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PHTY207 > Wk 10 Ortho Mx of hand and wrist > Flashcards

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”

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2
Q

2 components of ortho Mx

A
  1. surgical/ medical
  2. conservative
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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
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4
Q

incidence of distal radius fractures

A

17.5% of all fractures

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5
Q

what age group & gender are distal radius fractures most common?

A

females 60-70 age group from a FOOSH

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6
Q

how does a distal radius fracture occur in younger people?

A

high energy injury (speed, height)

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7
Q

anatomical components of distal riadiu

A
  1. radial inclination
  2. articular surfaces/ facets where scaphoid & lunate bone sits
  3. dorsal/ volar tilt
  4. relative height of the radius in relo with the ulna
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8
Q

radial incliniation is?

A

relative slope from the radial styloid down to the distal RU jt

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9
Q

what is the slope of the radial inclination generally recorded as?

A

20-22*

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10
Q

on an xray, what is the normal volar tilt * of the end of the radius?

A

11*

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11
Q

what is the height difference between the Radius and ulna at the distal RU jt?

A

1-2mm (radius longer)

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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.

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13
Q

Smith’s # MOI

A

fall onto flexed hand

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14
Q

Smith’s #

A

“Reverse Colles” with volar
displacement

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15
Q

Barton’s #

A

displaced, unstable articular fracture
subluxation with carpus following

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16
Q

DRF 3 steps in medical management

A
  1. Obtain a good reduction
  2. Maintain a good reduction (till callus formation & bone stable again)
  3. Early motion as fracture stability allows
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17
Q

anatomical considerations for a good reduction

A
  1. Articular congruity
  2. Radial shortening/Ulnar variance
  3. Dorsal angulation
  4. Radial inclination
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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)

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19
Q

what is ulnar variance?

A

the ulnar can look longer than the radius due to the dorsal displacement of the distal radius

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20
Q

ulnar variance long term complications:

A
  1. pain with pronation/ supination
  2. whole movement of the carpal bones (lunate will hit into the distal ulnar)
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21
Q

what is dorsal tilt?

A

end of radius is sitting in an upright position

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22
Q

how does dorsal tilt affect the patient?

A
  • extension = easy
  • flexion - difficult as carpus cant move down
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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

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24
Q

what does Rx options depend on?

A

type and nature of fracture

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25
Q

immobilistaion is used for?

A

nondisplaced fractres

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26
Q

what is used when there is ligamentous damage & thus instability / laxity with the fracture?

A
  • Closed reduction
  • Pins and Plaster
  • External fixation
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27
Q

what is the other more common Rx for fractures?

A

ORIF +/- bone grafting

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28
Q

Principles of Hand surgery
- diagnosticians

A

accurate assessment and appropriate investigations (Xrays, CTs, MRIs, US)

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29
Q

what are the priorities of a surgical plan?

A
  • bony and joint stabilisation
  • soft tissue coverage
  • nerve
  • tendon
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30
Q

What do you assess in a hand surgery Pre-Op?

A
  • 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
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31
Q

what else do you ask about in the hand surgery pre-op?

A
  • risks explained
  • general health
  • complications / concern common to wrist & hand surgery
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32
Q

what are the pre-op questions about general health?

A
  • anaesthetic complications
  • blood clots, respiratory and cardiac complications
  • smokers, diabetics, obese pts have higher risks
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33
Q

what are the complications of hand surgery common to wrist and hand surgery?

A
  • infection
  • scar formation
  • Nerve injury/altered sensation, CTS
  • Malunion, Stiffness,
  • CRPS
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34
Q

what is required to prep patient for surgery?

A
  • Surgery game plan needs to
    developed
  • Patient preparation – skin
    care, hair removal, draping
  • Tourniquet (prevents excessive bleeding)
  • Appropriate surgical
    approach
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35
Q

what muscle is dissected in DRF ORIFs?

A

pronator quadratus

36
Q

hand surgery post operative care efforts made to:

A
  • minimizing postoperative swelling = compression, elevation
  • relieve pain – adequate analgesia
  • limiting immobilisation – back slab/splint
  • Hand Therapy!!!
37
Q

Principles of Hand Therapy Treatment

A
  1. Knowledge of Healing Timeframes
  2. Wound Management and Oedema Control
  3. How to keep still or promote appropriate movement -
    Splintage
  4. How to move – Therapeutic exercise, Manual therapy
  5. Scar Management
  6. Sensory re-education
  7. Functional integration
38
Q

HEALING TIMEFRAMES
Why is it important to know about the healing timeframe?

A

vital for CR

39
Q

what are a great majority of wrist/ hand injuries?

A

post traumatic/ surgery

40
Q

what must you know about the bone/ tendon/ nerve/ ligament?

A

how long they take to heal

41
Q

what are the healing phases

A
  1. inflammation
  2. proliferation of fibroplasts
  3. fibroplasia
  4. remodelling
42
Q

how long is the inflammation phase of healing?

