based splint with injured digit and adjacent digits- MCPs at ~ (-) degrees
3-4 weeks: Transition to buddy straps with (AROM/PROM)
Surgical Management
Indication:
Complete tear
Displaced avulsion fracture
Complications:
Extensor lag
Restoring full (flexion/extension) of MCP joint
Hand based split – flex MCP to 30-50 degrees (maintain the length of the collateral ligaments)
If MCP is in (extension/flexion) will cause collateral ligaments to shorten and could lead to a contracture and problems with flexion.
Regaining ROM is a challenge in surgical management
30-50; AROM; flexion; extension
MCP Joint Injuries
Sagittal Band Injury
Boxer’s Knuckle”
Primary lateral stabilizer of the (EDC/FDS) at the MCP joint
Prevents bowstringing during (hyperextension/hyperflexion)
MOI: usually after forceful deviation of the digit against resistance with the MCP (flexed/extended)
Stabilizes the EDC centrally over the joint
Boxers knuckle – closed hand and strike a sharp object
RA can cause rupture of the sagittal band
Extensor tendon has subluxed laterally in the picture
EDC; hyperextension; extended
Left side - intact sagittal band. Right - Extensor tendon is being pulled (radially/ulnarly) because the ulnar sagittal band is intact.
ulnarly
Sagittal band injury
Conservative Management
Indicated for minor injuries-
Without extensor tendon instability
With extensor tendon subluxation
Yoke splint (relative extension splint)
Surgical Management:
Indicated for complete tears with extensor tendon dislocation -
Centralization of EDC with repair or reconstruction of sagittal band
Hand-based splint with MCP in full (flexion/extension)
Progress to yoke splint
AROM at _ weeks
Precautions: Monitor for (flexion/extension) lag
When pt makes fist, his injured digit is held in extension relative to the adjacent digits – (more/less) demand on the sagittal band.
Have them leave the brace on for 4-6 weeks, if they can make a fist after without subluxation of the extensor tendon then we can progress.
(Contracture/Lag) – physically have a restriction passively and actively
(Contracture/Lag) – passively you have the motion, can get them into full extension but actively you can’t
extension; 3; extension; less; Contracture; Lag
PIP Joint Injuries
PIP Joint Anatomy
Extensor Mechanism:
Central Slip - continuation of the EDC, helps (flex/extend) the PIP
Lateral Bands - Come off the EDC proximal to the pip and move laterally and come back together to form the tendon. Help (flex/extend) the pip
Transverse Retinacular Ligament - attaches to the (central slip/lateral bands) and helps hold the (central slip/lateral bands) in place. Make sure they don’t shift volar or dorsal.
Triangular Ligament - help prevent the (dorsal/volar) shift of the lateral bands.
Oblique Retinacular Ligament - linking the motion at the pip and dip. As the pip extends the ligament is going to tighten and help facilitate the (flexion/extension) at the dip. If there is flexion the opposite happens.
Palmar Surface:
Volar Plate - help prevent (hyperextension/hyperflexion) of the joint
Collateral Ligaments - help with varus and valgus stresses
Check Rein Ligaments - extensions of the (volar plate/lateral bands)
extend; extend; lateral bands; lateral bands; volar; extension; hyperextension; volar plate ;
Buddy taping vs. single finger splint
Strap goes across the phalanx and not across the joint. Only trying to provide lateral stability
Try to put the injured collateral ligament (in the middle/on the outside) of the two digits.
Looking at the long finger – injured ligament on the long finger should be in the middle of their buddy taping. (Ulnar/radial) got injured. If ring finger got injured it would’ve been the (radial/ulnar) collateral ligament .
Single finger splint – put pt in that to give more support.
in the middle; Ulnar; radial
Pip joint injuries
Central Slip Injury
MOI:
Forceful blow to (an extended/a bent finger) (“jammed finger”)
Central slip laceration
Can occur during volar dislocation of the (DIP/PIP) joint
Central slip – continuation of the edc, help (flex/extend) the PIP
Examples - Knife slips and get a cut along the dorsum of the PIP, Jammed finger.
