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PCE Exam prep > Wrist and Hand Complex > Flashcards

Wrist and Hand Complex Flashcards

1
Q

What is colles # and what is the MOI

A
  • distal radial fracture –> dorsal displacement (posterior) of the distal fragment

MOI: FOOSH wrist in extension
More common in osteoporotic Woman

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2
Q

What are complications with Colles

A

Compression neuropathy (most commonly median N) (carpal tunnel), CRPS, and arthritis (b/c load is distributed differently more likely to get degenerative changes)

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3
Q

What are the S+S Colles #

A
  1. Dinner fork deformity***
  2. Dorsal* wrist pain and tenderness
  3. Swelling**
  4. May present with bruising
  5. Paresthesia (compression of the Median N)
  6. Difficulty lifting and grasping
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4
Q

What are the PT and Medical Interventions Colles

A

Meidcal
- Immobilization
- Stable: cast (spica) - Closed reduction internal fixation (CRIF)
- Unstable/Displaced: ORIF (open reduction internal fixation)
X-RAy after 2 weeks to make sure calcification

PT (post -immobilization)
- Mobilization - while in the cast move fingers to promote circulation –> move elbow and shoulder
–> NO PRONATION or SUPPINATION (radius goes over ulna)

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5
Q

What is Complex Regional Pain Syndrome?

A

A CHRONIC pain disorder caused by the SYMPATHETIC NS mlafunction

  • pain that is out of proportion tot he original insult or injury

Occurs in Females more than males 3:1

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6
Q

What are the two types of CRPS

A

Type 1: Occurs after injury to tissue (mm, tendons, ligaments, bone) - Unknown cause
- Previously known as Regional Sympathetic Dystrophy (RSD)*

Type 2: Injury to NERVE
- Formerly known as Causalgia*

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7
Q

What are the S+S of CRPS (5) (4 Abnormal + pain)

A
  1. Severe Pain: commonly burning pain
  2. Sensory abnomalities: Allodynia/Hyperalgesia
  3. Abnormal Bloodflow: Vasomotor changes - excessive vasodilation or vasoconstriction
  4. Abnormal sweating: Sudomotor changes
  5. Abnormal Motor function: Weakness, poor coordination, stiffness etc*** (HALLMARK present even before edema)
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8
Q

What are the Trophic changes in CRPS

A
  • Color changes (mottled, pink, red, cyanotic, or pale)
  • Temperature changes (wamr/hot or cold)
  • Edema
  • Shiny tight skin
  • Abnormal Hair growth and nails
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9
Q

What is Hyperalgesia/allodynia with CRPS

A

Hyperalgesia: Hyper painful response to actual stimulus
- with CRPS the pain threshold is lowered and therefore small stimuli - like a small pinch will cause a lot of pain. (Abnormal response)

Allodynia: Hyper painful response to non-noxious stimuli: for example blowing on the back of their hands can cause pain

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10
Q

What is the Clinical Course (3 stages of CRPS)
Stage 1

A

Stage 1: Acute/reversible stage
- several days after injury or insidious after many weeks
- Charcateristic: pain, Hyperhidrosis (sweating) (abnormal sweating is a S+S: sudomotor), warmth, erythema (redness), rapid Nail growth, edema distally

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11
Q

Stage 2 CRPS

A

Stage 2: Dystrophic or vasoconstriction (ischemic stage)
- 3 months after –> lasts for 3-6 months
- Characteristic: BURNING pain, SYMPATHETIC HYPERACTIVITY, Hyperesthesia (increased sensitivity to stimuli), mottling and coldness, brittle nails, OP**

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12
Q

Stage 3 CRPS

A

Atrophic stage
- 6 months to 1 year - lasts months to years
- Characteristic; Pain either decreases or becomes worse, SEVERE Osteoporosis, mm wasting, contractures

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13
Q

What are the Interventions for CRPS

A

PT
1. Education - about the condition
2. Mobility
* Early AROM
* Tendon Gliding
* Nerve mobilization (glides)
3. Encourage ADLS
4, Compressive loading - hand outstretched on table and weight bear
5. Distraction
6. Desensitization (using different material on skin)

