Wrist and Hand Examination (Lecture #2) Flashcards
1
Q
What are the two main arteries in the hand?
A
Ulnar artery
Radial artery
2
Q
What are the names of the palmar aches?(blood)
A
Superficial palmar arch
Deep palmar arch
3
Q
What part of the hand does the ulnar artery supply?
A
Medial portion of hand (think digits 4/5)
4
Q
What part of the hand does the radial artery supply?
A
Lateral portion of the hand
5
Q
KNOW: sometimes lack of blood flow in the hand will cause numbness / tingling / change in skin color
A
6
Q
What is the name of the special test that test for blood flow in the hand?
A
Allens test
7
Q
How is allens test performed?
* Whats a pathologic and normal amount of time?
A
Compress both the radial and ulnar arterys at the same time.
Have the pt make a firsta few times which will blanch the hand (cut off BF) - hands turn white
Then let go of one of the arteries and see if blood flow comes back on that side (should go from a pale hand back to normal color)
2-3.5 seconds = normal
>6 seconds = abnormal
8
Q
What is this and what does it indicate?
A
Nail clubbing
Indicates cardiovascular or pulmonary disease
9
Q
What is this and what does it indicate?
A
Yellowing of nail
Indicates nail infection
10
Q
What is this and what does it indicate?
A
Scaling/ridging (looks like a fish scale about to pop off)
11
Q
What is this and what does it indicate?
A
Spooning/depression
Thyroid dysfunction
12
Q
What is this and what does it indicate?
A
Ridging
Poor nutrtion
13
Q
What are the 4 creases of the hand?
A
Distal palmar crease
Proximal palmar crease (proximal transverse crease)
Thenar crease
Distal wrist crease
14
Q
How to measure gross ROM at the fingers
A
Proximal transverse crease to the finger tips
Would take a ruler and measure from fingertips to that crease
15
Q
What are the 3 arches in the hand?
A
Proximal transverse arch
Distal transverse arch
Longitudinal arch
16
Q
Which arch of the hand is the most mobile?
A
Distal transverse arch
Lets the metacarpals rotate around something that you’re grabbing
* hand can wrap around the object in a transverse way
KNOW: Longitudinal arch also has some movement but that movement is mostly coming from the thumb
17
Q
What bone articulates w/ the first metacarpal?
A
Trapezium
18
Q
What metatarsal does the longitudinal arch go through
A
3rd
This is basically the midline of the hand (doesnt move w/ abduction)
19
Q
What is this?
* why do they develop
* painful?
A
Ganglion cyst
spontaneously develop - not painful
If they get to large they limit motion
20
Q
Where is listers tubercle?
A
On the dorsal side of the radius
go to ulnar styloid process and slide over find a hole then the next bump on the other side of the hole
21
Q
What makes listers tubercle approximate - supination or pronation?
A
Supination
Put one finger on listers tubercle and the other on the ulnar styloid process. Do supination and notice that your fingers are now closer together
22
Q
Why would we measure hand volume?
A
To confirm edema
23
Q
What are the two ways to measure the hand?
A
Figure 8 method - utilizing a tape measure around wirst and MCP
Volumetric
* most accurate / sensitive to change
* Measure by how much water is displaced
* often utilized by hand specialists
24
Q
KNOW: Extensor digitorum allows us to extend all the joints down to the DIP
it inserts on the middle phalanx and bifercates and has 2 off shoots that both insert on the distal phalanx
A
25
What is the main purpose of the extensor hood?
To keep extensor digitorm down (not let it pop up off the bone)
If there was nothing holding that tendon down it would probs spring up and pull us into hyperextension
OR
The tendon could slide laterally or medially
26
**While the extensor hoods primariy job is holding down extensor digitorum what 2 muscles attaches to it and how does it affect these muscles actions?**
Dorsal interossous - pulls on extensor hood to create abduction (DABs)
Lumberciles - runs on the palmar surface of hand then attaches to extensor hood which is on the dorsal surface of the hand
* the lumbercles attach to the extensor hood right at the MCP joint (which is where the extensor hood begins)
*** This attachment points means the lumbercles do MCP flexion, proximal interphalangeal extension (because extensor hood runs on dorsal surface) and distal interphalngeal extension (same reason).**
* This is why the lumbercles job is MCP flexion, PIP / DIP extension (not flexion at every joint like I thought)
27
Where does the extensor hood start?
justdistal to MCP joint
28
What is the lumbercles position (do it with hand)
29
What position normally goes with abduction of the fingers?
