Wrist and Hand Disorders Flashcards
1
Q
Common orthopedic impairments for the wrist and hand
A
- Nerve lesions: carpal tunnel syndrome & carpal tunnel release
- Sprain & tendinopathies: TFCC injury, Dequervain’s tenosynovitis, Dupuytren disease
- Tendon injuries: mallet finger, boutonniere deformity, jammed finger
- Tendon repairs: flexor tendon repairs, extensor tendon repairs
- Bone injuries: radius fractures (Colles and Smith), scaphoid fracture, scaphoid lunate advanced collapse, phalangeal fracture
- Complex regional pain syndrome
2
Q
What runs through the carpal tunnel
A
- median nerve
- flexor digitorum superficialis
- flexor digitorum profundus
- flexor pollicis longus
3
Q
Causes of carpal tunnel syndrome
A
- MOI: median nerve compression
- etiology varies
- repetitive motion = swelling
- dislocation of lunate
- double crush
- increase bony size of tunnel
- normal pressure = 3mmHg and 20mmHg over time elicits CTS
4
Q
Signs & symptoms of acute carpal tunnel syndrome
A
- paresthesia with repetitive finger flexion
- numbness at night
- symptoms decrease with shaking of hands
5
Q
Signs & symptoms of subacute carpal tunnel syndrome
A
- paresthesia
- more consistent weakness, difficulty with fine motor activities
6
Q
Signs & symptoms of chronic carpal tunnel syndrome
A
- paresthesia constant
- muscle wasting thenar eminence (FPB, APB, OP)
- loss of opposition of the thumb
- fine motor function impairments: writing, prehension, dexterity
- loss of grip strength
7
Q
What would see on observation for carpal tunnel syndrome
A
- may have brace in place (neutral to 20 degrees extension)
- shaking of hand when symptoms occur
- atrophy along thenar eminence
8
Q
Typical evaluation of carpal tunnel syndrome
A
- History: see symptoms
- AROM: may have symptoms with wrist extension
- PROM: may have symptoms with wrist extension
- RROM: may have symptoms with resisted flexion when wrist is in an extended position
9
Q
Neurology of carpal tunnel syndrome
A
- decreased sensation at thumb & possibly fingers 1 & 2 (no sensory loss at palm of hand)
- Positive Tinel’s sign
- Positive Phalen’s or reverse Phalen’s test
10
Q
Clinical prediction rule for carpal tunnel syndrome
A
- Age > 45
- Shaking hands relieves symptoms
- Wrist ratio > 0.67 (divide AP by ML wrist width
- Reduced sensation median nerve (at thumb)
- Symptom severity scale score > 1.9
11
Q
Treatment for carpal tunnel syndrome
A
- bracing (cock up splint or Manu brace)
- NSAIDs, Corticosteriods
- Gentle median nerve flossing
- Surgery
12
Q
Education for carpal tunnel syndrome
A
- education to avoid repetitive movements and sustained grip/eliminate aggravating factors
- computer work stations and hand tools should position wrists close to neutral
- avoid prolonged palmar and solar pressure, vibration, and cold exposure
- use large handles grips and padded work gloves
13
Q
Management of carpal tunnel release
A
- splinting/immobilization 1-2 weeks
- differential tendon gliding post-op day 4: no wrist + finger flexion (bowstring risk)
- nerve gliding at 2 weeks
- scar tissue mobilization
- no finger flexor strengthening or grip exercises for 4-6 weeks
- transverse ligament divided
14
Q
Structures of the TFCC
A
- Ulnar collateral ligament
- Articular disc
- Palmar ulnocarpal ligament
15
Q
Describe the TFCC (trianglular fibrocartilage complex)
A
- sits between ulna and triquetrum/lunate
- injury usually refers to meniscal tear
16
Q
Typical history of a TFCC injury
A
- fall on outstretched hand in a pronated position
- bowling, golf, bicep curls
- pain ulnar side of wrist: can be very diffuse
- may have popping/clicking/catching with pronation/supination
- pain with power grip
17
Q
Evaluation of a TFCC injury
A
- Observation: may hold hand in an ulnar deviated position with slight flexion, reluctant to shake hands
- Palpation: tenderness ulnar side of wrist (especially fovea)
- AROM/PROM: pain with radial deviation + extension, end range supination pain
- RROM: negative, except ECU which attaches along TFCC