Edema control
Modalities
Mirror Therapy** - tricking brain to think hand is Ok -plastic changes
Aerobic activity - releases endorphins

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14
Q

What are Warning signs of Immobilization (someone in Cast)

A
  • Increased pain
  • Cast tightness - if getting tighter - increased edema (could be CRPS)
  • Cast Looseness - not stabilizing the segment
  • Changes in surrounding skin colour/sensation –> CRPS or nerve compression/blood vessel compression
  • Increased swelling
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15
Q

What are the Dos and Donts of Immobilization

A

Do:
1. Maintain ROM of joints above and below
2. Check skin integrity above and below
3. capillary refill
4. educate pt on reducing swelling - RICE
5. Educate on warning signs/precautions
6. remove any tight jewelry

DONTS
1. stick things in the cast (stick to scratch) - cold develop infection
2. get the cast wet

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16
Q

Describe Schapoid #
Etiology
Epidemiology

A

of the scaphoid
Complications: Avascular necrosis, nonunion #, arthritis

Etiology: FOOSH - younger pts
MVA (high force hyperextension - steering wheel)
Epidemiology: Young males (high risk activities)

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17
Q

What is the blood supply for the scaphoid

A

Dorsal branch of Radial Branch supplies 80%

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18
Q

What are S+S of Scaphoid #

A
  • Radial sided wrist pain
  • Tenderness in the anatomical snuffbox - SPL+SPB tendons
  • Swelling in anatomical snuffbox
  • Pain with LONGITUDINAL COMPRESSION OF THUMB*
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19
Q

What is the Medical and PT intervention for Scaphoid #

A

Medical
- immobilization
Stable: Cast - CRIF
unstable: ORIF

PT
- Mobilization
Strengthening - immobilized for 2 weeks –> X-Ray to check for calcification –> cast off and X-ray
–> increased stiffness and decreased strength

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20
Q

Describe De’Quervains Tensosynovitis

A
  • painful inflammation to the sheath (synovium) which surrounds the tendons of the 1st dorsal compartment
  • abductor pollicis Longus and Extensor pollicis bevis)
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21
Q

What is the Etiology for De’quervains

A

Chronic overuse
- repetitive wrist and thumb movements - golfing, carpentry, office work, gripping, pinching, wringing objects

Direct trauma (rare)
- blunt trauma to Radial styloid process

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22
Q

What are the S+S for De’Quervains

A
  • Radial sided wrist pain (may extend proximal/ or distal along tendons) (differential diagnosis for Scaphoid)
  • Tenderness - Travels up
  • Swelling-
  • Wrist movements make it worse - stretching or compression of APL + EPB
  • may have crepitus

Special test: FInkelsteins

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23
Q

What is the PT and Medical intervention for De’quervains

A

PT
- Activity modification
- Cryotherapy - reduce swelling
- Splinting (thumb spica)
- Gradual strengthening and stretching

Medical
- NSAID
- Corticosteroid injection (VERY EFFECTIVE) –> More than PT
- Surgical release (rare)

24
Q

Describe TFCC tear and Etiology

A

A tear in the ligamentous and cartilaginous structures of TFCC - ulnar sides wrist pain

(Radioulnar ligaments, Extensor carpi ulnaris tendon sheath, Ulnar collateral ligament) (Articular disc, Meniscus homologue)

  • it is a load bearing structure and a major stabilizer of the distal radioulnar joint

Etiology: Compressive loads tot he wrist - especially in ulnar deviation (Push up - gymnast back hand springs)
* Distal radio-ulnar fracture