Volar dislocation – the middle phalanx dislocates volar to the proximal phalanx.
a bent finger; PIP; extend;
Central Slip Injury Complications:
ORL/Lateral Band Tightness
Encourage (PIP/DIP) ROM for terminal tendon excursion
Contracture causes volar displacement of lateral bands which can lead to a (Boutonniere/Swan neck).
Boutonniere deformity - If central slip avulsion goes unrecognized
Can test for this tightness – Test with PIP extended and flexed. The ORL is going to tighten as we (flex/extend) the PIP, and will relax as we (flex/extend) the PIP. If the dip flexes more when we flex the pip the ORL is (tight/loose). To stretch the orl, you will hold the pip in (flexion/extension) and you will passively (flex/extend) the DIP.
If can flex the dip when we flex the pip there is (tightness/looseness) of the ORL.
Encourage the ROM of the (proximal/distal) joint, helps maintain the length, and excursion.
DIP; Boutonniere; extend; flex; tight; extension; flex; tightness; distal
Pathomechanics of a boutonniere
Central Slip disruption
⬇
Central Slip/Triangular ligament attenuation
⬇
(Dorsal/Volar) subluxation of lateral bands
⬇
Produces (flexion/extension) moment at PIP joint
⬇
Increased (flexor/extensor) pull on distal phalanx
Attenuate – to weaken and become lax
Triangular ligament – helps prevent volar shift of the lateral bands. If they are falling volar to the joint it will provide a (flexion/extension) moment.
The PIP flexes down and will increase pull on the flexor tendon.
Boutonniere -
PIP - (Flexion/Extension)
DIP - (Flexion/Extension)
Volar; Flexion; extensor; flexion; flexion; Extension
PIP Joint Anatomy
Central Slip Injury
Conservative Management
Immobilization with PIP in full (flexion/extension) and DIP (flexed/free) - _ weeks
AROM at _ weeks
Surgical Management
Central Slip Repair
+/- lateral band involvement
Post-op Hand Therapy
Orthosis with PIP/DIP in (flexion/extension)
Short arc motion protocol with surgeon agreement
Want them to flex the dip to have the excursion of the terminal extensor tendon and maintain the length of the ORL. Flexion pulls the lateral bands more dorsally.
If splinting does not correct the deformity, might need to have surgery.
Short arc – little templates and they have to flex down to the template.
extension; free; 6; 6; extension;
PIP Joint Injuries
Volar Plate Injury
MOI: (hyperflexion/hyperextension) force to (flexed/extended) finger
Associated with (volar/dorsal) dislocation of the (PIP/DIP) joint - middle phalanx dislocates dorsally to the proximal phalanx
Collateral ligaments often injured - attach to the volar plate which is why they can get injured
Volar plate helps protect against (hyperflexion/hyperextension)
hyperextension; extended; dorsal; PIP; hyperextension
Volar Plate Injury Complications
Swan Neck Deformity -
PIP - (Hyperflexion/Hyperextension)
DIP - (Flexed/Extended)
Swan Neck – opposite of the boutonniere. Hyperextension of the pip and flexion of the dip.
Have to be able to tell the difference between swan and boutonniere.
Hyperextension; flexed
Pathomechanics of a swan neck deformity
Volar plate is stretched at (PIP/DIP) joint
⬇
Transverse fibers of Retinacular Ligament are stretched - prevents dorsal shifts of the lateral bands, but now they are shifting
⬇
(Dorsal/Volar) subluxation of lateral bands
⬇
Produce extension moment at (PIP/DIP) joint
⬇
Produces stretch to (FDP/EDC) > pulls DIP into (flexion/extension)
PIP; Dorsal; PIP; FDP; FDP; Flexion
Volar plate injury
Conservative Management
Extension block splint in _° (flexion/extension) - Active flexion, but extension only to splint
Edema management
Increase extension in splint _° weekly as tolerated moving towards full extension as long as symptoms are under control
Oval 8 vs. buddy taping at 3 weeks
No extension splinting until - weeks - pip extension passively will stress the volar plate. Wait until time frame to wait to push further on those pts.
Strengthening
Surgical Management
Volar plate arthroplasty - K-wire pinning with static immobilization 3-4 weeks
Offload the volar plate by blocking the (flexion/extension).