Extension (because of extensor hood connections)
Try abducting fingers in full flexion
30
What muscle does DIP flexion?
Flexor digitorum profundus
31
Where does flexor digitorum superficialis insert?
Middle phalanx
32
KNOW: Volar = palmar
33
Which two things do PIP flexion?
Flexor digitorum superficialis
Flexor digitorum profundus
34
What keeps flexor digitorum superificalis and flexor digitorum profundus attached to the metacarpals / phalanxes on the palmar side?
Pulleys
35
What two tendons do the pulleys keep attached?
Attach flexor digitorum superficialis and flexor digitorum profundus attached to the palmar surface of the metacarapls / phalanxes
36
How many pulleys are there?
5
37
which two pulleys only attach flexor digitorum profundus?
4/5
38
Where is A1 Pulley?
Distal end of metacarpal
39
Which one of the 5 pulleys causes most issues?
A1 Pulley
Because when you grip something most of the pressure is going to be at the metacarpal (bigger surface area to come into contact w/ object). These forces are the 1st metacarap apply that compression force on the A1 pulley which causes it to get injruied more often
Also when you grip something you often do it at the PIP joint and that pressure travels down through the metacarapal
40
Who normally gets A5 pulley injuries and why?
Rock climbers
Because they're doing lots of DIP flexion to wrap their fingertips all the way around the rock
May also get an avulsion fracture of distaal phalanx due to the flexor digitorum profundus pulling so hard
41
Which pulleys does the thumb have (less joints)
A1/2 pulley
A1 = at metacarpal head
A2 = proximal phalanx (regardless of thumb or finger)
42
What part of extensor digitorum is most commonly rupture w/ Boutonniers deformity?
Around the PIP joint
42
What is Boutonniers deformity?
A central slip injury or rupture of extensor digitorum
NOTE: Central slip means the central part of the extensor digitorum slips (not that it slips to the center)
43
What two things normally cause boutonniers deformity
Trauma to dorsal PIP or extreme PIP flexion (which lengthens extensor digitorum)
44
With a boutonnieres central slip what can we expect of the finger?
PIP flexion
Because this tendon will have slid medially or laterally at the PIP joint. Instead of being ontop of it it will be off to the side - so when it contracts it pulls that PIP into flexion instead of extension
**NOTE: this slip happens when the extensor hood is no longer keeping it tight to the dorsal aspect of the phalanxes**
45
What two things will be lost w/ Boutonniers deformity?
ROM is greatly decreased (cant go into extension anymore)
Strength is greatly decreases (the muscle lever system is messed up so it cant even pull the finger into extension)
46
What do we do for someone w/ Boutonnieres deformity? (3)
Put them in a splint that holds them in extension. If they stayed in that flexion a contracture could happen
gentle ROM (to prevent contracture)
Strengthening
47
Can we fix someone w/ Boutonnieres deformity
We can help, but if its not surgically corected they won't ever really have that extension
48
What joint is boutonnieres deformity at?
PIP
49
KNOW: Pathologies of extensor hood often create boutonniers deformity because they don't hold extensor digitorum in place correct and it slips laterally or medially
50
How long should someone w/ Bountonniers deformity be in a splint?
4 weeks
51
Is the volar plate on the palmar or dorsal side of finger?
Palmar
Remember palmar = volar
52
Where are our volar plates (how many are there)
Palmar side (volar side)
One at the DIP joint, PIP, MCP joint
53
What normally causes volar plate pathologies? (4)
RA / terminal extensor tendon injury, spastic conditions, fractures to middle phalanx
54
Which volar plate is most likely to be damaged?
One at PIP joint
55
What is a common presentation of someone w/ a swan neck deformity. Also explain the pathology
Volar plate injury (palmar) OR disruption of oblique retinacular ligament
* NOTE this is at the PIP joint
This plate not being intact or inflammed causes the lateral bands of extensor digotrum (shown on atlas) to slip superiorly and pull the PIP joint into hyper exension
* however - since this joint is in hyper extension the extensor digotorum is pulled taut which causes it to flex at the DIP and MCP joints giving you a swan looking finger
So its all about those lateral bands that split off from the main part of extensor digitorum slipping superiorly (dorsally) which pulls the PIP joint into hyperextension
NOTE: if the oblique retinacular ligament got torn that PIP joint would pop into hyper extension causing this same deformity (shown below)
56
Which way do the lateral bands slip in boutonnieres deformity?
What about in swan neck deformity
Boutonnieres deformity = slip inferiorly
Swan = slip superioly
57
What is this made to correct?
