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207 > Wrist and hand > Flashcards

Wrist and hand Flashcards

1
Q

Triangular fibrocartilage ligament complex (TFCC)

A
  • Load bearing across the wrist
  • Shock absorption
  • Stabilises medial aspect of the wrist between ulna and carpus and the distal RUJ
  • Can injure acutely (FOOSH) or chronically

Diagnosis

  • Positive TFCC grind and/or supination lift off test
  • Observe and palpate
  • Clicking, reduced grip strength in all ROM)
  • MRI (coronal image best)

Treatment:

  • Bracing
  • Stabilisation exercises (especially ECU and PQ)
  • ADL and/or sport technique re-education/correction
  • Arthroscopic repair (extended period of immobilisation, graded return to full ROM and strength)
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2
Q

Acute conditions of the wrist

A

Common

  • Distal radius fracture (often intra-articular in the athlete)
  • Scaphoid fracture
  • Wrist ligament sprain/tear (intercarpal ligament, scapholunate ligament, Lunotriquetral ligament)

Less common

  • Fracture of hook of hamate
  • TFCC tear
  • Distal radioulnar joint instability
  • Scapholunate dissociation

Not to be missed

  • Carpal dislocation
  • Anterior dislocation of lunate
  • Perilunar dislocation
  • Traumatic ulnar artery aneurysm or thrombosis (karate)
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3
Q

Chronic conditions of the wrist (Dorsal)

A

Dorsal

  • Ganglion
  • Intersection syndrome
  • Kienbock’s disease
  • Dorsal pole of lunate and distal radius impingement
  • Posterior interosseous nerve entrapment
  • Inflammatory arthropy
  • Degenerative joint disease
  • Extensor carpi ulnaris tendinopathy
  • Extensor carpi ulnaris subluxation
  • Injuries to distal radial epiphysis (children)
  • Extensor pollicis longus impingement on Lister’s tubercle
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4
Q

Chronic conditions of the wrist (Volar)

A
  • Scaphoid aseptic necrosis
  • Stenosing tendinopathies
  • Flexor carpi ulnaris tendinopathy
  • Flexor carpi radialis tendinopathy
  • Carpal tunnel syndrome
  • Ulnar tunnel syndrome
  • Pisotriquetral degenerative joint disease
  • Avascular necrosis of the capitate (weight-lifters)
  • Extensor pollicis longus impingement/rupture (gymnasts)
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5
Q

Chronic conditions of the wrist (ulnar)

A
  • Triangular fibrocartilage complex tears
  • Ulnar impaction syndrome
  • Distal radioulnar joint instability
  • Carpal instability
  • Scapholunate dissociation
  • Ulnar nerve compression (cyclists, golfers)
  • Flexor carpi ulnaris tendinopathy
  • Extensor carpi ulnaris tendinopathy
  • Extensor carpi ulnaris subluxation
  • Distal radioulnar joint impaction syndromes (golfers)
  • Scaphoid impaction syndrome
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6
Q

Chronic conditions of the wrist (Radial)

A
  • Scaphoid fracture
  • Non-union scaphoid fracture
  • De Quervains tenosynovitis
  • Scaphoid impaction syndrome
  • Intersection syndrome
  • Flexor carpi radialis tendinopathy
  • Dorsal pole of lunate impingement distal radius
  • Scapholunate dissociation
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7
Q

Acute conditions of the hand

A

Common

  • Metacarpal fracture
  • Phalanx fracture
  • Dislocation of the PIP joint
  • Mallet finger
  • Ulnar collateral ligament sprain/tear, first MCP joint
  • Sprain of the PIP joint
  • Laceration
  • Infections
  • Subungual hematoma

Less common

  • Bennett’s fracture
  • Dislocation of the MCP joint
  • Dislocation of the DIP joint
  • Radial collateral ligament sprain, first MCP joint
  • Sprain of the DIP joint
  • Stress Fractures
  • Glomus tumour

Not to be missed

  • Potential infection
  • Avulsion of long flexor tendons
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8
Q