25
What are the S+S of TFCC
- ULNAR sided wrist pain - tenderness and swelling over the dorsal aspect HALLMARK: clicking with wrist moveemnt Pain in wrist extension and ulnar deviation (MOI) - compressing TFCC --> pain with that movement restricted
26
What are the special tests for TFCC
1. TFCC load Test (sharpeys) --> compressive load through wrist - Ulnar deviation + wrist extension and flexion + = CLICKING pain 2. Press Test: do dips on chair + = Pain
27
What is the PT and Medical intervention fo rTFCCC
PT - Immobilization - Activity mod - Bracing (widget) - Cryotherapy - reduce swelling - Progressive strengthening and mobility exercises Medical - NSAID - corticosteroid injection - Surgery - Debridement, repair and tigthen
28
What are the Muscle Innervations of Median N
2 LOAF * Lumbricals 1 and 2 * Opponens pollicis * Abductor pollicis Brevis * Flexor Pollicis Brevis
29
What is the Muscle innervetions of Radial N
BEST Brachioradialis Extensors of the wrist Supinator's Triceps and anconeus
30
What is the Muscle innervations for Ulnar N
* Lumbricals 3 and 4 * Hypothenar mm - Flexor digiti minimi - Abductor digiti minimi - opponens digiti minmi * Palmaris brevis * Interossei (PAD, DAB) * ADDUCTOR pollicis Brevis
31
What hand deformities are seen with Medial N lesion
APE hand (low level lesion) - Inability to abduct or oppose thumb - Held in same plane as D2-D5 HAND OF BENEDICTION (high level lesion) - inability to flex D1-D3 WHEN ATTEMPTING TO MAKE A FIST** - Only when ACTIVELY trying to flex digits
32
Hand deformities of Ulnar N
Claw Hand - hyperextension of MCP flexion of IP joints of D4-D5
33
Hand deformities of Radial N
- Wrist drop (BEST) ( if wrist extensors not active the flexors will overtake) - inability to extend te wrist or the MCP joints of the hand.
34
describe Carpal Tunnel Syndrome
- localized compression of the MEDIAN N as it passes through the carpal Tunnel Carpal tunnel: narrow passage way for Tendons and the median N on the Volar side of the hand, created by the carpal bones (floor), and the flexor retinaculum (roof)
35
What is within the carpal tunnel
9 tendons in total: the tendons of flexor pollicis longus 4 tendons of flexor digitorum profundus 4 tendons of flexor digitorum superficialis Median N
36
Etiology and Epidemiology of Carpal tunnel (7)
- Typically insidious - repetitive hand movements (typing, assembly line work) - Vibration (power tools) Associated conditions 1. RA and other inflammatory diseases (inflamm of flexor tendons) 2. Colles fracture (fracture of distal radius dorsally) 3. Lunate subluxation Conditions: 4. Hyperthyroidism - Excessive fluid retention 5. Pregnancy 2nd trimester) 6. DM --> fluid retention 7. Obesity - tissue crowding area and water retention F>M
37
S+S of Carpal Tunnel
- paresthesia and pain in median N distribution of hand - 1st,2nd,3rd and half of fourth (palmer) - worse with sustained or repetitive wrist movements - Nocturnal numbness and pain - increased at night - Relieved by "flicking" wrist - John Cena motion - reduces compression of Median N Weakness - decreased grip strength - Frequently dropping objects Severe cases - atrophy of thenar eminence and first 2 lumbricals
38
What are the special tests for Carpal Tunnel
- Tinels tets - Phalens test - Reverse Prayer pose - Reverse Phalens - prayer pose - carpal compression test - compressing carpals - Resisted APB - exclusively innervated by Median - ULTT median N bias - Electromyography (EMG)
39
What are the PT and Medical interventions for CTS
PT - Activity modification - Splinting wrist in NEUTRAL - MObility techniques: --> Nerve mobs --> Tendon Gliding --> joint mobilization (if restricted) Mm performance - gentle multi-angle mm setting - progress to resistance and endurance - fine finger dexterity Medical - NSAID - Corticosteroid - Carpal tunnel release
40
Post-op carpal tunnel release management