Swan neck deformity to push the PIP joint into flexion (which gives more slack to extensor digitorum and allows MCP / DIP to not have to be in hyperflexion)
58
59
Where does mallet finger occur at?
DIP joint (hitting finger w/ hammer)
60
Which tendon is affected in mallet finger?
Extensor digitorum
61
What is the common presentation of mallet finger?
DIP flexion (because extensor digitorum is no longer holding them in extension)
62
What are the two kinds of mallet finger?
Extensor digitorum rupture / avulsion distal phalanx
63
Other than a hammer, what causes mallet finger?
Foreful jamming into flexion will cause an avulsion style injury or rupture (because tendon will be pulled taut)
64
What place would someone w/ mallet finger not be able to actively extend?
DIP joint due to pathologica extensor digitiorum
| resting pos
65
KNOW: mallet finger common in athletic pop
66
KNOW: Mallet finger often treated w/ a splint / tendon repair (often not repaired though because who cares if theres a little bit of flexion here)
67
What fingers are most likely to have trigger finger?
1,3,4
68
Where does trigger finger typically occur?
At the A1 pulley
69
What causes trigger finger?
The A1 pulley becomes inflammed / to tight and it becomes to narrow for flexor digitorum superficialis / flexor digotrum profundus to go through. this pressure on the tendon causes the tendon to get more and more angery at that spot (positive feedback loop). It almost creates a little bubble on the proximal side of this pulley
Flexion doesnt hurt because it leaves more slack and this bubble doesnt have to go under the A1 pulley
* so they will be able to flex finger fine
Extetension hurts because this tendon is pulled taut and this little bubble is pulled udner the A1 pulley
* so they wont be able to extend their finger
* everytime they do this it adds irritation
Look at fingertips in the picture below - its flipped from what you would think in they're in flexion in both of those piecutres (but the top one is moving into extension)
| Bottom flexion top extension (flipped from what you would think)
70
Who is most likely to have trigger finger
Diabetes mellitus
Young children
**RA **
**Menopausal women**
71
What would this bracing be for? Why?
Trigger finger
Because they're keeping that MCP in extension when they try to grasp for something (so that bubble doesnt get pulled back out)
NOTE: flexion normally isnt painful but its getting it back into extension thats painful because that bubble has to be pulled back under the A1 pulley
72
Where is trigger finger normally painful (joint)?
MCP joint (thats where the A1 pulley is)
73
KNOW: Treatment for trigger finger:
* MCP flexion block splint in 0 degrees
* Intiially avoiding/eliminating provocative movements
* Corticosteriod injections (2-3x)
* In refractory cases, surgical release of A1 pulley performed
as therapist we would do things like keep mobility in the other joints in the area (dont let them get disuse misuse)
74
What is Dupuytren contracture?
* How it progresses
* Which joints most affected?
* Which digit most involved?
* Risk factors / why it develops
* Whos more likely to need surgery men or women
* Surgery indicated?
* How do PT's treat
Palmar fasciitis
palmar aponeurosis (fascia) shortens
At first we get development of nodulues which tne progress to tendon like cords then thickening and shortening of fascia
MCP / PIP joints most affected
5th digit most involved (normally ulnar side of hand is most affected) - the picture below shows 4th but the 5th is more common
Idiopathic
Risk factors:
* Alcoholism (drys up the palmar aponeurosis [which is the hand fascia])
* Diabetes
* Epilepsy
* Tobacoo use
* Often seen after surgery (her anicdotal risk factor)
Men 7-15x more likely to require surgery for this
KNOW: Surgery is often required
**Treated w/ mobility EX** (and strengthening)
* Note this pulls PIP / MCP into flexion so we work on extension
* NOTE: pushing yourself up from the ground is main reason we want to train pt to have that extension - but we might not ever get there (and honestly most of life is lived in flexion so its not the end of the world)
* We want to just get them to a point where they're functional
75
Does RA go away?
Life long
76
What happens in the acute phase of RA? (4) What causes the flare ups?
Pain
Swelling
Warmth
Limited ROM
Its due to synovitis and tissue proliferation (causes little nodules or swollen IP joints)
77
What is the inflammatory process for RA? What problem does this cause?
