Wrist and hand pathology Flashcards
common pathologies of the wrist and hand
1: colle’s/smith’s fx
2: scaphoid fx
3: MC/phalanx fx
4: DeQuervain’s disease
5: Dupuytren’s contracture
6: carpal tunnel/ulnar tunnel
7: tendon injuries
colle’s/smiths fx
- FOOSH
- fracture of distal radius
- difference=angulation
- closed reduction if stable
- ORIF (pins, plates) if unstable
-rehab for impairments: strength, ROM, flexibility
Common complications of colle’s/smith’s fx
carpal tunnel
RSD
colle’s fx
distal segment angulated dorsally
smith’s fx
distal segment angulated ventrally
scaphoid fx
- most common carpal fx
- FOOSH- esp w/ radial deviation
- pain on palpation in snuffbox
- pain on overpressure- radial/ulnar deviation
- requires imaging to dx
- closed reduction if stable
- ORIF (screw fixation) if unstable
-rehab for impairments: strength, ROM, flexibility
common complications of scaphoid fx
AVN
scapho-lunate advanced collapse (SLAC)
-OA and lunate subluxation
MC and phalanx fractures
- trauma
- pain on: distal end tapping, palpation over bone
- closed reduction if stable
- ORIF (screw fixation) if unstable, intra-articular
- MC often unites in 6 wks; phalanx in 3wks
-rehab for impairments: strength, ROM, flexibility
common complications of MC and phalanx fractures
carpal tunnel
fixed ROM loss
DeQuervain’s disease
- stenosing tenosynovitis of the APL & EPB at radial styloid
- overuse (friction syndrome)- thumb and wrist
- most common in women 30-50
- tender, thickened sheath
- (+) Finklestein’s test
DeQuervain’s disease treatment
Conservative Rx:
- refrain from aggravating postures/motions
- thumb spica splint
- physical agents for inflammation
- steroid injection
- surgical release of first dorsal compartment
Dupuytren’s contracture
-palmar fascia thickens with nodules; adheres to flexor tendons and skin
Most common:
- digits 4 & 5
- in men
- Northern European origins
- drinkers and smokers
- autosomal dominance??
Dupuytren’s contracture treatment
Conservative tx to slow progression:
- heat-paraffin
- stretching
- splints
- maintain joint ROM (constant length)
- steroid injection or enzymes
- surgical release
Carpal tunnel syndrome (CTS)
=compression of medial nerve under flexor retinaculum
median nerve
- innervates palmar skin of 1-3 and 1/2 of 4
- innervates lumbricales 1 & 2 and thenar ms. except for Adductor pollicis
CTS caused by:
- trauma
- prolonged wrist extension
- repetitive wrist flex/ext
- lunate dislocation
- fluid retention (pregnancy)
clinical presentation of CTS
- “toothache” pain progressing to numbness in medial distribution
- thenar weakness/atrophy
- night pain- hand “flicking”
conservative tx for CTS
- splinting in neutral- night splints
- refrain from aggravating postures/motions
- agents for inflammation reduction
- posture from c-spine distally
- nerve gliding
surgical tx for CTS
open or endoscopic surgical release (incision on carpal ligament to release pressure)ulnar
post op PT: based on impairments
- scar mobilization
- strengthening
- ROM
- flexibility
ulnar tunnel syndrome
=compression of the ulnar nerve as it passes into the wrist
- similar to CTS but in ulnar distribution
- similar txs
ulnar nerve
innervates skin of digit 5 and 1/2 of 4
innervates hypothenar, all interossei, lumbricales 3 & 4, adductor pollicis, FPB
zone 1: motor and sensory (over pisiform and med side)
zone 2: motor (lateral to 1)
zone 3: sensory (distal to 1)
tendon injuries
-finger posture depends on balance of forces
terminal tendon affects..
mallet finger and swan neck
Swan neck:
- synovitis of the flexor tendon sheath.
- increased flexion pull on the MP ioint causes an imbalance to the extensor central slip through the long extensor tendons and the intrinsic muscles
- stretch to the volar plate at the PIP jt causes hyperextension of the PIP
- the lateral intrinsic tendons shift dorsally and reciprocal flexion occurs at the DIP jt
central slip affects..
