Wrist and Hand- CTS thru Dislocations Flashcards
What cervical spinal nerves, if impinged, may produce hand symptoms?
C6, C7, C8
What S&S must we differentiate between radiculopathy and peripheral nerves?
C6 spinal nerve and musculoskeletal nerve
C7 spinal nerve vs. radial nerve
C8 spinal nerve vs. Ulnar nerve
Where is the medial nerve entrapped?
At the wrist
What are the functional questionnaires for carpal tunnel syndrome?
- Katz hand diagram
- Boston Carpal Tunnel Questionnaire Symptom Severity Scale
- Hems Questionnaire
- Disability of the arm, shoulder, and hand questionnaire (DASH)
What is the guideline for carpal tunnel?
Carpal Tunnel Syndrome Clinical practice Guideline
What is the prevalence of carpal tunnel syndrome?
2.7% with clinical and electrophysiological confirmation
Carpal Tunnel is the most common _______ _________________.
Entrapment Mononeuropathy
What is the gold standard for carpal tunnel syndrome?
A nerve conduction study
What is a nerve conduction study?
Electricity in body and see how well the nerves carry it, seeing how fast it travels compared to norm
What are risk factors for carpal tunnel?
Obesity, over 45 years of age, biological female, forceful hand activity with work
What are some lesser linked risk factors for carpal tunnel?
- Circulatory conditions such as cardiopulmonary (CHF, HTN) or diabetes
- Age related joint changes
- hypothyroidism
- family hx of CTS
- Sedentary lifestyle
- Wide hand
- short stature
- Work involving repetitive work and vibration
What is the etiology of carpal tunnel syndrome?
Decreased axonal transport by:
* local inflammation at wrist
- repetitive/forceful use
- age-related joint changes
- trauma - lunate subluxation/dislocation
* Systemic inflammation
- auto-immune conditions
- circulatory conditions
- Pregnancy
* Benign ganglion cyst
How many tendons are in the Carpal Tunnel?
10 - FCR, FPL, FDS, FDP plus the nerve under the transverse carpal ligament
Where does the palmar branch of the median nerve travel? What does it provide?
OVER tunnel, provides sensory input to proximal palm, particularly the thenar surface
What nerve goes through the Carpal tunnel?
Superficial branch of median nerve
What does the superficial branch of the median nerve provide sensory input to?
Volar surface of first 3 and a half digits and their dorsal tips
What does the superficial branch of the median nerve provide motor input to?
1st/2nd lumbricals
opponens pollicis
abductor pollicis brevis
flexor pollicis brevis
What digit loses motor input first with carpal tunnel?
THUMB
What happens first: sensory or motor deficits?
Sensory, weakness is only if significant or prolonged lack of conduction
What are symptoms of CTS?
- Gradual onset of tingling that can become numb in volar surface of 1st 3 and a half digits and dorsal tips
- Worse at night and with other prolonged/repetitive wrist positions, especially flexion
- shaking hand reliefes symptoms
- weakening grip, pinch and tip strength
What are signs of carpal tunnel with function?
Limited dexterity
How can we test limited dexterity?
Purdue pegboard
Dellon-modified Moberg pick up test
What are general signs of carpal tunnel with observation?
possible thenar atrophy
What are general signs of carpal tunnel with ROM?
Symptoms with prolonged wrist flexion or extension
What are general signs of carpal tunnel with Resisted / MMT?
Weakening grip, pinch, and tip strength, primarily 1st and 2nd digits
What are general signs of carpal tunnel with neurological testing?
- Diminished sensation with fast progression to numbness over volar surface of the 1st 3 and a half digits and dorsal tips
- DTRs and Myotomes WNL
- ULTT for median nerve (conflicting support)
What are general signs of carpal tunnel with Accessory Motion Testing?
Possible hypo- or hyper mobility with carpal, RC, or distal RU joints
What are carpal tunnel special tests?
- Carpal tunnel compression (inconsistent)
- Wainner’s CPR (best to rule in)
- Two-point discrimination
- Tinel’s (inconsistent)
- Wrist Ratio Index
- Decreased sensation on involved fingers
- Phalen’s (inconsistent)
- Reverse Phalen’s
What is the PT rx for carpal tunnel syndrome?