Traumatic presentation

A

Majority of hand patients are traumatic/post surgical

Ask patient

  • MOI, force, duration of injury
  • Time interval between injury and treatment
  • Medical/surgical management
  • Structures damaged, repaired and technique
  • Vital to maintain good communication between surgeon and therapist (and the wider treating team)
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9
Q

Physical assessment

A
  1. Review radiology films, reports, operation and/or interventional reports
  2. Observation and wound assessment (if indicated)
  3. Oedema
  4. Palpation
  5. Sensation (+/- reported neurological signs during interview) and sensibility
  6. Range of motion (+/- surgeons post-op. orders)
  7. Muscle testing (+/- surgeons post-op. orders) including potential nerve lesions
  8. Functional evaluation
  9. Special orthopaedic tests (if appropriate and you are the primary point of contact/wanting to make a diagnosis)
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10
Q

Radiology abnormalities

A

Typical radiography

  • PA wrist neutral, radial and ulnar deviation
  • PA with clenched fist for ligament injury
  • PA view should show smooth Giula’s arc with no scapho-lunate gap

Lateral view
- assesses distal radius, scaphoid, lunate and capitate

Scaphoid fracture
- special ‘scaphoid view’ (routine oblique plus ulnar deviation)

Hook of hamate and ridge trapezium - carpal tunnel view + radial deviation

Ultrasonography - tendon injury, synovial thickening, ganglions, synovial cysts

MRI & CT - more sensitive and specific than bone scan for fracture detection

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11
Q

PA: general observation

A
  1. Upper limb and general posture
  2. Wounds, scars, lacerations
  3. Skin condition and colour (red/shiny or dry/scaly)
  4. Oedema
  5. Deformity, wasting
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12
Q

PA: wound assessment

A
  1. Location and size of wound
  2. Wound type
    - Tidy
    - Untidy
    - Tissue loss +/- soft tissue coverage
    - Infected
  3. Type of closure
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13
Q

PA: oedema

A
  • No normal standards
  • Note location and type (pitting or hard brawny oedema - any associated infection signs)
  • measurement (circumference, volumetric, photo diary)
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14
Q

PA: palpation

A

Examine for:

  • Skin temperature, sweating
  • Scar tethering
  • Hyper/hyposensitivity (presence and location)
  • Muscle spasm
  • Tenderness over bones, joints, tendons
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15
Q

PA: sensation

A

Cutaneous innervation:

  • Median nerve (palmer surface of the hand, palmer surface of digits 2 and 3, thumb, dorsal surface of digit 2 and 3 at DIP)
  • Ulnar nerve (palmer or dorsal surface if digit 5, lateral side of digit 4)
  • Radial nerve (dorsal surface of the hand, dorsal surface of digits 2 and 3 up to PIP)
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16
Q

Sensibility

A
  • The ability to feel or perceive
  • Involves recognition and discrimination or sensory impression
  • Test sensibility to aid in diagnosis, determines degree of denervation, prognostic hand function, determine appropriate rehabilitation

Tests

  1. Temperature recognition
  2. Tinel’s sign (used to predict level of renervation distal to repair/injury)
  3. Pressure threshold test (Semmes weinstein monofilaments, used to determine light touch/deep pressure)
  4. Static two-point discrimination (to assess tactile gnosis)
  5. Moving two-point discrimination (reportedly greater ability to assess tactile gnosis)
  6. Moberg’s Pick up test (assess tactile gnosis, pick up everyday objects with eyes open and closed; time taken measured)
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17
Q

PA: Extrinsic FLEXOR tightness

A

Test for longer finger flexors - FDP, FDS, FPL

Confirmed when

  • In MCP joint flexion: PIP and DIP can passively extend
  • In MCP joint extension: PIP and DIP cannot passively fully extend
  • In MCP and IP extension passively extend the wrist - the fingers are pulled into flexion
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18
Q

PA: extrinsic EXTENSOR tightness

A

Test long finger extensors - EDC, EI, EPL

Confirmed when:

