Week 8 Regional wrist examination and intervention Flashcards
Radial-sided wrist pain
Intersection Syndrome
DeQuervain’s Tenosynovitis
Basal Joint Arthritis
Out of the above radial-sided wrist pain, which is the least common?
Intersection syndrome
Radial-Sided Wrist Pain
Intersection syndrome
Tenderness, friction, and crepitus during wrist (flex/ext / pronation/supination) with (RD/UD)
Where: distal forearm 4-5cm proximal to the (radial/ulnar) styloid
Where 1st dorsal compartment crosses over the 2nd
MOI: forceful, repetitive wrist (flex/ext / pronation/supination)
Rowing, weightlifting, racquet sports
These patients - they can hear a noise or squeaking, feels like wet leather
Most often the pts do crew or some sort of rowing
flex/ext; RD; radial; flex/ext
Intersection syndrome
Initial treatment:
Rest from aggravating activities
Splinting to abate acute symptoms - Thumb spica
Modalities -
Cryotherapy
Ionto? - dexamethasone .
It is an option but less insurance companies are covering it.
Progression-
Stretching
Strengthening
Surgical management is not common
APL and EDB cross the radial sided wrist extensors.
Really need to shut the patient down, to calm the symptoms.
Symptom free with (AROM/PROM) before progressing to strengthening.
Happens at this intersection point.
Have to shut down these patients and put them in an orthosis. The intersection point goes to the thumb so the wrist control is not going to be enough in these patients. Have to be able to support the wrist and thumb.
Don’t want to be in splint all the time when pain free.
When pain free, start stretching of _____ and _____ , and begin (active/passive) ROM.
Once going through active ROM with no symptoms, can start strengthening.
; AROM; ECRL and ECRB; active
Radial-sided wrist pain
Dequervain’s tenosynovitis
Pain/swelling over 1st dorsal compartment: what muscles make up the 1st dorsal compartment?
+ ______ Test
+ pain with resisted thumb (adduction/abduction)
Differentiates this issue from Wartenbergs Syndrome – doing the test with the forearm pronated will differentiate, because the tenosynovitis is (less/more) provoked in this position.
Can test with the finklesteins – thumb down flexed, make fist, ulnarly deviate.
Dequervain’s is extremely common
Common with mothers and new moms because picking up their kids in an (adducted/abducted) position, reaching down, and (radially/ulnarly) deviating (strain on the 1st dorsal compartment)
APL; EPB; Finklestein’s; abduction; less; abducted; ulnarly
Dequervain’s tenosynovitis
Conservative Management:
Splinting prn
Patient education/activity modification
1st dorsal compartment stretching as tolerated
Strengthen as appropriate
Surgical Management: 1st dorsal compartment release Splinting prn Scar management Pain management (including hypersensitivity) Regain (AROM/PROM) Strengthen as appropriate
Looking at how they pick up the baby, how they might be able to pick up the baby safely, but w/o Ulnar deviation and thumb abduction(?) prior to contraction.
Stretching is the Finkelstein position, start light and slow short duration at the beginning.
Pain free (AROM/PROM) before strengthening.
Rubber bands are good tools – easy to grade by how far around the fingers you place the band.
Post surg-
Splinting is short lived.
DSRN (Dorsal sensory radial nerve) can get aggravated from the surgical technique.
Urge pts to kneel down and scoop up
Pts who have DQ – need smaller cup to be able to grasp
1st dorsal compartment stretching – do Finkelstein’s test for a stretch. Fine line between tightness and pain. Cant hold stretch for 30 seconds, so start with maybe 15 seconds. Have to start somewhere.
Do wrist and thumb AROM. For the thumb, work palmar (abduction/adduction) (CMC abduction) and (radial/ulnar) abduction (hand flat on the table and sliding thumb radially)
Strengthening with radial abduction – use a rubber band. If need to decrease tension, have the rubber band go around (more/less) fingers to be able to change the tension of a single band.
Injections if they fail conservative treatment
1st dorsal compartment release – (increase/decrease) compression of the 1st dorsal compartment
AROM; AROM; abduction; radial; less; decrease
Dequervain’s or intersection syndrome?