- POLI (no c) ED - bc compression is most often the cause
- pt education
- Modalities
What is the patient education for CTS?
Pathology and risk factors
Aggravating factors
What should we know about modalities for CTS?
Conflicting evidence or recommended not to use with some
- short term pain control with others
What is the patient rx for computer use?
Use computer mouse less, alternate hands, use arrow keys or touch screens
- keyboards with lower strike force
What/when are orthoses used for with CTS?
Neural wrist splint especially at night , also during the day when night only use is ineffective
What can we immobilize with CTS?
MTP joints PRN
What joint mobs can be done with CTS?
Joint mobilizations for neck, forearm, wrist, for short term progress
What are better for CTS: neural glides or tendon glides?
Tendon glides
What is the purpose of tendon glides?
The 10 tendons don’t all move at the same time, need to slide on each other, sheath can build up scar tissues which are then needed to be broken up
What MET is recommended for CTS?
Lack of research for CTS :(
What treatment combination is helpful for CTS?
Orthoses and stretching
What is the frequency of sessions for CTS?
3 weekly sessions and a HEP
- combination of STM, neural and tendon glides
What are the results after the recommended session frequency and combination of treatments?
Better pain relief and functional abilities at 1 and 3 months, equal to sx with pain and function at 6 and 12 months
What amount of patients are helped by a cortisone injection with CTS?
1/3
What is the surgery for CTS?
A carpal tunnel release, cutting of the transverse ligament
What is the CTS sx similar to? (Another treatment)
3 manual therapy treatments following 12 months of symptoms
What is the rx for manual therapy treatments for CTS?
From neck to hand
improved symptoms and punch tip grip force
What is damage to the median nerve referred to as?
Ape hand
What does the denervation of the median nerve result in?
- weakness in the thenar muscles
- thenar atrophy with the thumb more in the plane of the hand
- Inability to flex, oppose or abduct the thumb
What is the denervation of the ulnar nerve known as?
Claw hand
What are symptoms of the denervation of the ulnar nerve?
- Atrophy of hypothenar eminence
- Deficient interossei muscles
- claw like deformity
What systemic disease can cause innervation issues?
Diabetes
What are some bone and joint problems in the hand?
- RA
- Fractures
- Dislocations
What is the most common of all fractures?
Colles
What population is Colle’s fracture most common in?
Biological women middle aged and older
What is the etiology for Colles?
FOOSH
What structures are involved with Colles?
The distal radius breaks
Where does the distal radius break with Colles?
Within 2.5 cm of the wrist, displaced dorsally
What is Colle’s also known as?
Dinner fork deformity
What is reverse Colle’s due to?
A fall on the dorsum of the hand
What is the most common carpal to be fractured?
Scaphoid
What is the etiology of a scaphoid fracture?
FOOSH
What is a complication of a scaphoid fracture?
Avascular necrosis may be an issue in the proximal and distal poles of the scaphoid, circulation complicates healing
What are S&S of a scaphoid fracture?
- Pain at anatomic snuffbox is primary complaint
- Functional test; pain with thumb to index pinch
- ROM - pain with wrist extension and pronation
- special tests - stethoscope test
What is a Boxer’s (Fighter’s) fracture?
Fracture at the neck of the 2nd, 3rd, 4th, or 5th fingers
**MOST common of fingers
What is Bennett’s Fracture?
Proximal 1st MC
MOST common of thumb
What is the MOST common fracture of the thumb?
Bennett’s fracture
What is the PT rx for fractures?
- Deal with scan findings - may be accessory motion may be stability tests
- Find what is weak - is there ligament damage?
What is the etiology of dislocations?
FOOSH
What carpal is most commonly dislocated?
Lunate
What other stabilizing structure is attached to the lunate?
Disc and fibrocartilage
Where is the most common instability in the hand?
Scapho-lunate joint
What special tests can be done for the scapho-lunate joint?
Watson’s - dorsal glide of scaphoid moving from ulnar deviation and extension to radial deviation and flexion
What is the PT rx for dislocations in the hand?
- work on tissue proliferation/integrity if damage
- Work on stability if needed
- May splint if muscle system can’t make up all the difference