  • in MCP joint extension - PIP and DIP can passively flex
  • With MCP joint flexion - PIP and DIP cannot fully passively flex if wrist is in neutral
  • With finger flexion - passively flex the wrist and note when fingers pulled into extenion
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19
Q

Radial nerve

A
  • ECRB
  • Supinator
  • ECU
  • EDM
  • Extensor digitorum communis
  • Abductor Pollicic Longus
  • EPL
  • EPB
  • EI

Deficits:

  • Pure PIN palsy - attempted wrist extension causes radial deviation of the wrist because of preservation of ECRL and brachioradialis
  • ECU is lost
20
Q

Median Nerve

A
  • Innervates all the flexors in the forearm except FCU, and ‘shares; FDP to little and ring fingers with ulnar nerve

Hand innervation = LOAD

  • 1st and 2nd Lumbricals (index and middle fingers)
  • Muscles of the thenar eminence (opponens pollicis, abductor pollicis brevis, flexor pollicis brevis)

Assessment and special tests

  • MMT - FPB, OP, Abp, lumbricals 1st and 2nd
  • Ape hand
  • Inability to oppose thumb
  • Loss of web space
  • Inability to perform chuck pinch
  • Decreased power grip
  • Loss of sensation (palmar side of the thumb, index and middle finger, half the ring finger)
  • OK sign (fingers make a square instead of circle)
21
Q

Ulnar nerve

A

Innervation

  • FCU
  • FDP
  • 4 dorsal interossei
  • Palmar interossei 2/3/4
  • Lumbricals 3 and 4
  • Adductor Pollicis
  • Muscles of the hypothenar eminence (abductor digiti minimi, Opponens digiti minimi and flexor digiti minimi)

Patient interview and observation:

  • Hook of hamate fracture can compress the nerve
  • Wrist prolonged compression
  • Hypothenar and interosseous atrophy
  • Claw hand of ring and little finger
  • Loss of lateral pinch and decrease power grip
22
Q

Treatment principles of the hand

A
  1. Wound healing
  2. Oedema control
  3. Therapeutic exercise and manual therapy
  4. Splintage
  5. Scar management
  6. Sensory re-education
  7. Functional integration
23
Q

Wound healing phases of the hand

A
  1. Inflammation
    0-48 hours
    Negligible wound strength
    Mx: rest, elevation, oedema control
  2. Proliferation of fibroblasts
    12hrs-10 days
    Mx: exercise, oedema control, function
  3. Fibroplasia
    Day 4 - 28 days
    Collagen deposition
    Mx: exercise, oedema control, function
  4. Remodelling
    1 Month - 2 years
    Scar maturation
    Mx: exercise, manual techniques, function
24
Q

Oedema control of the hand

A
  • Oedema control is vital in the hand
  • It ensures maximal healing and return to function
  • Rest, elevate and compress (coban bandage, lycra finger sleeve, isotoner glove, pressure garments)
  • retrograde massage, contrasts baths, appropriate exercise
25
Q

Therapeutic exercise of the hand

A
  • Ensure writst extension and combine exercise with elevation
  • Encourage and reassure patients
  • Management of patient expectations paramount
  • Care +++ WITH PASSIVE EXERCISE as it can lead to pain and swelling, creating more stiffness
  • Ongoing splint use may be required overnight or in between exercise sessions
  • If post-surgical, adhere to surgeons orders
26
Q

Splintage of the hand

A

Aims

  1. Protect healing tissues
  2. Maintain optimal anatomic position
  3. Restrict/control motion
  4. Promote/improve range of motion (during later fibroplastic stage to stretch and mobilise the scar matrix)
  5. Promote function
Position of safe immobilisation - POSI
- Wirst 25-30 degrees of extension
MCP flexed 60 degrees
- IP joints variable
- Thumb in palmar abduction
- Place hand in this position
27
Q

Scar management of the hand

A

Scars can significantly impede gliding and hand function

Techniques

  • Scar massage/frictions from Day 21+
  • Thermal agents
  • Electrotherapy
  • Silicone products
28
Q

Sensory re-education of the hand

A

Indications

  • Hyper/hyposensitivity
  • If no protective sensation - SAFETY

Methods:
Education
- Taught to avoid excessive temperatures, sharp objects
- Avoid excessive force
- Change tools frequently
- Observe skin for signs of stress
- Skin care (soaking, oil, care for blisters etc.)