Symptoms of someone with DQ – pic to the (right/left) . Tracking through 1st dorsal compartment and hitting the thumb
Intersection – pic on the (right/left). More dorsal and less radial
left; right
Radial Sided Wrist Pain
Basal Joint (CMC) Arthritis
Basal joint - 1st CMC
Pain at base of (1st/2nd) metacarpal
Pain with (pinch/grip)
+ _____ Test
+/- Shoulder sign
Note: x-rays are not always consistent with subjective pain complaints
Some pts will have a lot of pain but the xray shows mild degenerative changes at the joint
Pic on the left – 1st metacarpal and trapezium. The 1st metacarpal is kind of subluxed and slipping off the trapezium radially. The webspace is a lot smaller on the left compared to the right hand. As this 1st metacarpal subluxes radially, causes the _____ pollicis to contract. Collapses the webspace and not very functional for out patients.
1st; pinch; Grind; adductor
Radial-Sided Wrist Pain
Basal Joint Arthritis
Shoulder sign – Beak ligament gets lax.
With ______ pollicis pulling during making a fist, it accentuates the radial sublux causing a shoulder sign.
Blue arrow – base of the metacarpal has subluxed radially (shoulder sign)
Red arrow – webspace is collapsing
____ Test - Axial compression through the thumb and rotating it. People with arthritis will have pain with this maneuver
adductor; Grind
Basal joint arthritis
Conservative Management
Splinting for pain relief
Maintain webspace
Maintain (AROM/PROM)
Thenar cone strengthening - Proper tip pinch requires several muscles to work at once!
Surgical Management
Basal Joint Arthroplasty -
Remove the trapezium
multiple options to replace with soft tissue.
no artificial components.
biggest complaint – patients struggle getting their hand flat on a table
surgeon tightens the thumb in prehension on purpose
do not force it flat – it will get there over time.
Post-op treatment:
Protective splinting with (CMC/IP) free
AROM at _ weeks
Strengthening at _ weeks
Prevent contracture of the adductor ____
If they aren’t in pain, not going to be in a brace at that point.
Maintain webspace – important for functional activities to grasp objects
Tip to tip pinch requires several muscles to work at once which helps spread the force to preserve the joint
Basal joint arthroplasty – completely remove the trapezium and take a redundant portion of a tendon and weave it into the vacant space where the trapezium was and stabilize the thumb in a functional position (position where you can pinch and grasp.
AROM; IP; 4; 6; pollicis;
Proper tip pinch requirements
Main actions:
Opposition to Index Finger (IF)
(1st and 2nd/3rd and 4th) MC stabilization to facilitate tip to tip prehension
Work from C to an O
Opposition to index finger (IF) – When we oppose have to use multiple muscles
Stabilization – need multiple muscles to work at once.
If there are weakness in these muscles, will have a collapsed pinch and flattening of the thumb to occur. Will increase compressive load on 1st CMC joint.
Teach them to go from a C to an O – The pinch using a C forces the CMC joint at the thumb to work a lot (harder/less).
1st and 2nd; harder
Ulnar-sided wrist pain
FCU tendonitis
Common in tennis players, rock climbers, and those who use scissors frequently
Scissors – barbers, hair stylists
Wrist (flexion/extension) and (RD/UD)
Typically a (shallow/deep) ache
Can be confused with _____ injury
Can test with MMT and palpation
Treatment – wrist splint then treat like all other tendinopathy
Can have pain with MMT or tenderness to palpation
Because it is ulnar side of the wrist, can be confused with TFCC injury
Wrist splint for aggravating activities
Gentle progression of AROM (pain free – lead to strengthening)
flexion and UD; deep; TFCC
Ulnar-Sided Wrist Pain
ECU tendonitis or subluxation
Tendonitis:
Tender to palpation (TTP) and with resistance to the ECU - (Extension and UD/Flexion and RD)
+ ECU _____ Test
Subluxation:
Subluxation, pain and snapping with (pronation/supination), (UD/RD), and (flexion/extension)
Common in racquet sports, golfing, and rowing
Treatment:
Splinting (limit (UD/RD); possibly (supination/pronation))
Isometric (RD/UD)
Eccentric wrist (flexion/extension)
If more of a subluxation – try to limit rotation.
Pain free isometric before prescribing.
Pic – ECU ____ test. Elbow in a supinated position with wrist in neutral. Going to put pressure on the middle finger and thumb and have them radially abduct. When the pt does that, that causse the ECU and FCU to co contract. Will cause symptoms in the ECU and not compressing the TFCC so no false positives compared to other tests.
Great test for tendonitis of the ECU.
Extension and UD; Synergy; supination, UD, and flexion; UD; supination; UD; extension; synergy
Ulnar-Sided Wrist Pain
TFCC Injury
Classifications:
Type 1 – (traumatic/degenerative)
Type 2: (traumatic/degenerative) - Associated with + ulnar variance
MOI (type 1): fall on (flexed/extended) wrist with (pronation/supination) or traction injury to ulnar side of the wrist
Chief complaints: (Pain/paresthesia's) with (UD/RD) and rotation (increased/Decreased) strength Pain at (beginning/end) ROM Tenderness
Many c/o clicking in the wrist
Tfcc is a shock absorber in the wrist – stabilizes DRUJ.