18
Q
Special tests for TFCC
A
- hyper supination (overly rotating the forearm in a palm up position)
- loading the wrist in a position of ulnar deviation & wrist extension
- Press test: pain with pushing up out of a chair with wrist extended (sensitivity about 100%: if neg. then you don’t have it)
19
Q
Treatment for TFCC
A
- NSAIDs
- Immobilization in wrist flexion & slight ulnar deviation by cast or splint X 4-6 weeks
- Removable splints & physical therapy: progressive ROM avoiding painful movements, specially into full ulnar deviation, once full ROM without pain, begin strengthening
- Surgery
20
Q
Describe DeQuervain’s Tenosynovitis
A
- thickening of the synovial sheaths of the APL & EPB
- Causes: idiopathic and possibly linked to repetitive thumb movements
- Symptoms: pain, tenderness, and swelling over radial wrist
21
Q
Evaluation of DeQuervain’s Tenosynovitis
A
- Observation: nothing
- History: pain on radial side of thumb near wrist
- Palpation: pain along APL and EPB
- AROM: pain with ABD and extension of the thumb
- PROM: pain with flexion of thumb if wrist is ulnarly deviated
- RROM: pain with ABD and extension of the thumb
- Special test: Finklestain’s test
22
Q
Treatment for DeQuervain’s Tenosynovitis
A
- splinting (thumb spica)
- activity modification
- cryotherapy, ice massage
- Iontophoresis
- pain free ROM
- tendon gliding: straight, hook fist, full fist, & platform position
- surgery
23
Q
Describe Dupuytren disease
A
- formation of pits & firm nodules that lie just below the skin of the palm
- nodules may be fibroblasts/collagen or skin that “bunches” in response to a longitudinal contraction of the underlying fascia
- greatest incidence in caucasian men or Northern European descent
- flexion contractures of the MCP and PIP joints (usually fingers 4-5)
- often bilateral
24
Q
Treatment of Dupuytren disease
A
- treatment centered on patient reassurance and education (PT not effective)
- steroids or collagenase injections: the patient wears a night extension splint for 4 months & performs finger ROM exercises
- surgery
25
Post surgical management of Dupuytren disease
- following surgical dressing removal, assess edema, sensation, and ROM
- if full extension not achieved, splinting with a static, progressive, hand-based orthotic that is adjusted to increase extension
- after suture removal & wound closure, the therapist initiates scar massage & a silicone gel pad is scarring is prominent
- 3 weeks post-op, the patient may progress to stretching & resistive exercises
26
Describe Mallet finger
- interruption of the extensor tendon mechanism over the DIP joint (Zone 1)
- MOI usually forceful flexion of extended DIP joint
- closed injuries without fractures: immobilization in sight hyperextension (no skin blacking) for 6-8 weeks
- begin gentle ROM at 6-8 weeks, increasing flexion (20 degree increments/week) as long as active full extension is not compromised
27
Describe boutonniere deformity
- interruption of the central tendon (slip) and triangular ligament at the PIP joint (zone III) allows the head of the proximal phalanx to herniate dorsally (through the hood)
- Goal: approximate the ends of the tendon so they can heal together
- remodeling may be required as swelling decreases and splint or cast loosens
- active and passive DIP flexion is encouraged
- after 6 weeks, active motion of the PIP is initiated, but the digit is splinted in between session for 2-4 weeks
28
Describe jammed finger/volar plate injury
- Symptoms: pain, stiffness, catching, hypertension deformity >15 degrees
Mild: buddy taping 1-2 weeks and continued taping with at risk activities until full pain free ROM
- Dislocation or middle finger injury: flexion splinting (10-30 degrees) every 2 weeks, ROM activities after 2 weeks, and buddy taping 4-6 weeks
29
Describe flexor tendon injuries/repairs
- rehab involves careful balance between protecting the repair & gliding the tendon
- goal of surgery and therapy: a strong repair that glides freely, smooth, mechanically efficient pulley/sheath system
