Wrist and hand Flashcards
What is positive and negative ulnar variance
Positive - Ulna further than the radius
Negative - Ulna shorter than the radius
What is used to diagnose ulnar variance
X-ray
What population may develop ulnar variance and why
Child gymnasts
Due to chronic compressive loads closing distal radial physes
What does the ulna move distal naturally
Normal gripping and pronation
More positive with age
What are some injuries associated with ulnar variance
Lunotriquetral ligament tears
Scapulolunate instability
Ulnar impaction syndrome
TFCC tears
Describe negative ulnar variance
Increases risk for Kienbock’s disease
Osteochondrosis of the lunate
Describe the MOI for TFCC pathology
Fall on supinated outstretched wrist
Chronic repetitive rotational loading
What activities may aggravate TFCC pathology
Tennis
Golf
Occupational tasks
What is the clinical presentation of TFCC pathology
Medial wrist pain distal to ulna in dorsal anatomic depression
- increased with end-range PRO and SUP, forceful gripping
Painful click with wrist motions
Describe the eligibility for TFCC repair
The center is avascular and not amenable for repair
The outside is vascular and repairable
What special tests and imaging is used to determine TFCC pathology
TFCC stress test
TFCC compression test
MRI
Describe TFCC bracing for mild and unstable cases
Mild - splint for ulnocarpal support Unstable - Long arm cast - elbow in 90 - wrist in UD and EXT
While immobilized educate to avoid ulnar deviation or extension and radial deviation
After the cast is removed what is the progression of strengthening exercises for TFCC pathology
FLEX, EXT
PRO, SUP
UD, RD
2 weeks after cast is removed strengthen hand a wrist, avoid torsion loads
Describe ulnocarpal impingement syndrome
Cystic and erosive changes on the ulnar head and lunate
Caused by positive ulnar variance
Diagnosed with radiographs
Describe the presentation of DRUJ instabilities
AROM / PROM C - pain with pronation and supination
PROM A - pain with dorsal and volar glides
+DRUJ instability test
Describe DRUJ management
Minimize mal alignment External stabilization - taping, bracing Internal stabilization - Therex for: Strengthening, proprioception, stabilization
Describe Static intercarpal instability
Involves a tear of a ligament or fracture
More severe
Describe dynamic Intercarpal instabilities
Occur when the wrist is stressed
What is the difference between dissociative and non-dissociative instabilities
diss - between carpal bones in the same row
non diss - carpal bones in different row
How do you manage intercarpal instabilities
Cast immobilization
Surgery for chronic cases
What is the most common tumor of the hand
Ganglia
Describe what a ganglia is and how it develops
Thin walled cysts containing hyaluronic acid
Spontaneously over joint capsule or sheath
Anterior and posterior wrist and fingers
Describe the clinical presentation of ganglia
May not cause pain
As they grow they may ache with flexion and extension
May compress median and ulnar nerve
Describe the physical properties of a ganglion
Smooth
Round
Multilobulated
Tender under pressure
Describe the management strategy for ganglion
Symptom relief
- splint immobilization, may shrunk ganglion
Needle aspiration
Surgical removal if necessary
What is the rehab protocol for ganglia at 2 weeks
Remove short term splint
AROM and AAROM wrist flexion and extension
Splint between exercise and at night
What is the rehab protocol for ganglia at 2-4 weeks
Resisted ROM and strengthening
Stop splinting at 4 weeks
What is the rehab protocol for ganglia at 4-6 weeks
Allow normal activities to patient tolerance
What is the rehab protocol for ganglia at 6 weeks
Allow full activity
What are some activities associated with UCL sprain
“Game keeping”
Breakdancing
Skiing
Briefly describe UCL sprains
Injuries to the MCP joint
Most common ligament injury of the hand
What is the MOI for UCL sprains
Forceful abduction and hyperextension
What is the clinical presentation of UCL sprain
Pain, swelling, tenderness on ulnar side of MCP
Weak pinch
Instability
What classifies a UCL sprain for surgical intervention
Grade 1-2 sprain extension greater than 35-40 degrees compared to the other side
How do you manage a grade 1-2 UCL sprain
6 weeks of immobilization followed by 2 weeks as necessary
AROM of flexion and extension to begin at 3 weeks
Strengthening to begin at 8 weeks
What type of stress is to be avoided in the first 2-6 weeks of UCL management
abduction stress of the MCP
What nerves are of concern during UCL sprain management
Superficial radial
Ulnar digital
What is the medical management of a grade 3 UCL sprain
Thumb spica splint for 3-5 weeks, not worn during flexion and extension exercises
All other guidelines the same as 1-2 grade sprains
Describe the arthrokinematics of thumb flexion and extension
Cave - metacarpal
Vex - trapezium
Flexion - ulnar glide
Extension - Radial glide
Describe the arthrokinematics of thumb adduction and abduction
Cave - Trapezium
Vex - Metacarpal
Abduction - Dorsal glide
Adduction - Palmar glide
Describe briefly mallet finger
Traumatic disruption of terminal tendon
Very common extensor tendon rupture
Baseball catcher, football receivers
Describe the MOI for mallet finger
Longitudinal force to the tip of the finger producing sudden flexion of finger resulting in tendon rupture or fracture
Describe the clinical presentation of mallet finger
Flexion deformity at the DIP
Can be extended passively but not actively
What is the primary goal when treating mallet finger
maximize functional range of motion
How do you manage a mallet finger with no fracture
8 week immobilization in slight hyperextension
How do you manage mallet finger with a fracture
6 week immobilization in neutral extension
Exercise uninvolved side
Maintain extension force at DIP
How do you progress mallet finger management
AROM in 20-35 degrees after active extension is achieved Splint between exercises Progressive exercise at week 8 No more splinting at week 9 Unrestricted use at week 12
Describe the longitudinal arch of the hand
Wrist to fingertips
Grasping
Describe the proximal transverse row
Distal carpal row
stable gripping base
Describe the distal transverse arch
Metacarpal shafts to heads
Allows hand to adapt to different shapes
Describe this test
Watson / scaphoid shift test
Tests for dynamic stability of the wrist - scapholunate ligament
+ if clunk or pain in posterior wrist
(not very effective)
Describe this test
Carpal compression test
Pressure over median nerve at carpal tunnel for 30 seconds
+ reproduces symptoms that subside in minutes after pressure is removed
indicates carpal tunnel syndrome
Flex wrist to 60 to make more sensitive
Describe the UMT palmar glide
Assesses TFCC
+ is pain
Indicates TFCC pathology
Describe Weber’s two pint discrimination
Finds threshold of discrimination
Less than 6mm is normal
Describe the Digital blood flow test
Capillary refill test
Longer than 3 seconds indicates arterial insufficiency
Describe this test
TFCC stress test/ compression test
+ is pain
Indicates TFCC pathology
Describe the DRUJ instability test
Tests for DRUJ instability
Pain
What is the pattern of loss in continuity
sensory more vulnerable than motor
Large touch cells more affected than thin pain cells
Describe Vasomotor assessment
Blood vessels
Allen’s vascular test
Describe Sudomotor assessment
Sweating response
Describe Pilomotor assessment
Goose flesh response
Describe Trophic assessment
Atrophy of tissue from skin to bone
Describe a threshold test
Measure Intensity of the stimulus for depolarization
Describe a functional test
How long to place items in a bin
Describe objective tests
How quickly a nerve depolarizes
Describe a Provocative test
Stressing a tissue for a response
What are the two phases of sensory reeducation
Sensory preparation
Sensory reeducation