Stretching --> healing --> Scaring
Causes significant soft tissue damage around distal joints
Leads to progressive weakness (due to damaged soft tissue)
Muscle strength and length imbalances
78
What joints are most likely to have RA
Distal joints
79
What is this
RA
This is a zig zag thumb sign for RA
IP flexion
MP hyperextension
CMC flexion
Kind of like a swan neck deformity but of the thumb
80
All the metatarsals converge on the
Scaphoid
81
When you flex your fingers they all converge on the
Scaphoid
82
KNOW: Middle finger is considered the center of your hand
* does not move during abduction
83
With RA we can get damage of collateral ligaments which leads to a palmar subluxation of phalanges in a radial or ulnar drift?
Ulnar drift is common w/ RA
This metacarpals shift downwards and thats why the nuckles look more prominent
84
CMC osteoarthritis affects which cmc joint the most?
1st (because of it having more motion)
also in the hand OA is most likely seen in CMC joints
85
Why would someone w/ 1st CMC OA pull on their thumb?
Distraction
86
Why would someone w/ CMC OA not like thumb flexion / opposition?
Its the close packed position causing approximatin
anything w/ grip or approximation is painful
87
What would someone w/ thumb OA report? 4
Griding / creptitits / deep pain / distraction helps
88
What modality is best for someone w/ 1st CMC OA
parafin
89
What special test is utilized for someone w/ 1st CMC OA?
1st MCP/CMC grind test
Approximating 1st CMC joint by grabbing 1st metacarap and approximating it w/ trapezium and then twist it
Scouring
They will have pain w/ approximation - so pos = reproduction of symptoms at joint line
90
What muscle is this primarily utilizing
Flexing at DIP so flexor digitorum profundus
91
What muscle is primarily being utilized
Not flexing at DIP = flexor digitorum superficialis
92
KNOW: dynomometer = for grip
* can check for all cause mortality
93
KNOW: Bottom grip strength for women = 46, M = 68 (just know around these numbers is the lowest non pathologic - if were much lower than this we've got a problem)
She doesnt have these memorized
94
this is a palmar pinch. What muscles are working the most here
Lumbecles / flexor digitorum profundus
95
What kind of grasp is this?
Cylinderical grasp
96
What kind of grasp is this?
Sphereical grasp
97
What kind of grasp is this?
Hook or snap
98
What kind of grip?
power grip
Because of the thumb adduction (thumb comes all the way in)
KNOW: If you're holding something its isometric contraction of the fingers / thumb
99
When your thenar / hypothenar eminineces are getting together which arch is getting shorter (mostly)
proximal transverse arch (most flexible)
100
Can you do a powergrip without intact function of ulnar side of hand?
No - you need all 4 fingers going around
NOTE: this rule is for all the grips but specifically this one
101
For a power grip is your wrist in flexion, neutral or extension
In slight extension (think about gripping as hard as you can and notice how it goes into extension)
102
Any approximation of the fingers to the thumb is defined as ____ (2)
Opposition/Pinch
Its pinch when you have an object between fingers and thumb
103
What is prehension?
Skillful pinch - pinch w/ a purpose
104
What kind of grasp is this?
Conoid grasp
making a cone w/ your hand
Note this is considered prehension (pinch w/ a purpose)
105
What grasp is typicaly utilized for writing?
Tripod
Pinch w/ purpose = prehension
106
There are two kinds of Tripod grasps. Which one is this?
Dynamic (normal)
107
There are two kinds of tripod grasps. Which one is this?
Adapted (between third and fourth finger)
Abnormal
108
PIP ROM is often on boards (which means it might be on this exam)
Were looking at a test that diliniates between capsule causing the resitrction and muscle tightness causing the resitrction
If I cant flex PIP joint very well what muscle is the problem?
How would we decide if limitation is coming from muscle or capsule?
Extensor digitorum
We would take ROM of PIP flexion with MCP extended
* Were thinking its more of a capsular issue because extensor digitorum isnt taut
Then take ROM of PIP w/ MCP flexed
* If its limited here were thinking its a muscular issue of extensor digitorum (because that muscle will be taut)
Called bunnel-littler test to differntial diganosis (think it works w/ extension as well)
109
Bunnell Littler test (think it can be done w/ extension as well)
110
TFCC = Triangular fibrocartilage complex
Its the fibrocartilage disc that becomes inflammed
Fibrocartilage disk between the medial and proximal carpal row and distal ulna
111
TFCC injuries MOI is proably (2)
FOOSH (mostly on ulnar side)/ Chronic repetitve rotational loading (rotation during compression)
* lots of this in new crossfiters doing cleans - load happens ulnarly
* also seen in snatched in people who have a lack of external rotation and bar will land on ulnar side of wrist
112
Where is a TFCC most likely going to cause pain?
Medial wrist pain
113
What positions make TFCC hurt the most?
