Wk 10 Ortho Mx of hand and wrist Flashcards
1
Q
what is orthopaedics?
A
“branch of
medicine concerned with
the correction or prevention
of deformities, disorders, or
injuries of the skeleton and
associated structures”
2
Q
2 components of ortho Mx
A
- surgical/ medical
- conservative
3
Q
what does ortho Mx of wrist / hand involve?
A
- Applied Knowledge of wrist/hand anatomy and
biomechanics - Applied knowledge of wrist/hand pathologies
Applied diagnostics – accurate assessment and use of
investigations – Xray, CT, MRI, US - Evident based knowledge of wrist/hand treatment
options
4
Q
incidence of distal radius fractures
A
17.5% of all fractures
5
Q
what age group & gender are distal radius fractures most common?
A
females 60-70 age group from a FOOSH
6
Q
how does a distal radius fracture occur in younger people?
A
high energy injury (speed, height)
7
Q
anatomical components of distal riadiu
A
- radial inclination
- articular surfaces/ facets where scaphoid & lunate bone sits
- dorsal/ volar tilt
- relative height of the radius in relo with the ulna
8
Q
radial incliniation is?
A
relative slope from the radial styloid down to the distal RU jt
9
Q
what is the slope of the radial inclination generally recorded as?
A
20-22*
10
Q
on an xray, what is the normal volar tilt * of the end of the radius?
A
11*
11
Q
what is the height difference between the Radius and ulna at the distal RU jt?
A
1-2mm (radius longer)
12
Q
Colles’ #
A
originally defined as a non-articular (not extending into jt surface) fracture, occurring 3-5 cm proximal to the radiocarpal
joint.
13
Q
Smith’s # MOI
A
fall onto flexed hand
14
Q
Smith’s #
A
“Reverse Colles” with volar
displacement
15
Q
Barton’s #
A
displaced, unstable articular fracture
subluxation with carpus following
16
Q
DRF 3 steps in medical management
A
- Obtain a good reduction
- Maintain a good reduction (till callus formation & bone stable again)
- Early motion as fracture stability allows
17
Q
anatomical considerations for a good reduction
A
- Articular congruity
- Radial shortening/Ulnar variance
- Dorsal angulation
- Radial inclination
18
Q
when does a DRF need surgical fixation in relation to articular congruity?
A
anything that has a ‘step-off’ or a difference of 1-2mm in articular step where the bone is rubbing (articulation with scaphoid/ lunate)
19
Q
what is ulnar variance?
A
the ulnar can look longer than the radius due to the dorsal displacement of the distal radius
20
Q
ulnar variance long term complications:
A
- pain with pronation/ supination
- whole movement of the carpal bones (lunate will hit into the distal ulnar)
21
Q
what is dorsal tilt?
A
end of radius is sitting in an upright position
22
Q
how does dorsal tilt affect the patient?
A
- extension = easy
- flexion - difficult as carpus cant move down
23
Q
radial inclination affects the patient how?
A
loss of inclination from the radial styloid to the distal RU jt = unusual wear patterns in the articular surface + early degenerative jt disease
24
Q
what does Rx options depend on?
A
type and nature of fracture
25
immobilistaion is used for?
nondisplaced fractres
26
what is used when there is ligamentous damage & thus instability / laxity with the fracture?
- Closed reduction
- Pins and Plaster
- External fixation
27
what is the other more common Rx for fractures?
ORIF +/- bone grafting
28
Principles of Hand surgery
- diagnosticians
accurate assessment and appropriate investigations (Xrays, CTs, MRIs, US)
29
what are the priorities of a surgical plan?
- bony and joint stabilisation
- soft tissue coverage
- nerve
- tendon
30
What do you assess in a hand surgery Pre-Op?
- allergies, reactions to antibiotics, anaesthetic drugs
- bleeding disorders, previous problems with blood clots
- recent or long term illnesses
- psychological or psychiatric illnesses
- keyloid scars or poor healing
31
what else do you ask about in the hand surgery pre-op?
- risks explained
- general health
- complications / concern common to wrist & hand surgery
32
what are the pre-op questions about general health?
- anaesthetic complications
- blood clots, respiratory and cardiac complications
- smokers, diabetics, obese pts have higher risks
33
what are the complications of hand surgery common to wrist and hand surgery?
- infection
- scar formation
- Nerve injury/altered sensation, CTS
- Malunion, Stiffness,
- CRPS
34
what is required to prep patient for surgery?
- Surgery game plan needs to
developed
- Patient preparation – skin
care, hair removal, draping
- Tourniquet (prevents excessive bleeding)
- Appropriate surgical
approach
35
what muscle is dissected in DRF ORIFs?
pronator quadratus
36
hand surgery post operative care efforts made to:
- minimizing postoperative swelling = compression, elevation
- relieve pain – adequate analgesia
- limiting immobilisation – back slab/splint
- Hand Therapy!!!
