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Upper Test 3 > Wrist and hand Examination (Lecture 3) - same powerpoint as lecture 2 > Flashcards

Wrist and hand Examination (Lecture 3) - same powerpoint as lecture 2 Flashcards

1
Q

KNOW: Sprains normally happen from foreful over pressure passed the normal ROM
* Has immediate intense pain
* Swelling in the first 1-2 hours

A
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2
Q

What tissue is normally involved in a sprain

A

Ligaments

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3
Q

What kind of tissue is involved in a strain?

A

Muscle tissue (strain hard to lift something)

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4
Q

Ecchymosis =

A

Bruising

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5
Q

Pt has a ligamentous strain. What are the 2 biggest thing we want to rule out?

A

Ligament tears / fractures

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6
Q

For wrist sprains how long do we have immobilization?

A

3-5 days (use a wrist splint)

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7
Q

How do you find the lunate?

A

Flex the wrist and it should pop into your finger

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8
Q

Which ligament is most likely disrupted with most common carpal bone dislocation

A

Scapholunate ligament (both scaphoid and lunate commonly dislucate [lunate more I think] which strains this ligament)

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9
Q

Which was does the lunate primarily dislocate and why?

A

Dislocates palmarly

Which you extend the wrist it goes palmarily. During a FOOSH we have and extended wrist which leads to a palmar dislocation of the lunate:
* This makes sense - flex the wrist and see how it pops up (going dorsally) then extend the wrist and notice how it goes palmarily (leaves a little hole behind on the dorsal side)

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10
Q

What position would a perilunate dislocation most likly hurt?

A

Weight bearing on hands in extension
* Extension because the MOI was more than likely hyper extension in weight bearing (FOOSH)

NOTE: Swelling amay also be present

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11
Q

KNOW: W/ a perilunate dislocation you may notice a divit in the dorsum of the hand (because it would have displaced palmar)

A
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12
Q

Which nerve is most likely to be injuired w/ a perilunate dislocation?

A

Median n

This is because the bone slides palmarily and hits right around where the median n is

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13
Q

What test do we do to rule in Perilunate dislocations?

A

Scaphoid shift test
* This tests for instability of the scaphoid lunate joint

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14
Q

What are 2 names are there for game keepers thumb?

A

Skier’s thumb / UCL sprain of thumb

KNOW: This is the most common ligament injury to the hand

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15
Q

Which joint is Gamekeepers thumb at? What is torn?

A

MCP

UCL sprain of thumb

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16
Q

Which two forces happen during gamekeepers thumb that cause the UCL to be strained?

Which way is the impact?

A

Extension and abduction (Valgusing at the MCP joint) - remember abduction is like hitting a space bar

Radially directed impact (ski pole pushes radially)

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17
Q

KNOW: Presentation for game keepers thumb (UCL tear)
* Local swelling
* Pain
* Tenderness of the ulnar aspect of 1st MCP
instability
weakness during pinching

A
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18
Q

Which grade gamekeepers thumb would you need surgery?

A

Grade 3 = complete tare = surgery

Grade 1/2 = conservative management

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19
Q

What is De Quervain Tenosynovitits
* What degerenates / get thicker?
* Which two tendons become entrapped?

A

Degeneration and thickening of extensor retainacilum
* this causes the fibro-osseous canal to narrow (which houses the tendons)
* The tendon sheaths that the tendons run through can also become irritated and swollen
* Abductor pollicis longus / Extensor pollicis brevis become entrapped

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20
Q

What makes up the anatomic stuff box?

A

Abductor pollicis longus

Extensor pollicis brevis

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21
Q

Where is pain w/ De Quervain Tenosynovitits?

A

around the Radial styloid

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22
Q

What special test do we do for De Quervain Tenosynovitits?

A

Finkelstein Test

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23
Q

What two movements hurt for De Quervain TEnosynovitits?

A

Thumb abduction / extension

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24
Q

NOTE: We often use a splica splint for De Quervain TEnosynovitits / NSAIDS

We do ROM Ex / Carpal mobilizations for this

A
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25
Q

What kind of jobs do people w/ De Quervain normally have?

A

Grabbing and radial deviation jobs

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26
Q

What two motions are limited for De Quervain?

A

Ulnar deviation / Thumb flexion

This is because they have pain w/ resisted thumb abduction / extension so the movements above are essentially stretching the tendons

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27
Q

KNOW: The Finkelstein’s Test is for DeQuervain’s Syndrome. However, it may also be posititve for Wartenberg syndrome (entrapment of sensory branh of radial N)

A
28
Q

What is intersection syndrome?
* what muscles are involved
* Which muscles are in pain
* What actions cause pain?
* Where is the pain?
* How do we treat it?