Exercises (5-10 minutes, 3-4x days)

  • Discrimination of various textures
  • Discrimination of various sized objects
  • Finding objects in bowl of rice, sand, etc.
  • Eyes open, eyes closed then eyes open
29
Q

Distal radial fractures

A
  • FOOSH or high force+ injury (in younger people)
  • Colles’ #: non-articular, 3-5cm proximal to the RCJ, fall on to extended wrist
  • Smith’s #: ‘Reverse Colles’ with volar displacement, fall on to flexed wrist
  • Barton’s #: is a displaced, unstable articular fracture-dislocation of RCJ

Assessment

  • Subjective interview (mechanism of injury etc.)
  • Observe
  • Palpate
  • AROM +/- PROM
  • Extension clearing test

Management:

  1. Obtain a good reduction (open or closed)
  2. Maintain a good reduction (immobilisation + fixation)
  3. Early (24-72 hours post op) active mobilisation
    - Oedema control (elevation and compression)
    - Finger and wrist AROM
    - Shoulder, neck and elbow ROM
    - Remove splint for wrist F/E, RD/UD exercises
    - Splint stays on for supination/pronation AROM exercises

Complications

  • Significant mal or non-union
  • Stiffness, OA, pain
  • Carpal tunnel syndrome (CTS)
  • TFCC tears
  • EPL rupture
  • Complex regional pain syndrome Type 1
30
Q

Carpal fractures

A

Scaphoid
Hook of hamate (cycling, golf, FOOSH)
Lunate (rare, necrosis more common - Kienbock’s disease)

  • Most carpal # present late - send for imaging confirmation
  • Overt ligament injury
  • Assess disruption to (normally smooth) Gilula’s arcs on XR

Assessment

  • Observe
  • Palpate
  • Imaging
  • AROM +/- PROM
  • 10 tests of the hand
31
Q

Scaphoid fracture

A

Most common carpal fracture
MOI = FOOSH or direct blow

Classification:
Tubercle/Distal
- Not usually displaced
- Rx: immobilisation

Waist

  • 70-80%
  • Increased displacement
  • Increased need for surgery

Proximal pole

  • Increased risk of arterial compromise
  • High chance of surgery

Assessment

  • Subjective interview (MOI, pain)
  • Observe
  • Palpate (snuff box tenderness and swelling)
  • AROM +/- PROM
  • Positive Watsons Scaphoid shift
  • +/- Positive 1st CMC grind test

Management
Refer for imaging (X-ray)
- Follow up XR at 10-12/7 post-injury usually diagnostic
- Bone scan at 4/7 post-injury is 100% sensitive
- MRI at 72 hours post-injury is 100% sensitive

Splint

  • Closed treatment (stable, non-displaced fracture of waist distal pole)
  • Contraindications for closed treatment = proximal pole #, delayed union, comminution

Open treatment (surgery)

  • Unstable, displaced fracture of proximal pole
  • Involves ORIF +/- bone graft
  • Intra-operative stability will determine commencement of mobilisation

Complications

  • Avascular necrosis
  • Delayed, incomplete and/or non-union
  • Associated ligament sprains +/- instability
  • Due to reduced radial artery supply, originating distally to proximally
32
Q

Metacarpal and phalangeal #

A

Metacarpals

  • Boxers #: 2nd to 5th metacarpals
  • Bennett #: 1st metacarpal (base) with dislocation of 1st CMC joint

Phalanges
- Can be complex - central slip of extensor tendon, volar plate, subungual haematoma +/- infection, crush #

Diagnosis:

  • X-ray
  • ROM and muscle strengthening of CMC

Management:

  • RICE
  • Referral to emergency - imaging - reduction - splint (4-6/52)
  • Upon cast/splint removal, early mobilisation (repeat imaging to check healing)
  • +/- ongoing use of protective device e.g. neoprene brace
33
Q

Scapholunate instability

A

Tear of scapholunate ligament
MOI: FOOSH

Assessment and special tests:

  • Subjective interview (MOI, 24/24)
  • Observe
  • Palpate
  • AROM +/- PROM
  • Dorsal-central pain/swelling, instability, possible clicking
  • Positive watson’s scaphoid shift test
  • 10 tests (laxity/pain ‘lunate on scaphoid’ or vice versa
Management:
Grade 1 tear
- Initial immobilisation in splint
- Limit gripping, pushing
- Progressive wrist strengthening - co-contraction, proprioception, ADL's

Grade 2 tear
- Possible surgery (arthroscopic repair; ORIF)

Grade 3 tear

  • Untreated leads to progressive degenerative changes and SLAC (scapholunate advanced collapse)
  • ORIF +/- fusion (permanent loss of wrist ROM)
34
Q

Skier’s (Gamekeeper’s) thumb

A
  • MCP ulnar collateral ligament tear +/- instability
  • MOI forced abduction and hyperextension (e.g. FOOSH still holding pole)

Assessment and special tests

  • HX and palpation
  • Compare to other side
  • XR to rule out avulsion #
  • UCL stress test

Management
Grade 1/2: conservative management
- Thumb spica splint hand based 6/52
- Wk 3- flex/ext AROM, out of splint 3-4 times a day
- Wk 6 - gentle PROM, lateral and palmar pinch strengthening

Grade 3 (+/- displaced avulsion #)
- Surgical repair - postoperative management includes
- Hand based thumb spica until 6/52
- 2/52 flex/ext AROM
- 4/52 general ROM and strengthening
6+/52 modified splint for contact sports/manual work

35
Q

Interphalangeal dislocation

A
  • MOI: hyperextension and/or longitudinal compression
  • One or more collateral ligaments and volar plate disruption
  • Imaging is preferred to rule out associated fractures
  • PIP/DIP collateral ligament stress test
  • If volar dislocation at PIP, may observe Boutonniere deformity
  • If volar dislocation at DIP, may observe mallet finger deformity (can develop swan neck deformity)

Diagnosis

  • Observe
  • Subjective interview
  • Palpation
  • XR

Management

  • RICE
  • Buddy tape
  • Splinting (+/- dorsal extension block if severe)
  • Depending upon severity, surgery may be required
36
Q

Nerve lacerations

A
  • Require microsurgery
  • Aim of repair is to join as accurately as possible the connective tissue tubes of the peripheral nerve
  • Healing - the nerve sheath takes 3-4/52 to gain sufficient strength to withstand stress
  • Need to protect with splint until then

Diagnosis

  • Subjective interview (tingling, parasthesia, numbness)
  • neurodynamic test
  • neurological test

Management
0-3/4 weeks
- splinted in protected position (usually flexion)

3/4+ weeks

  • Gradual active regaining of ROM
  • Sensory re-education
  • Prevention of joint contracture - exercise, splintage
36
Q

Tendon lacerations

A
  • Refer patient to the ED (imaging and surgical repair)
  • Broadly either a flexor or extensor tendon repair
  • Jersey finger: disruption FDP off distal phalanx
  • Mallet finger: disruption extensor digitorum +/- bony fragment of distal phalanx (untreated leads to swan neck and/or boutonniere deformity)

Post operative therapy has 4 main aims:

  1. Restore maximal active tendon gliding (rupture vs adhesions)
  2. Prevent flexion contractures
  3. Maintain full ROM of adjacent joints
  4. Return to previous level of function

Post operative therapy has 3 main approaches:

  1. Immobilisation - rare today
  2. Early passive mobilisation
  3. Early active mobilisation (PREFERRED)
37
Q

Pathologies of the wrist and hand

A
  • OA
  • De Quervain’s Tenosynovitis
  • Carpal Tunnel Syndrome (CTS)
  • Ulna and radial nerve compresison
  • Dupuytren’s disease
38
Q