30; flexion; 10; 6-8; extension;
DIP tendon injuries
Dip joint anatomy
Main structures: Terminal (flexor/extensor) tendon (FDS/FDP) insertion Volar plate Collateral ligaments
extensor; FDP;
DIP Tendon Injuries
Jersey Finger
(FDS/FDP) rupture
MOI: forced (flexion/extension) of the DIP joint during active (flexion/extension) - Athlete’s finger catches on another player’s clothing
Signs: DIP rests in (flexion/extension), inability to (flex/extend) DIP
Refer to hand surgeon
Someone is actively trying to grasp and hand is pulled into extension
Natural resting hand position is in flexion. Have them make a fist, only ring finger is unable to flex at the DIP and that pt has a jersey finger. Can’t do anything about this, have to send them to hand surgery.
FDP; extension; flexion; extension; flex;
DIP Tendon Injuries
Mallet Finger
Rupture of terminal (flexor/extensor) tendon
MOI: forced (flexion/extension) to an (flexed/extended) digit- Can occur when a ball hits the tip of a finger
Signs: inability to (flex/extend) DIP joint
The extended digit is forced into flexion.
These pts can’t extend the DIP.
extensor; flexion; extended; extend;
Mallet Finger
Immobilize DIP in full (flexion/hyperflexion / extension/slight hyperextension) Leave PIP (in extension/free) if able
Encourage ROM of uninvolved joints
Splint in extension/slight hyperextension for 6-8 weeks
extension/slight hyperextension; free;
Mallet Finger
Conservative Management
Immobilize DIP in full (flexion/hyperflexion / extension/slight hyperextension) for _-_ weeks Avoid DIP (flexion/extension) during hygiene or splint change Full ROM of uninvolved joints
Wean from splint while maintaining extension of DIP
NO passive DIP (flexion/extension)!
Surgical Management
Typically pinning of DIP
Measure extension after 6-8 weeks and start a weening process.
No passive DIP flexion because will stress the extensor tendon.
extension/hyperextension; 6-8; flexion; flexion;
If mallet finger is left untreated, (boutonniere/swan neck) can occur.
There becomes an imbalance on the extensor side of things. Extension power is left to the central slip so the hyperextension at the pip and volar plate starts to (strengthen/weaken). Have to use hx to find out what came first. If you treat the swan neck but the mallet came first, that (is/isn’t) going to take care of the mallet because it was the original issue.
Hand surgeons need to be involved in all of these injuries.
swan neck; weaken; isn’t
Thumb Injuries
Gamekeepers/Skier’s Thumb
(RCL/UCL) tear at the MCP joint of the thumb
MOI: forced (adduction/abduction) of the 1st MCP joint
Stener’s Lesion:
Proximal end of the (RCL/UCL) displaces outside of the adductor aponeurosis
(requires surgery/treat conservatively)
Special Tests: (Valgus/Varus) testing of the MCP
UCL injuries to the thumb – Gamekeepers . Skiers – more so for acute injuries. Both referring to UCL tear at the MCP.
Stenars – adductor aponeurosis will get stuck between the UCL and its’ insertion at the proximal phalanx. Cant’ do conservatively, will need surgery.
UCL; abduction; UCL; requires surgery; valgus
Gamekeepers/Skier’s Thumb Treatment
Conservative Management
Incomplete tear or non-displaced avulsion fracture -
Hand-based thumb spica with IP (in extension/free): - weeks
(AROM/PROM) of MCP at _ weeks
No tip pinch for _ weeks
Surgical Management
Complete tear or displaced bony avulsion
Rehab:
Hand-based thumb spica with IP (in extension/free): - weeks
(AROM/PROM) MCP - weeks
Strengthening - weeks
Pic - wrist and tip of thumb is clear to move
No tip pinch (OK sign) because puts stress on the (RCL/UCL)
GOAL:
Stable pain-free joint - don’t stress ROM over everything
free; 3-6; AROM; 4; 8; free; 4-6; AROM; 4-6; 8-10; UCL;
Thumb Injuries
Radial Collateral Ligament Injury
Far (more/less) common than UCL injury
Special Tests: (valgus/varus) testing of 1st MCP joint
Prognosis - these tend to go very well because it is a fluke accident and the normal stresses we have everyday more so impact the UCL than RCL.
less; varus;