A

Tenosynovitits of extensor carpi radialis brevis and extensor carpi radlis longus where they cross under abductor pollicis longus and extensor pollicis brevis

It causes pain in the ECRB / ECRL

Extension / abduction of the wrist cause pain

Pain is posterior forearm
* NOTE its distal forearm but not quite as distal as De Quervains syndrome

NOTE: This is a tendonpathy - so we treat it w/ tendon loading principles (Isometrics –> Heavy slow –> Fast light –> Heavy fast –> plyo)
* NOTE were doing this to the muscle itself (so if it does extension / ulnar deviation focus these tendon loading princples towards that
* Maintain / improve mobility

29
Q

Tenosynovitits

A

Inflammation of tendon sheath which is the lining sheath that surrounds a tendon

30
Q

Compare and contrast the location of pain for intersection syndrome and De Quervains syndrome

A

De Quervains syndrome is distal and more latearl to intersection syndrome which is more proximal (but still distal forearm) and in the middle of the wrist

NOTE: its all posterior

31
Q

NOTE: You can have a tendonpathy of any of the tendons in the forearm

A
32
Q

Where is the ulnar n primarily entrapped in the hand?

A

Guyon’s Canal

33
Q

Where is the median n primarily entrapped in the hand?

A

Carpal tunnel

34
Q

What is considered a normal 2 point discrimination in the hand?
* Fair
* Poor
* Protective / diminished sensation
* Anesthetic

A
35
Q

2 point discrimination test:
* Therapist applies pressure to 2 adjacent points in a longitudinal direction on the long axis of a finger
* Moves in a proximal direction and progressively makes points ckiser ti each other
* Used to indicate areas of diminished sensation
* Patient cannot look at hand during the test

A
36
Q

What is this?

A

Monofilament testing

37
Q

What is consdered a normal size monofilament? (2)

A

2.83 / 3.22

38
Q

These are points to do monofilament test

A
39
Q

NOTE: We will often do sensory testing for when the nerves are blocked in the hand

A
40
Q

What pathology do we use 2 point discrimination on the middle finger?

A

Carpal tunnel

41
Q

What are the 3 special tests for carpal tunnel syndrome?

A

Phalen’s Test
Tinel’s at the carpal tunnel
Carpal compression test

42
Q

Presence of 3/4 of these things indicates that we should do special tests for carpal tunnel syndrome

A

Patient 45+

Hand shaking to relieve symptoms

Wrist ratio index >0.67
* Wrist width to depth ratio
* Basically if this ratio is larger that means they’re going to be more wide and less deep. And if they’re less deep than they’re not going to have room in their hand told hold all the nerves and stuff and it will be compressed

Boston Carpal Tunnel Questionnaire-symptom severity scale >1.9

43
Q

Why can’t we do a median n tension test (ULTT1) to just figure out of its carpal tunnel or not?

A

because something further up the chain could be the issue

44
Q

What 3 tests are not appropriate to use to diagnosis carpal tunnel?

Questionaires for this? (2)

A

1) ULTT1 for median n
2) Scratch collapse test
3) Vibration sensation test of median n - the problem is that this virbation can be picked up by other nerves in the area because its a relatively small area (ulnar n)

DASH
Boston Carpal Tunnel Questionnaire

45
Q

KNOW: Flexion / extension of wrist can bring on carpal tunnel pain

Purdue pegboard: how long it takes them to put the beg board togather

Moberg pick up test: how long it takes them to pick up each item

the last 2 are a way to track their progress over time

strength = grip / pinch strenght compared to norms

KNOW: we wouldnt use sensation tests to track change over time

A
46
Q

For carpal tunnel syndrome we use grip strength / pinch strength as a way to asses over all strength. However - theres one kind of pinch we don’t want to use. Which one and why

A

adductionof the thumb Because thumb abduction is innervated by the ulnar n

47
Q

What are the 3 highest level evidence interventions for carpal tunnel syndrome (Level B)

A

They are actually things that you shouldnt do

1) Do not use low level laser
2) Do not use magnets
3) Do not use iontophoresis (in mid to mod CTS –> however you can use it in acute / high irritability)

48
Q

Level C evidence for carpal tunnel syndrome (7)

A

1) Education about work ergonomics and modifiable risk factors
2) Heat
3) Diathermy
4) IFC
5) Do not use ultra sound in mild to moderate CTS
6) Manual treatment to cervical spine and UE = short term reielf (really just trying to treat the nerve)
7) Combined orthotic and stretching program

49
Q

KNOW: Posterior interosseous n is an offshoot of the radial n and does only posterior innervation

A
50
Q

What n does the anterior interosseous n come off of?