Injuries to the tfcc can be traumatic (fall with extended wrist in pronation or traction injury- diving on the ball and glove gets caught)
Tenderness to palpation on the TFCC
traumatic; degenerative; extended; pronation; pain with UD; decreased; end;
Fovea Sign
Palpate between the (radial/ulnar) styloid and the (FCU/ECU)
Fovea is a groove at the base of the (radial/ulnar) styloid that serves as an attachment for the _______
+ test = tenderness to palpation
Tests tenderness to palpation
These pts are extremely tender to palpation
ulnar; FCU; ulnar; TFCC
TFCC Load Test
Detects TFCC (dislocation/tear) or ulnocarpal abutment
+ pain, clicking, crepitus, or reproduction of symptoms
Place pts elbow on the plinth. Other hand places axial load through the wrist and move them into (radial/ulnar) deviation.
tear; ulnar
Ulnocarpal abutment - Aka impaction or impingement
Can be causes by (radial/ulna) shortening or angulation s/p distal radius fx
Symptoms: Pain – (dorsal/volar) aspect of wrist over (PRUJ/DRUJ) or directly over \_\_\_\_ Clicking sensation (Increased/decreased) strength/ROM Activity-related swelling
Special Tests: _____ test
Length of the ulna in relation to the radius – ulna variance
Look at space on the ulnar side of the wrist, it is very open.
pic – positive ulnar variance. Ulnar styloid compresses in on the TFCC and cause irritation of that.
Can also happen after distal radial fracture
Ulnar variance will (increase/decrease) in supination, (decrease/increase) in pronation, and (decrease/increase) during gripping.
When someone has ulnar side complaints, may want to avoid the (pronated/supinated) position initially in these patients.
radial; dorsal; DRUJ; TFCC; decreased; GRIT; decrease; increase; increase; pronated
Gripping rotatory impaction test (GRIT)
Identifies articular disc tears associated with ulnar impaction syndrome
Gripping in pronation ⬇️ ↑ positive ulnar variance ⬇️ ↑ impaction of ulna on ulnar-sided structures
Measures grip strength in 3 forearm positions
Neutral
Full supination
Pronation
Supination/pronation values are calculated as a ratio relative to neutral grip
Gripping in pronation – making the assumption it will be weaker due to pain. Gripping when we pronate (increases/decreases) the positive ulnar variance which will likely result in (increased/decreased) strength.
increases; decreased
Gripping rotatory impaction test (GRIT)
GRIT ratio = (supinated/pronated) grip strength
/
(supinated/pronated) grip strength
Ratio (greater/less) than 1 = potential for impaction or an articular disc tear is high
Example: Supinated grip strength – 30 kg Pronated grip strength – 20 kg GRIT ratio = 30/20 = 1.5 Likely injury to TFCC 2/2 ulnar impaction
Ideally these will be close to 1 (not thinking the pt has any issue with ulnar impactment syndrome)
In the ex:
Likely had decreased strength due to pain
Neutral should be the strongest of the three. When they take the neutral it is not included in the ratio. Neutral grip strength is taken just so pt is comfortable.
Supination and pronation grip strength should be of similar value, supination a little more.
supinated; pronated; greater;
TFCC injury
Conservative Management
Splinting
Modalities prn
Maintain (AROM/PROM)
Progress to strengthening as able while limiting pressure on TFCC - Consider strengthening in (supination/neutral rotation/ pronation) and progress to (supination/neutral rotation /pronation) as tolerated
Surgical Management
Central or peripheral tear?
Debridement
Central tear
Splinting as needed initially
Progress as tolerated
Repair
Peripheral tear
May be arthroscipic or open
Requires immobilization 4-8 weeks
Ulnar shortening osteotomy
Post debridment if poor outcome
If ulnar-positive variance is considered a precipitating factor
2 main types
Ulna shortedned with rigid plate fixation
Muenster splint for 6 weeks
Followed by ulnar gutter for 2 weeks
Ulnar head resection or wafer procedure
No need for osteotomy site to heal
Splinting if rotation is a major component of the issue, may need a splint that reduces rotation.
Central – poor blood supply – debridement
Peripheral tear – better blood supply – repair
immobilization period – derotation - 2-3 months
function limited for > 3 months
Use wrist control splints and limit ulnar deviation – this is ideal to not lock them up
Want to limit forearm rotation but not interfere with their ADLs
If can go through AROM w/o increased symptoms, can now start strengthening.