30
What are the 3 approaches to rehab for flexor tendon injuries/repairs
1) Immobilization: following repair, the wrist & hand casted or splinted for 3-4 weeks before beginning active & passive exercise
2) Early passive mobilization: passive flexion & active extension allowed within splint limits
3) Early active mobilization: with these programs, the tendon is moved actively within 48 hours of repair & within carefully outlined limits set by the surgeon
31
What should all protocols for flexor tendon injuries/repairs emphasize
- emphasize tendon excursion rather than increased force through the musculotendinous unit
32
Define the zones for flexor tendon repairs
- Zone I: isolated FDP tendon lac's and avulsions
- Zone II: usually involve FDS & FDP tendons, requires special consideration to maintain gliding & prevent tendon-to-tendon adhesion
- Zone III: palm tendon injuries may be accompanied by nerve, vascular, and/or lumbrical damage
- Zone IV: carpal tunnel; may also involve the median nerve
- Zone V: tendon injuries here may occur with neuromuscular injuries
33
Describe extensor tendon repairs
- sutured extensor tendons are only 50% as strong & do not retain sutures easily because of their thinner substance
- Goals: protect the tendon during healing, restore gliding, & tensile strength
- excursion range should be great enough to stimulate biochemical changes & to avoid adhesions, but small enough to avoid gapping of the repair
34
What does treatment and timing of rehab depend on for bony injuries of the wrist and hand
- number of fragments
- fragment orientation (displaced or in alignment)
- approach used to restore alignment (closed reduction or open reduction)
- method used to maintain reduction (external fixation: cast, splints; internal fixation: pins that protrude through the skin into the bone)
- involvement of articular surfaces
35
Describe Colles fracture
- radial fracture with dorsal displacement of the distal fragment & radial shift of the carpal bones
- the greater the extension of the wrist at impact generally results in greater injury including a comminuted fracture
- management ranges from closed reduction with cast or external fixation to surgical reduction and internal fixation
- fracture healing takes 5-8 weeks with expected full functional recovery in 4 months
36
Describe Smiths fracture
- distal portion of radial fracture dislocates palmarly
- surgery usually required
- fracture healing in 5-9 weeks with expected full functional recovery in 6 months to 1 year
37
General treatment for wrist fractures
- While casted: ROM digits, elbow, & shoulder; goal to reduce edema, prevent capsular/tendinous tightness
- Cast removed: gentle ROM thumb and wrist (pain free range); goal is edema control
- If continued limited ROM: joint mobilizations may need to be incorporated
- Once full ROM: strengthening exercises can be added
38
Describe scaphoid fracture
- most common fracture of carpal bones (60-70%)
- FOOSH history
- Complications: non-union or necrosis due to blood flow interrruption
39
Describe scaphoid fracture rehab
- Begins during immobilization: primary focus is to reduce edema, maintain ROM of uninvolved distal joints
- Following cast removal, use thumb spica splint: wrist exercises for differential gliding of the wrist & finger muscles; strengthening with exercise putty, sustained grip activities, & gradual closed chain activities progress to tolerance; return to full activity within 12 weeks after cast removal
40
Describe phalangeal fractures
- splinting unless unstable, displaced fractures
- Distal phalanx: splint 2-4 weeks, AROM at 2-4 weeks, PROM 5-6 weeks, PRE 7-8 weeks
- Middle phalanx: splinting 3 weeks, AROM when non painful, PROM at 4-6 weeks, PRE 6-8 weeks
- Proximal phalanx: buddy tape (unless intra-articular), AROM immediately, PROM 6-8 weeks
41
Describe the intrinsic plus position
- worst extension
- MCP flexed 60-70 degrees
- IPs fully extended
