Wrist And Hand Flashcards
What are the carpal bones?
What muscles/structures attach to them?
Scaphoid, lunate, triquitrum, pisiform Hamate, capitate, trapezoid, trapezium FCU attaches to pisiform Hamate: flexor retinaculum Trapezium makes saddle joint
What are Heberdens’ nodes? Bouchard’s nodes?
What is Gamekeepers injury?
What are Stener lesion?
Heberden’s nodes: DIP osteophytes
Bouchards: PIP osteophytes
Gamekeepers: thumb UCL disruption
Stener lesion: UCL tear
What are the hand extensor extrinsics that are in each compartment?
221 211 APL, EPB (over radial styloid -> Dequervain's) ECRL, ECRB EPL ED, EI EDQ (extensor digiti quinti) ECU
What are the hand flexor extrinsics?
What are the muscle in the hypothenar eminence?
What are the muscles in the thenar eminence?
Flexor extrinsics: FCU, FCR, FDP, FDS
Hypothenar: ABD dig minimi, flex dig minimi, opponens Di minimi
Thenar: APB, OP, FBP, add Poll
What do the following morphological chances of the hand mean?
- Flattening of palmar arches
- Ulnar claw hand
- Ape hand
- Ulnar drift
- Boutonnière deformity
- Swan neck deformity
- Dry skin
- Tropic changes
- Clubbing of nails
- Spoon shaped nails
- Intrinsic wasting
- Hyperextension of ring and small MP joint with flexion of IPjoints
- Unable to ABD thumb -> median nerve
- Ulnar drift - seen in pts with RA
- Flexion of PIP with hyperextension of DIP
- Flexion of DIP with hyperextension PIP
- Peripheral nerve lesion
- CRPS
- IBD
- Iron deficiency
What do the following function movements test?
- Hook fist
- Straight fist
- Full fist
- Key grip
- Tip grip
- 3 point pinch
- Opposition
- Lumbrical extensibility
- Max FDS gliding
- Max FDP gliding
- Ulnar nerve
- AIN
- Median nerve
- Median nerve
DeQuervain’s cluster
What are you thinking about in your differential diagnosis?
How do you differentiate?
- Finkelsteins
- TTP at APL, EPB tendons
- Pain at radial styloid
- Thickening
- Swelling
- Pain with resisted thumb extension
- Pain in 1st compartment with wrist movement
Want 5/7 positive
Differentially diagnose intersection syndrome
Intersection syndrome: ~4cm from wrist (more proximal and dorsal) no pain with resisted wrist extension
Semester Weinstein monofilament test:
What is normal?
What is loss of protective sensation?
What is normal two-point discrimination distance?
Normal: 2.83
Loss of protective sensation: 4.56
Normal 2 point <6mm
What are the zones of the flexor tendon injury?
What area is most prone to stiffness?
I fingertip to PIP II PIP to distal palmar crease III distal palmar crease to distal margin of flexor retinaculum IV flexor retinaculum (carpal tunnel) V proximal to wrist crease Zone II
Post op protocol for finger flexor tendons (regular)
Early (0-4 weeks) cast at 20-25 wrist flexion and 50-60 MCTP flexion
Intermediate stage (4 weeks) neutral wrist orthosis, PROM
- begin AROM and tendon glides at 10 deg wrist extension to emphasize tenodesis (synergistic wrist motion)
- assess after 3-4 days
- if composite PROM >AROM flexion >50 then adhesions have formed (good) and pt can progress to next phase
Late immobilization phase (4-6 weeks) discontinue orthosis, isolated joint blocking exercises
Late stage (8 weeks) tendon gliding and initiate resisted exercises
Flexor tendon repair early active protocol
Dorsal block splint wrist at 20 flexion MP at 80-90 and Ip at extension
2 days of rest
2 reps of passive flexion and active flexion every 4 hours, starting with Contralateral 4 fingers stacked on Palm as target and then decreased fingers until patient is flexing to Palm
Intermediate (3.5 - 8 weeks) d/c splint if restricted tendon gliding or else wear 1-2 more weeks
- if flexion contracture, orthosis fabricated with PIP into extension
Late stage (8 weeks) continue with active flexion and extension exercises
Full flexion expected at 12 weeks
What are the zones of extensor tendons?
I DIP II middle phalanx III PIP IV proximal phalanx V MCP joint VI dorsal surface of hand VII dorsal forearm TI thumb distal phalanx TII thumb proximal phalanx TIII thumb MCP TIV dorsum of MCP
How do you treat zone III/IV extensor tendon injuries?
What are short arc programs and how do they differ from other protocol
PIP joint extension orthosis with DIP free for 6 weeks for complete and 3 weeks for partial
MP and DIP join active flexion exercises daily with PIP immobilized
6-8 weeks, wean off splint and begin AROM through full arc
Light resistance at 8 weeks
Short arc: wrist at 30 flexion and MO at 0 and allow PIP motion from 0-30 flexion
After two weeks flexion to 40, 3 weeks flexion to 50, 4 weeks flexion to 70-80
Strengthening at 6 weeks
How are zone V and VI extensor injuries managed?
What are safe movements during healing time?
Immobilization with wrist at 35-40 extension and Ip at 0
Use gliding exercises that include active flexion and passive extension to improve quality of healing tendon
Safe movements of MP joints: 2nd and 3rd digit: slight hyperextension to 30-45 deg flexion, ring and small fingers: slight hyperextension to 40-50 flexion
MP held in extension whil IP full flexion
Wean off orthosis weeks 4-6
What is the protocol for zone VII repairs?
Early motion programs?
Troublesome area
Immobilization protocol with orthosis in wrist and MP extension for 3-4 weeks
No active PIP or MP ext
Earl motion programs: dynamic orthosis with wrist at 40-45 ext and MP at 0
Early motion outside of orthosis from 10 wrist flexion to 20 wrist extension from 0-3 weeks
- can also perform flex MP 30-40 with wrist ext, then MP flex 40-60 by week 4 and 70-80 by week 5
- mild strengthening at week 6
