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Clinical Medicine II > Wrist and Hand Disorders > Flashcards

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
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2
Q

What runs through the carpal tunnel

A
  • median nerve
  • flexor digitorum superficialis
  • flexor digitorum profundus
  • flexor pollicis longus
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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
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4
Q

Signs & symptoms of acute carpal tunnel syndrome

A
  • paresthesia with repetitive finger flexion
  • numbness at night
  • symptoms decrease with shaking of hands
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5
Q

Signs & symptoms of subacute carpal tunnel syndrome

A
  • paresthesia
  • more consistent weakness, difficulty with fine motor activities
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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
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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
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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
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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
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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
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11
Q

Treatment for carpal tunnel syndrome

A
  • bracing (cock up splint or Manu brace)
  • NSAIDs, Corticosteriods
  • Gentle median nerve flossing
  • Surgery
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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
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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
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14
Q

Structures of the TFCC

A
  • Ulnar collateral ligament
  • Articular disc
  • Palmar ulnocarpal ligament
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15
Q

Describe the TFCC (trianglular fibrocartilage complex)

A
  • sits between ulna and triquetrum/lunate
  • injury usually refers to meniscal tear
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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
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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
Q

Post surgical management of Dupuytren disease

A
  • 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
Q

Describe Mallet finger

A
  • 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
Q

Describe boutonniere deformity

A
  • 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
Q

Describe jammed finger/volar plate injury

A
  • 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
Q

Describe flexor tendon injuries/repairs

A
  • 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
Q

What are the 3 approaches to rehab for flexor tendon injuries/repairs

A

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
Q

What should all protocols for flexor tendon injuries/repairs emphasize

A
  • emphasize tendon excursion rather than increased force through the musculotendinous unit
32
Q

Define the zones for flexor tendon repairs

A
  • 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
Q

Describe extensor tendon repairs

A
  • 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
Q

What does treatment and timing of rehab depend on for bony injuries of the wrist and hand

A
  • 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
Q

Describe Colles fracture

A
  • 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
Q

Describe Smiths fracture

A
  • 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
Q

General treatment for wrist fractures

A
  • 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
Q

Describe scaphoid fracture

A
  • most common fracture of carpal bones (60-70%)
  • FOOSH history
  • Complications: non-union or necrosis due to blood flow interrruption
39
Q

Describe scaphoid fracture rehab

A
  • 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
Q

Describe phalangeal fractures

A
  • 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
Q

Describe the intrinsic plus position

A
  • worst extension
  • MCP flexed 60-70 degrees
  • IPs fully extended

Clinical Medicine II (21 decks)

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