- wrist may be immobilized 7 to 10 days post-op in slight extension with fingers free to move - splint can be removed for therapy - AVOID ACTIVE WRIST FLEXION and Finger Flexion with wrist flexed - 10 days post-op - may have pain in thenar and hypothenar eminences as result of release and palmer arch flattening = PILLAR PAIN (pillar from thenar to hypothenar)
41
During the maximum protection phase what upper extremity exercises can be donw?
active finger and thumb movements in all directions with WRIST STABILIZED in moderate wrist EXT - active wrist extension - Active radial and ulnar deviation of the wrist with the wrist in slight ext - pronation and supination - elbow and shoulder movements
42
Moderate and minimum
sutures removed post op 10-12 days - return to full activity 6 to 12 weeks residual impairments: weakness, sensory deficits, persistent edema, limited ROM, hypersensitivity pain
43
What is Ulnar Tunnel Syndrome
localized compression of the ulnar N as it passes GUYONS canal - semirigid canal between pisiform and hamate hook
44
Etiology of Ulnar N compression
Trauma - FOOSH with or without fracture of hook of hamate Chronic Pressure - cycling Space occupying lesions - ganglion cysts Extended use of crutches HIgh risk among cyclists, baseball ctahcers, karate (block chop), using jackhammer
45
S+S of Ulnar N compression
- Paresthesia and pain in Ulnar N distribution - 1/2 ring finger + pinky - MOtor weakness of mm innervated by Ulnar N: dec. grip strength fatigue with repetitive or sustained activities In severe cases: claw hand and atrophy of hypothenar eminence
46
Special test for Ulnar N compression
1. Froments sign - weakness of adductor pollicis 2. Guyons canal compression 3.Tinnel 4. ULTT ulnar 5. Nerve conduction veloity test
47
Intervention for Ulnar N
Pt - activity mods - cock-up splint - ergonomic and padded equipment (bike handle) - frequent hand position changes - nerve mobilization Med - NSAID - Corticosteroid - Guyons canal release
48
What is Gamekeepers Thumb/Skiers
- sprain of ulnal collateral ligament of the thumb - valgus force applied to MCP joint of thumb Seen in gamekeepers (maintains land + game (hare) when jamming the head also jams the thum - valgus force Skiing - holding pole and falling VB
49
S+S of Gamekeepers
- pain and tenderness at the base of the thumb on ulnar side of the MCP joint - pain with movement- worse with abduction and extension - Decreased pinch and grip strength - swelling and discoloration at base of thumb
50
Special test for gamekeeper
Thumb UCL laxity or instablilty test
51
Intervention for Game keepers
Activity mods - splint MCP in slight flexion - Gentle ROM - Strengthening - THERAPUTTY Medical - surgical repair - complete tear or displaced avulsion fracture ORIF
52
Thumb Carpometacarpal OA, Etiology and epidemiology
- OA of CMC of the thumb - repetitive moevemtns or previous joitn injury F>M
53
S+S of CMC OA
- pain at base of thumb - worse at night, changes with weather and overuse - tenderness at CMC - Decreased pinch and grip strength - mm wasting in thenam eminence possible instability (sublux or dislocation)
54
Special test of CMC OA
Grind Test
55
PT and Medical Management for CMC OA
PT - Activity mods - splinitng - Larger grip handles - puts less stress - AROM within tolerable limits - strengthening MEDICAL - NSAID - Corticosteroid - 1st CMC arthroplasty - remove trapezium with something else - 1st CMC Athrodesis - fuse CMC
56
What are the different finger deformities (8)
1. Dupuvtren contracture: contracture of Palmar fascia - seen in D4 and D5M>F 2. triggen finger: thickening of flexor tendon sheath (Nottas nodule) - tendon sticking, catching, locking when attempting to flex - can be associated with RA 3. Mallet Finger - flexion of DIP at rest - rupture or avulsion of the extensor tendon at distal phalanx from hyperflexion injury - splinting DIP for 6-8weeks 4. Bouchards nodes - PIP OA 5. Heberdens nodes - OA at DIP 6. Swan Neck: RA 7. Boutonniere: RA 8. Ulnar Drift: RA

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