End range pronation / supination/ forceful grasping
Supination = approximation
Pronation = distracting (stretching)
Will change the loads going through TFCC
114
KNOW: TFCC is like the meniscus of the wrist
* there for shock absorption / joint congruity
115
TFCC found by palpating little gap as end of ulna (feels like a divit)
* gap between ulna and carapal bones and push back
116
What innervates TFCC?
Ulnar n / posterior interosseous n (all motor)
117
TFCC = differintial diagnosis for medial wrist pain (mostly ulnar n innervation that gives that sensory reponse of pain)
118
KNOW: TFCC purpose is shock absorption. So if you go down on the ulnar side of your hand it will absorb most of that shock
119
**Whats a good way to determine if its a TFCC issue if its already known to be medial wrist pain?**
Painful click w/ wrist motions
120
Best diagnostic tool for TFCC injuries? (imaging)
MRI (because its discy and ligamentous [UCL right there])
121
What determines wether TFCC gets better or not?
Vascularization, just like mensicus
122
KNOW: Treatment for TFCC
* Splint
* Unstable TFF = cast w/ 90 degrees elbow flexion and wrist in ulnar deviation and extension for 6 weeks (reducing stretching of collateral ligaments)
* Activity modification (avoid ilnar deviation + loading) - so we can do ulnar deviation we just dont want to load it
* Progessive return to prior level of function (being able to do the stuff they were doing before)
123
KNOW: landing on or compressing hand will be painful for someone w/ TFCC
124
2 special tests for TFCC
TFCC Load/compression test (better)
TFCC press test (indirectly loads it so its a worse test)
125
How to perform TFCC Load/Compression test
Therapist provides ulnar deviation and axial load to wrist (will pinch that disc)
Positive = reproduction of patients pain in ulnar side of wrist
126
How to perform TFCC Press test
Patient attempts to lift his/her body weight from arms of chair
Positive = reproduction of patients pain in ulnar side of wrist
127
What kind of fracture is this?
Colles Fracture (Dinnerfork)
Distal portion of fracture deviates dorsally
128
What injury often causes Colles fractures?
FOOSH
129
Define what a colles fracture is?
Distal radius fracture with a posterior displacement of the distal fragment
130
What motion is lost w/ colles fracture?
Pronation/supination (and im guessing flexion/extension as well)
131
Do we have an open reduction or closed reduction w/ colles fracture?
Closed reduction w/ casting
They just set it without operating (pop it back in place) opposed to opening it up and putting it back together
132
What is a smith fracture?
Fracture of the radius where distal portion displaces anteriorly (palmar)
133
What is a Barton Fracture?
Fracture of the radius where distal portion can go anterior or posterior but we also have a subluxation of wrist
So wrist dislocation + fracture
134
What is buckle fracture? Who gets it? Why?
incomplete fracture
Children
Do to the amount of cartilage still in boney tissue
Not a greenstick because greenstick is just bending and this is an actual fractuer
135
Most commonly fractured carpal bone?
Scaphoid
70% of broken carpal bones
136
**What injury leads to a scaphoid fracture?**
FOOSH w/ proanted wrist
when you fall like this (what you think it is) you put most of you weight through your thenar emince (radial side)
NOTE: if you were fully supinated in a FOOSH (feels awkward) you would land on the ulnar side and this is where you would see more of your TFCC injuries
137
Where is pain w/ a scaphoid fracture? (2)
Dorsal, radial sided wirst pain / tenderness in anatomical snuff box
138
Special test for scaphoid fracture?
Axial compression of thumb
However, this sounds like grind test from earlier - we can differiniate by stabilizing trapezium to avoid compression of scahpoid (for OA)
139
**KNOW: X-rays do a really bad job of showing scapoid fractures - so if they have pain in this area and negative imaging they could still have a fracture here**
140
Best imaging for scapoid fracture?
MRI
141
What kind of cast do we use for scaphoid fracture?
Spica cast (thumb cast)
however immobilization leads to functional deficits - this is where PT comes in
142
Which part of the scapoid has the best healing rate? Why?
Distal heals better because its more vascularized
increased BF = increased healing
143
KNOW: 40% of fractures in the hands are the metacaraps
70% of that 40% is the scaphoid
144
What fracture normally happens w/ a punch or fall onto hand
Boxers fracture
most often in sports / high level activities
145
Where is a boxers fracture?
Fracture of 5th metacarpal
146
How do we treat boxers fracture?
Immobilization (splint / cast) / closed fixation
May need PT if there are functional deficits