A

0-48 hours

43
Q

what happens in the inflammation phase of healing?

A

vascular response, phagocytosis

44
Q

what is the wound strength for the inflammation phase of healing?

A

negligible (wound cant hold itself together thus, sutures)

45
Q

management for inflammation phase?

A

rest, elevation, oedema control (maybe ice)

46
Q

how long is the proliferation phase of healing?

A

12hr - 10 days

47
Q

what happens to the wound in the proliferation phase of healing

A

migrate & bridge wound edges

48
Q

management of proliferation phase of healing

A

rest, elevation, oedema, light exercise

49
Q

fibroplasia days?

A

4-28 days

50
Q

what happens in fibroplasia stage?

A

collagen deposition

51
Q

Mx of fibroplasia

A

exercise, oedema control, function

52
Q

remodelling timeframe

A

1 month - 2 years

53
Q

what happens to the scar in the remodelling phase

A

matures

54
Q

Mx of the remodelling phase of healing

A

exercise, manual techniques, function

55
Q

what do we look to do to remodel the collagen fibres for in the remodelling phase?

A
  1. they are more linear
  2. more tensile strength
  3. more ROM
56
Q

Wound Mx- Therapy role

A
  1. prevent & control infection
  2. minimise mechanical influences (oedema, tension at site, necrotic tissue)
  3. consider scar formation
57
Q

what do you do to ensure a good dressing

A
  • minimal bulk
  • moist environment
  • specific dressings
58
Q

what can excessive oedema limit?

A

wound healing and facilitate the development of stiffness (causes tethering & adhesion)

59
Q

how do you prevent excessive oedema?

A
  • Gentle decline in elevation from hand to shoulder
  • Early active range of motion and tendon gliding
    exercises
  • Cold packs
  • Compression
  • Manual Oedema Mobilisation
60
Q

compression types

A
  • coban bandage
  • Handy gauze
  • tubigrip
  • lycra finger stalls
  • gloves
  • pressure garments
  • Vary in the amount of
    compression and clinical
    application
61
Q

early phase goal

A

minimise stiffness

62
Q

structures in the fingers that stiffen easily

A
  • MCP collateral ligaments
  • volar plate on the PIP jts
63
Q

how do you immobilise the wrist?

A

wrist thermoplastic splint ( can move fingers but not wrist)

64
Q

what do you have to check for exercise prescription?

A

fracture stability

65
Q

what are the initial exercise types used for mobilisation?

A

active assisted/ active wrist ROM

66
Q

goals of exercise therapy?

A
  • independent wrist extension
  • full supination ROM
67
Q

what do you consider as fracture stability allows?

A

passive stretches, manual therapy, strengthening, and WB

68
Q

what is the best sort of exercise for the wrist/ hand?

A

function

69
Q

mobilisation - exercise & function

A
  • early mobilisation of hand and thumb
  • promotion of appropriate function
70
Q

SCAR TISSUE S
What do you consider the effect of?

A

scar- tethering, cosmetic, sensitivity

71
Q

what are some techniques to help mobilise the scar tissue

A

massage, taping, silicone products

72
Q

what can the scars on the hand become because it is a sensitive part of the body?

A

hypersensitive

73
Q

what do we do to reduce hypersensitivity

A

desensitisation

74
Q

aims of desensitisation

A

gradually increase the patient’s tolerance to tactile stimulation in an area of hypersensitivity

75
Q

what does desensitisation involve?

A
  • Involves mapping area of sensitivity and progressively
    introducing stimuli
76
Q

how many times do you apply the stimuli which provokes a response?

A

5 - 10 minutes, 3- 4 x times a day

77
Q

definition of sensory re-education

A

Method by which the patient learns to interpret the pattern of abnormal sensory impulses generated after an interruption in the peripheral nervous system.

78
Q

if no protective sensation:

A
  • ‘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
Q

when light touch perceived, move to:

A
  • 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
Q

once the fracture is healed, what do you commence?

A

resisted strengthening exercise

81
Q

what do you consider in exercise prescription?

A

whole UL – scapula stability down to finger tips (kinetic chain)

82
Q

return to function components

A
  • Promotion of ADL’s – start simple and then progress
  • provision of aids and appliances as required
  • Consider biomechanical upper limb chain
83
Q

how do you incorporate functional activies into daily life?

A
  • Outline functional capabilities for home/work
  • Organise work site visit, suitable duty plan
    recommendations
  • Provide advice re return to training/sport
84
Q

rehabilitation pointers

A
  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
Q

DRF complications

A
  1. Significant Malunion
    - stiffness, OA, pain
  2. Carpal Tunnel Syndrome
  3. TFCC tears
  4. EPL rupture
  5. Complex Regional Pain
    Syndrome Type 1
86
Q
A

PHTY207 (7 decks)

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