When we do strengthening, like more into the supinated and neutral forearm position for less load on the TFCC.
If central tear – central portion of the tfcc doesn’t have good blood supply (potential for healing won’t be good).
Debridement – symptom based progression
AROM; supination/neutral; pronation
Ulnar Sided Wrist Pain
Midcarpal Instability
Causes:
(Hyperflexion/Hyperextension) injury
(Hypomobility/Hypermobility) or ligamentous laxity
Laxity does not allow for congruency of proximal and distal carpal rows
Prevents smooth transition of PCR from flexed to extended position as wrist moves from (UD to RD/RD to UD)
+ ______/_____Test
Test:
Force applied palmarly to capitate as wrist is moved from RD to UD with an axial load
+ Test: (clunk and pain/paresthesia) as the wrist moves into UD
Between the carpal rows
Proximal carpal row (PCR) has (less/more) mobility
Distal Carpal Row (DCR) moves as a unit
We are going to focus on a Palmar Carpal instability
Patients will complain of a clunk with pain usually
Midcarpal joint – between proximal and distal carpal rows
These pts will have complaints of a clunk
(Dorsal/Palmar) midcarpal instability is the most common – pts have a palmar sag
Test:
Palmarly directed force, move the wrist from radial to ulnar deviation, when this happens we will feel a clunk and that clunk happens when the proximal carpal row shifts into extension.
To get rid of the clunk – dorsally directed force in the (hook of the hamate/pisiform) and do the same motion and that should remove the clunk and pain because motion will now be synchronous. (Hook of the hamate/Pisiform) helps maintain the contact forces between the proximal and distal row.
Least understood injury
Hyperextension; hypermobility; RD to UD; Mid-carpal shift/Catch up Clunk test; clunk and pain; more; Palmar; pisiform; pisiform
Conservative treatment for Midcarpal instability (MCI)
Pisiform (Ulnar) Boost Splint
Dorsally directed pressure on the pisiform and anterior on ulnar head
(Eccentric/Isometric) (RD/UD)
(Volar/Dorsal) sag seen with palmar MCI
Isometric UD – co contraction of the ___ and ____ and that dynamic stability is enough to reduce the sag. Can now stabilize the midcarpal joint.
These pts need to be followed by a hand surgeon if this does not alleviate their symptoms
Splint and isometric ulnar deviation is all you can do for these pts.
Isometric UD; Volar; FCU and ECU;
Ulnar-Sided Wrist Pain
Lunotriquetral (L-T) Ligament injury
Can occur during a fall backwards on outstretched hand with arm (ER/IR) and forearm (pronated/supinated) – wrist is (flexed and UD/ extended and RD)
Most present later with (radial/ulnar)-sided wrist pain
Non-op: isolated tears without instability
Orthosis
Strengthening to begin - weeks after mobilization with limited symptoms
(ECU/ECRL) is a dynamic stabilizer
Operative tx: debridement, direct repair, or ulnar shortening
FOOSH backward ER arm, wrist extension
ECU produces a pronation effect while the triquetrum wants to supinate – ECU stabilizes it.
Ulnar shortening is the idea of tightening the more distal soft tissues.
LT interval – space between lunate and triquetrum
Ecu is a dynamic stabilizer – triquetrum wants to extend and supinate. Ecu is a carpal pronator so it will fight against that.
ER and forearm supinated; extended and RD; ulnar; 2-4; ECU;
L-T Instability Special Tests
(Squeeze/Shear) test– pressure on the ulnar side of the triquetrum and push radially.
+: (pain/clicking)
Squeeze; pain
L-T Instability Special Tests
(Squeeze/Shear) test – stabilize the lunate with one hand and put pressure on the pisiform and press in the dorsal direction (shear force on the LT joint).
+: (pain/clicking)
Shear; pain
L-T Instability Special Tests
(Shear/Ballottement) – going back and forth to create the irritation at that interval.
+: (pain/laxity,pain,crepitus, or clicking)
When checking for laxity have to check the other side
Ballottement; laxity,pain,crepitus, or clicking
Central Wrist Pain
Ganglion cyst
Synovial cyst
Arises from synovial lining of joint or tendon sheath
Herniations of synovial lining that fluctuate in size
Typically a dorsal wrist ganglion Commonly from (LT/S-L) ligament
Observable swelling over dorsum of wrist
Minimal role for therapy conservatively
Address functional impairments
s/p ganglion excision:
Edema control
Scar management - can take gel pad over the scar to help with remodeling
Address hypersensitivity if present
ROM
Strengthening - (able/not able) to do in the first 4 weeks
Picture: A – volar cyst – tend to be more radial and can fluctuate in size. Dorsal wrist ganglion comes off the SL ligament.