37
Principles of Hand Therapy Treatment
1. Knowledge of Healing Timeframes
2. Wound Management and Oedema Control
3. How to keep still or promote appropriate movement -
Splintage
3. How to move – Therapeutic exercise, Manual therapy
4. Scar Management
6. Sensory re-education
7. Functional integration
38
HEALING TIMEFRAMES
Why is it important to know about the healing timeframe?
vital for CR
39
what are a great majority of wrist/ hand injuries?
post traumatic/ surgery
40
what must you know about the bone/ tendon/ nerve/ ligament?
how long they take to heal
41
what are the healing phases
1. inflammation
2. proliferation of fibroplasts
3. fibroplasia
4. remodelling
42
how long is the inflammation phase of healing?
0-48 hours
43
what happens in the inflammation phase of healing?
vascular response, phagocytosis
44
what is the wound strength for the inflammation phase of healing?
negligible (wound cant hold itself together thus, sutures)
45
management for inflammation phase?
rest, elevation, oedema control (maybe ice)
46
how long is the proliferation phase of healing?
12hr - 10 days
47
what happens to the wound in the proliferation phase of healing
migrate & bridge wound edges
48
management of proliferation phase of healing
rest, elevation, oedema, light exercise
49
fibroplasia days?
4-28 days
50
what happens in fibroplasia stage?
collagen deposition
51
Mx of fibroplasia
exercise, oedema control, function
52
remodelling timeframe
1 month - 2 years
53
what happens to the scar in the remodelling phase
matures
54
Mx of the remodelling phase of healing
exercise, manual techniques, function
55
what do we look to do to remodel the collagen fibres for in the remodelling phase?
1. they are more linear
2. more tensile strength
3. more ROM
56
Wound Mx- Therapy role
1. prevent & control infection
2. minimise mechanical influences (oedema, tension at site, necrotic tissue)
3. consider scar formation
57
what do you do to ensure a good dressing
- minimal bulk
- moist environment
- specific dressings
58
what can excessive oedema limit?
wound healing and facilitate the development of stiffness (causes tethering & adhesion)
59
how do you prevent excessive oedema?
- Gentle decline in elevation from hand to shoulder
- Early active range of motion and tendon gliding
exercises
- Cold packs
- Compression
- Manual Oedema Mobilisation
60
compression types
- coban bandage
- Handy gauze
- tubigrip
- lycra finger stalls
- gloves
- pressure garments
- Vary in the amount of
compression and clinical
application
61
early phase goal
minimise stiffness
62
structures in the fingers that stiffen easily
- MCP collateral ligaments
- volar plate on the PIP jts
63
how do you immobilise the wrist?
wrist thermoplastic splint ( can move fingers but not wrist)
64
what do you have to check for exercise prescription?
fracture stability
65
what are the initial exercise types used for mobilisation?
active assisted/ active wrist ROM
66
goals of exercise therapy?
- independent wrist extension
- full supination ROM
67
what do you consider as fracture stability allows?
passive stretches, manual therapy, strengthening, and WB
68
what is the best sort of exercise for the wrist/ hand?
function
69
mobilisation - exercise & function
- early mobilisation of hand and thumb
- promotion of appropriate function
70
SCAR TISSUE S
What do you consider the effect of?
scar- tethering, cosmetic, sensitivity
71
what are some techniques to help mobilise the scar tissue
massage, taping, silicone products
72
what can the scars on the hand become because it is a sensitive part of the body?
hypersensitive
73
what do we do to reduce hypersensitivity
desensitisation
74
aims of desensitisation
gradually increase the patient’s tolerance to tactile stimulation in an area of hypersensitivity
75
what does desensitisation involve?
- Involves mapping area of sensitivity and progressively
introducing stimuli
76
how many times do you apply the stimuli which provokes a response?
5 - 10 minutes, 3- 4 x times a day
77
definition of sensory re-education
Method by which the patient learns to interpret the pattern of abnormal sensory impulses generated after an interruption in the peripheral nervous system.
78
if no protective sensation:
- ‘Remember what it was like to touch’, Mental imagery,
use words about touch, watch touch
- Taught to avoid heat, cold, sharp objects
- Avoid excessive force
- change tools frequently
- observe skin for signs of stress
- skin care - soaking, oil, care for blisters etc.
79
when light touch perceived, move to:
- discrimination of various textures
- discrimination of various sized objects
- finding objects in bowl of rice, sand etc.
*do with eyes open, eyes closed, then eyes open*
80
once the fracture is healed, what do you commence?
resisted strengthening exercise
81
what do you consider in exercise prescription?
whole UL -- scapula stability down to finger tips (kinetic chain)
82
return to function components
- Promotion of ADL’s – start simple and then progress
- provision of aids and appliances as required
- Consider biomechanical upper limb chain
83
how do you incorporate functional activies into daily life?
- Outline functional capabilities for home/work
- Organise work site visit, suitable duty plan
recommendations
- Provide advice re return to training/sport
84
rehabilitation pointers
1. Knowledge of healing timeframes
2. Speak to surgeon to understand clinical
case
3. Control Oedema!
4. Limit immobilisation
5. Promotion of Function - the best therapy!
6. Consider Splintage to regain ROM if stiffness occurred – to provide low load progressive stretching
7. Consider upper limb biomechanics
8. Know and watch for complications
85
DRF complications
1. Significant Malunion
- stiffness, OA, pain
2. Carpal Tunnel Syndrome
3. TFCC tears
4. EPL rupture
5. Complex Regional Pain
Syndrome Type 1
86