OA first CMC joint

A
  • Progressive degenerative joint disease

Diagnosis

  • Subjective
  • Observe
  • Grind test of 1st CMC joint

Treatment - conservative vs surgical

  • Splinting
  • Strengthening exercises
  • Joint mobilisations
  • ADL modifications
  • Advice and education
39
Q

De Quervain’s tenosynovitis

A

Thickening and stenosis of 1st extensor compartment - abductor pollicis longus and extensor pollicis brevis

  • Females > males
  • pregnancy onset
  • More common 30-55 years

Causes

  • Chronic trauma: more motor control of thumb abd-ext, wrist RD-UD
  • Unaccustomed use
  • Sporting: racquet sports, rowing
  • Occupation: common overuse injury in manual tasks

Assessment

  • Pain and possible swelling at base of the thumb
  • Possible catching or crepitus
  • Positive finkelstein’s test

Conservative management

  • Rest (splintage, ADL modification)
  • EPA
  • tendinopathy strengthening program
  • +/- corticosteroid injection

Surgical management

  • Decrompression of 1st dorsal compartment
  • Post Op:
  • Wound/scar Mx
  • Gentle AROM
  • Strengthening after 6/52
40
Q

Carpal tunnel syndrome

A

Signs, symptoms and diagnosis

  • Numbness, P & N in median nerve distribution
  • Nocturnal symptoms
  • Weakness and loss of dexterity in hand
  • Sense of congestion/finger swelling
  • Positive Phalen’s and/or Tinel’s test

Pathogenesis

  1. Decreased size of Tunnel (bony abnormality, thickening TCL)
  2. Contents of Tunnel (9 tendons and 1 nerve; mass/ganglion/lipoma; haematoma)
  3. inflammatory (RA, infection, gout, overuse)
  4. Fluid balance (pregnancy, haemodialysis)
  5. Neuropathic (diabetes, alcoholism)

Management

  • Work/ADL modifications
  • Night splint holding wrist in neutral
  • Median nerve and finger tendon gliding exercises
  • Electrotherapy
  • Oedema control
  • Assess cervical spine/central component
  • Address pathogenesis
  • +/- surgical decompression
41
Q

Ulnar nerve compression

A
  • Most commonly seen in cyclists or baseball players
  • HX pisiform and/triquetral #
  • Months for weakness to be noticed
  • Tinel’s sign

Management

  • Address cause
  • Splinting
  • NSAIDs
  • +/- surgical decompression
42
Q

Radial nerve compression

A
  • Radial nerve vulnerable 5-7cm proximal to wrist
  • Hx of radial styloid #; tight jewellery; handcuffs; plaster cast; overuse (e.g. volleyball)
  • Positive Tinel’s sign

Management

  • Address causes
  • Splinting to offload/reduce supination/pronation
  • +-/- refer for CSI +/- surgical decompression
43
Q

Dupuytren’s disease

A
  • Usually in older adults and more common in men
  • Frequently bilateral and asymptomatic/painless
  • Patients present with nodular thickening of the palmar fascia and flexion contracture of the fingers (usually the 3rd, 4th and 5th)
  • Palpation and observation of lumps and rods
  • Lack of finger flexion

Management

  • Local heat and stretching
  • Splintage
  • Referral to specialist if joint contracture and/or pain developing
44
Q

Rheumatoid Arthritis of the hand

A
  • Pathologies of the wrist and hand: systemic
  • Autoimmune inflammatory disorder
  • Pain, multijoint swelling (+/- pitting oedema) and stiffness
  • Can be acute and/or chronic (relapsing/remitting) onset
  • Boutonniere and/or swan neck deformity

Diagnosis:

  • Observe
  • Palpation (swelling)
  • Blood test

Management

  • Conservative measures to manage pain (e.g. massive)
  • Referral to GP (FBE and management)

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