Can be deep in the joint
Tendon glides can be helpful as far as early edema control and that fluid flush and muscle pump for the hand
The last thing to come for these pts is weight bearing. Won’t be 100% with WB when done with these pts.
S-L; able;
Central Wrist Pain
Scapholunate (S-L) Ligament injury
FOOSH injury
(Dorsal/volar) tenderness at S-L interval
Tenderness at (proximal phalanx/snuffbox)
Pain with loading the wrist in (flexion/extension) in weightbearing
+ _____ Test
Treatment:
Splinting - provides external support to the ligament
Dart Thrower’s Motion
Consider (concentric RD/ isometric RD) - FCR can help reinforce the scaphoid stability
(Less/More) commonly injured than the LT.
Pic - palpation of the SL interval.
Dorsal; snuffbox; extension; Watson’s ; isometric RD; More;
Scapholunate (S-L) Ligament injury
Watson’s Scaphoid shift test
Starting Position:
Place your thumb over patient’s scaphoid tubercle – use other hand to bring wrist into UD/ext
End Position:
While applying pressure on scaphoid tubercle, bring patient’s wrist into RD/flex
(+/-) Test: a palpable and/or audible reduction of the scaphoid and reproduction of symptomatic pain > usually on the dorsal side
(+/-) Test: scaphoid moves normally, pushing back on examiner’s thumb with UD of the wrist and no reproduction of symptomatic pain
Testing for ligamentous laxity or injury to the SL ligament.
If there is an injury to the SL ligament and we have an unstable scaphoid , the scaphoid will be able to move on the dorsal rim of the radius and when we move the thumb the scaphoid will clunk back into position which will be a positive test.
+; -
Scapholunate (S-L) Ligament Injury
Treatment
Dart Thrower’s Motion
Wrist (flex/UD/ ext/RD) > wrist (flex/UD / ext/RD)
Allows motion while (limiting/maximizing) the elongation of the S-L ligament
Easy position for people to understand
A lot of daily activities happen in this dart throwing action
Most of this motion comes at the (midcarpal/CMC) joint
Doesn’t put more stress on the SL Ligament
If you wanted to work on the pts ROM but not stressing the SL ligament do the dart throwing motion
ext/RD > flex/UD; limiting; midcarpal
Instability patterns with Carpal ligament injuries
Carpal relationships
Scaphoid wants to (flex/extend), the Triquetrum wants to (flex/extend), and the Lunate wants attention. These are opposing forces and the (lunate/pisiform) balances these forces out.
flex; extend; lunate
Instability patterns with Carpal ligament injuries
Normal Wrist
Lunate to scaphoid angle is - degrees
30-60
Instability patterns with Carpal ligament injuries
Carpal Relationships
Dorsal Intercalated Segment Instability (DISI)
Scaphoid wants to (flex/extend), Triquetrum wants to (flex/extend) and the lunate wants attention.
Injury to S-L ligament > lunate (flexes/extends) with triquetrum
Now the connection between the scaphoid and the lunate has been interrupted. Now the scaphoid is going to flex and the lunate is going to extend with the triquetrum. If this happens the angle between the scaphoid and lunate is going to get (smaller/bigger).
Normal wrist: Lunate to scaphoid angle is - degrees
DISI: Lunate (dorsally/volarly) rotated
SL angle: (more than/less than) _ degrees
Pic - Capitate dislocated back on the lunate.
This leads to scapholunate advance collapse
Both surgical options result in (increased/decreased) ROM.
extends; bigger; 30-60;dorsally; more than; 70; decreased
Instability patterns with Carpal ligament injuries
Carpal relationships - Volar Intercalated Segment Instability (VISI)
Scaphoid wants to (flex/extend), the Triquetrum wants to (flex/extend), and the lunate wants attention.
Injury to L-T ligament > lunate (flexes/extends) with scaphoid
Lunate is no longer connected with the triquetrum so it will (flex/extend) with the scaphoid so the angle will get (smaller/bigger).
Normal wrist: Lunate to scaphoid angle is - degrees
VISI: Lunate (dorsally/volarly) rotated SL angle (less than/more than) _ degrees
If the SL angle is (less than/more than) 30 degrees think VISI or chronic injury to the LT ligament.
flex; extend; flexes; flex; smaller; 30-60; volarly; less than; 30; less than
