Wrist and hand Flashcards
Distal Radius Fracture - Clinical presentation (demographic, MOI, symptoms)
- all age groups, especially young and old
- FOOSH
- pain, swelling, bruising and tenderness all local to distal radius; focal bony tenderness over the distal raidus
- deformity? (dinner fork?)
Distal Radius Fracture - Acute Management
Apply makeshift splint and sent to ED
Distal Radius Fracture - Rehab
- From day 1 maintain finger, thumb, elbow and shoulder ROM
- light upper limb strength ex. as soon as tolerated
- 5-6 weeks: wrist AROM
- 7-8 weeks: PROM, gentle grip/wrist strength
- 8-9 weeks: weight-bearing on hand
Scaphoid Fracture - Clinical presentation (demographic, MOI, symptoms)
- teens/young adults
- FOOSH
- pain in radial wrist near base of thumb
- clamp sign
- local swelling - obscures contour of snuff box
- tenderness on scaphoid tubercle
- pain with longitudinal thumb compression
- pain with ulnar deviation in pronation
- pain with resisted supination
Scaphoid fracture - Acute management
Refer to ED
MRI
Scaphoid fracture - Rehab
From day 1: maintain finger, thumb, elbow and shoulder ROM
Light upper limb strength ex’s as soon as tolerated
6-9 weeks: AROM *depends on specialist advice
10-12 weeks: PROM, gentle grip/wrist strength ex
12+ weeks: weight-bearing ex’s
De Quervain’s Tenosynovitis - Clinical presentation (demographic, MOI, subjective and physical features
MOI: repetitive loading/overuse
Presentation:
- insidious, increasing, radial-sided wrist pain during activity
- thumb extension: passive no pain; active some pain; resisted some pain
- pain with tendon tension - wrist UD + thumb flexion/opp (Finkelstein)
- pain with retinacular loading
De Quervain’s Tenosynovitis - management/rehab
break the cycle!
- reduce pain/irritation
- education, activity modification, taping, splinting
- reduce inflammation
- time without irritation -> splint ~4 weeks
- > cortisone injections
- reduce thickening
Scapholunate ligament injury - Clinical presentation (demographic, MOI, subjective and objective features)
MOI: FOOSH or high-energy impact demo: younger, active patients Clinical findings: - radial/dorsal wrist pain - Xray: S-L widening, carpal instability - focal tenderness over dorsal scapholunate joint - Watson's test +ve -> MRI to confirm
Scapholunate ligament injury - management/rehab for acute injury
Acute:
surgical repair within 3 months of injury
rehab -> hand specialist
Scapholunate ligament injury - management/rehab for chronic injury
Education settle it down gentle rehab only cortisone inj. for temporary relief partial or complete wrist fusion will be required (via splint or surgery)
ECU Tenosynovitis - Clinical presentation (demographic, MOI, symptoms)
MOI: repetitive loading/overuse - grip-load-twist-repeat
demo: young, active patient - sports injury
presentation:
- ulnar sided wrist pain
- ‘popping’ of the wrist
findings:
- focal tenderness over ECU groove in ulnar head
- pain with stress loading of ECU (active supination + extension + ulnar deviation)
ECU Tenosynovitis - Management/Rehab
break the cycle
- taping or splinting to limit wrist movement inc. supination
- cortisone inj
- surgery for stabilisation
- sport-specific rehab
TRIANGULAR FIBRO-CARTILAGE COMPLEX (TFCC) - Clinical presentation (symptoms)
- ulnar sided wrist pain
- TOP of TFCC
- TFCC stress test
- supination lift test (TFCC disruption)
TRIANGULAR FIBRO-CARTILAGE COMPLEX - Management
- settle it down - rest, taping, compressive support, brace/splint
- build it up - target rehab to limited/painful activities, graduated loading
Carpal Tunnel Syndrome - Clinical presentation (demographic, cause, symptoms)
demo: any age
Typical presentation: intermittent P+N in thumb, Index finger and middle finger, worst at night
presentation varies greatly
Cause: anything that causes compression in the carpal tunnel
Carpal Tunnel Syndrome - Special tests
- phalens + reverse phalens
- tinels
- carpal compression
Carpal Tunnel Syndrome - Management
Consider the cause:
o Inflammation – try splint/rest, maybe cortisone injection
o Oedema – try elevation, drainage massage, AROM exs
o Wrist position – try splint, especially when sleeping
o Gripping/lumbricals – try activity/grip modification, keep fingertips away from palm
Educate, load manage, tape/support, isometric strength/control
THUMB MCP ULNAR COLLATERAL LIGAMENT INJURY (SKIER’S THUMB) - Clinical presentation (demographic, MOI, symptoms)
Demo: young, active population - sporting injury
MOI: impact against thumb
Symptoms:
- pain, swelling, bruising around the whole MCP joint
- focal tenderness over ulnar aspect of joint
- resting position - may be in radial deviation
- Skiers thumb test +ve
THUMB MCP ULNAR COLLATERAL LIGAMENT INJURY (SKIER’S THUMB) - management
- get diagnostic clarity
- US / surgical opinion
- splint thumb whilst awaiting US results
- protect
- 4-6 weeks in splint full time then phase out
- rehab
- start early with gentle AROM out of splint
- warm water exercises
- add light resistance e.g. sponge @ 3-4 weeks
- PROM only if MCP stiffness
MALLET FINGER - Clinical presentation (demographic, MOI, symptoms)
Demo: all ages
MOI: forced flexion of the fingertip/DIP joint
Clinical findings:
- terminal phalanx resting in flexion
- mallet finger test
- often no pain, swelling or bruising
- extensor mechanism disrupted -> no active extension
MALLET FINGER - management
- Xray
- Splint full-time 6-8 weeks: DIP in full ext. PIP free.
- Rehab
- gentle splint wearing
- gentle AROM only - PROM almost never needed
Jersey Finger - Clinical presentation (demographic, MOI, symptoms)
Demo: sporting
MOI: simultaneous maximal grip/effort with FDP muscle, and passive extension of digit
clinical findings:
- pain, swelling and bruising of whole finger
- general loss of ROM
- specific loss of active DIP flexion (rupture/avulsion of FDP)
- unable to flex DIP with the examiner holding the PIP in ext.
- make a fist and check if the DIP flexes
Special tests:
- test for flexor integrity passive) - FDP and FDS
- palpation: check for retracted tendon in palm -> surgery
Jersey Finger - management
- refer to ED!
post-op care:
- 6 weeks in dorsal blocking splint
- specific post-op management in care of hand therapy clinic
FINGER JOINT INJURIES (PIP) - Clinical presentation ( MOI, symptoms)
MOI: impact/jarring, ball vs. fingertip, hyperextension
presentation:
- fusiform swelling around injured joint, local bruising
- MCP’s may rest in hyperext; IP joints in flex
- check for ulnar/radial deviation at rest
- loss of full AROM
FINGER JOINT INJURIES (PIP) - Management
- Xray!
- volar plate avulsion -> hand therapy
- dislocation -> ED
- fracture -> ED - once xray clear
- test volar plate
- test for tendons integrity (passive) radial collateral and ulnar collateral lig -> soft x 3, med x 3, firm x 3
- test major ligaments for stability (sprain vs. rupture) - hand therapy
- protect from re-injury
- regain full finger flexion
- regain strength/function
- prevent/treat PIP flexion contracture