A

Comes from the median n

51
Q

What typically causes anterior interosseous n syndrome?

A

Trauma / Entrapment

52
Q

Where does the anterior interosseous n primarily get entrapped (causing anterior interosseous n syndrome)

A

Distal tendinous edge of pronator teres

53
Q

**What two muscles are affected by entrappment / trauma of anterior interosseous n?

these of these two muscles will make us unable to make what sign?

A

Flexor digitorum profundus (second digit only)

Flexor pollocis longus

Unable to make an OK sign
* This is because we lost DIP flexion and we lost IP flexion at the thumb

54
Q

What is Froments sign?
* what nerve being damaged causes it?

A

Patient holds a peice of paper between thumb and 2nd digit

Therapist pulls paper

If pt flexes at the IP joints or MCP flexion, this indicates weakness of adductor pollicis due to ulnar N compromise
* she said “if you flex your thumb than you’re going to have ulnar n compromise (im not sure if finger flexion is involved at all or not - but in the picture you can clearly see that they are flexing their thumb
* Thumb flexion = positive because other nerves (median n) are jumping in to help stabilze the paper

So ulnar N is pathologic

Bottom one is positive

55
Q

What n does the posterior interosseous branch off of?

A

Radial n

NOTE: Its all motor

56
Q

Where does the posterior interosseous become entrapped?
* what causes this entrappment?
* Which two movements are weakened?

A

Dorsal wrist capsular = entrapment site

Due to repetitive wrist extensinon

Weakness of finger extension primarily, could have weakness of wrist extension (makes sense branch of the radial n) - could also be supination because it perices that supinator belly - depends on how high up its cut off

57
Q

KNOW: The radial n have two branches
* Motor only = Posterior interosseous
* Superficial branch = sensory only

A
58
Q

Whatis wartenberg syndrome?

Which nerve being entrapped causes wartenberg syndrome?

A

Inflammation of tendons in first dorsal compartment (APL, EPB)

Superficial Branch of radial

59
Q

What is Wartenberg syndrome?
* Inflammation of what two tendons causes it
* Which compartment is it in?
* What symptoms does it present w/
* Which n is entrapped
* Which other muscles tendon can compress this area in pronation?
* What other pathology is very similar to this and how do you differntially diagnosis

A

Inflammation of tendons in first dorsal compartment
* Abductor pollicis longus tendon
* Extensor pollicis brevis tendon

NOTE: First dorsal compartment is talking about where it is sectioned off by the extensor retinaculum

NOTE: this is more of a neuritits because its inflamamtion affecting the nervous tissue
* So the inflammation of the APL / EPB tendons compress the nerve in this dorsal compartment - which causes the pain / paresthesia / numbness of the radial aspect of the rist

NOTE: during pronation tendons of ECRL can also compress the nerve in pronation (note - this is a great differential diagnosis because pronation / supination will affect symptoms (pronation brings it on) - however De Quervain does not have any change w/ supination/pronation (also theres no numbness w/ De Quervain and there is w/ this)

60
Q

NOTEL We often have wartenberg syndrome and De Querves going on at the same time. This is because w/ the swelling of the tendons w/ de Querves it will press on the superficial radial n causing wartenberg syndrome

A
61
Q

Where is the unlar n exntrapped at the wrist/hand?

A

Guyon canal (often called ulnar canal)

62
Q

What causes ulnar tunnel syndrome (ulnar n entrapped at Guyons canal)

A

Trauma, lesion (space occupying, vascular)

Prolonged/repetitive compreddion of canal (cycling, crutches, jackhammer)

63
Q

What causes claw hand presensation? Why?

A

Ulnar N entrapped at Guyon canal (ulnar tunnel syndrome)

unable to keep flexion so goes into extension at MCP

Atrophy of interosseous

64
Q

What muscles are weak w/ ulnar n exntrapment in wrist?

A

1) flexor digiti minimi
2) Abductor DM
3) Opponens DM
4) Adductor policis
5) Interossesi
6) Medial 2 lumbericles
7) Palmaris brevis

NOTE: all these muscles all start and end within the hand. This is because the entrapment is at the wrist
* for differential diganosis to figure out where the entrapment site is we could look and see if the forearm is affected as well - then we can say that the entrapment sight isnt priamrily at the wrist

65
Q

What is the Ulnar N exntrapment special test?

A

Wartenberg sign

66
Q

How do you perform wartenberg sign?

A

Patient places hand on table

Therapist passively abducts the fingers

Patient then attempts to adduct all fingers

positive if 5th digit remains abducted, indicating ulnar N compromise

Upper Test 3 (7 decks)

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