boutonniere deformity
-can result from an injury or disease which ruptures the central slip, subluxing the lateral bands volarly to the axis of the middle joint (PIP). may develop over several days or many months after injury as the lateral bands drift volubly
finger flexor tendon injuries
complex anatomy:
- cruciate and annular pulleys
- vincula
- FDS splits
- FDS/FDP sliding
5 zones:
zone 2=”no man’s land”
treatment of tendon injuries
post surgical rehab:
- clinical specialty (CHT)
- based on tissue healing and functional anatomy
- protocols as guidelines specifics from surgeon: protected motion to prevent ripping repair (PROM, AAROM, AROM, RROM)
- key is HEP and pt ed
- move anything not immobilized-constant length principles
- often sensory problems as well as musculoskeletal
treatment of bone and joint injuries
- splinting for partial tears and fractures
- isometric contractions as soon as possible
- adjunctive interventions (ice, therapeutic modalities, etc)
- PROM/AAROM/AROM- mobilization (consider stage of healing
- strengthening exercises to restore dynamic function
examination and evaluation
- shoulder include comprehensive exam of upper quarter
- presence of co-morbidities requires different techniques than in those pts w/o issues
- med hx along with objective information forms basis for chosen interventions
relevant scales
VAS DASH: disabilities of the arm, shoulder and hand PSFS: pt specific functional scale UEFS: UE functional scale Boston questionnaire
general observation
- posture- head and neck
- muscle tone
- quality, color, temp of skin
- quality of nails
- swelling
- resting position of hand
- ability to use limb
observe resting position of hand
- swan neck deformity
- boutonniere deformity
- ulnar drift
- clubbing of DIPs
- Heberden’s or Bouchard’s nodes
- claw fingers
- Dupuytren’s contracture
- mallet or trigger finger
clubbed fingers
low levels of oxygen
lung or heart problems (CF, CHF)
claw fingers
caused by nerve lesions or tendon lacerations
Heberden’s or Bouchard’s nodes
caused by OA
Heberden’s- DIP
Bouchard’s - PIP
mobility examination of wrist
AROM/PROM
Overpressure for flex/ext, radial/ulnar dev
Distraction and ant/post glides
radial/ulnar glides
radiocarpal/midcarpal, intercarpal, CMC assessment
mobility examination of the hand
AROM/PROM
overpressure: flex/ext, abd/add
distraction and ant/post glides
radial/ulnar glides
muscle extensibility
all muscles crossing the elbow, wrist and hand
intrinsic muscles of the hand
TAM
=total active motion
TPM
=total passive motion
TAM & TPM
method of expressing overal finger ROM
if TAM is significantly < TPM implicates problem with tendon gliding
performance based functional measures
1: arthritis hand function test
2: hand mobility in scleroderma test
3: keitel functional test
evaluation tests
- pinch force measurements
- isometric grip tests
- ligament stability
- soft tissue mobility
- neurologic status
- functional status
instability special tests
1: gamekeeper’s (skier’s) thumb test
2: varus/valgus stress test (MCP, PIP, DIP)
3: Watson scaphoid test
4: ulnomeniscotriquetral dorsal glide
gamekeeper’s (skier’s) thumb test
indicates UCL instability or tear and accessory collateral ligaments
pt seated.
PT stabilizes pt’s hand in 1 hand and then pt’s thumb into extension with other hand
while holding thumb into extension, apply a valgus stress to MCP to stress UCL
Positive test=valgus is greater than 30-35 deg- complete tear
varus/valgus stress test
indicates instability of the MCP, PIP or DIP
positive test=laxity or excessive motion
*MOI is usually trauma
Watson scaphoid test
indicates scaphoid instability
PT grasps wrist from radial side with thumb over scaphoid tubercle. other hand grasps the metacarpals.
Starting in ulnar dev and slight extension, the wrist is moved into radial dev and slight flexion
PT’s thumb presses the scaphoid out of normal alignment when laxity exists and when the thumb is released there is a “thunk” as the scaphoid moves back into place.
**maintain skin contact to feel subluxation
positive test=subluxation or clunk, pain
Ulnomeniscotriquetral dorsal glide
indicates TFCC tear, triquetral instability
Pt places thumb dorsally over ulna, and PIP of index finger over pisotriquetral complex where they apply a dorsal glide
positive test=reproduction of pain or laxity in the ulnomeniscotriquetral region
DeQuervain’s disease special tests
Finklestein test
finkelstein test
indicates paratendonitis/ thumb tenosynivitis
pt makes a fist with thumb inside fingers and ulnar deviates
**active test
positive test=pain over abductor pollicis longus and extensor pollicis brevis tendons at the wrist
special tests for arterial filling
allen test
allen test
indicates decreased circulation
elbow resting on table, fingers pointed up
PT occludes radial and ulnar As
pt opens/closes fist x30 seconds
PT releases 1 side and observes filling pattern and time
**compare bilaterally!
carpal tunnel syndrome special tests
1: Katz hand diagram
2: phalen’s test
3: reverse phalen’s test
4: flick maneuver
5: tinel’s sign
6: median nerve compression
7: semmes-weinstein monofilament
Katz hand diagram
indicates carpal tunnel syndrome
pt is asked to fill out a diaphram using a key of numbness, pain, tingling and decreased sensation.
subdivided into pts that have classic, probable, possible and unlikely CTS based on completion of diaphragm
Phalen’s test
indicates CTS
wrist flexion between both hands
positive test= reproduction of symptoms along median nerve distribution
Reverse phalen’s test
indicates CTS
wrist extension between both hands
positive test=reproduction of numbness, tingling in median nerve distribution within 60 seconds
Flick maneuver
indicates CTS
pt vigorously shakes their hands
positive test=resolution of paresthesia symptoms during or following flicking
Tinel’s sign
indicates CTS
pt’s wrist supinated and in neutral.
PT uses finger or reflex hammer to tap on median nerve where it enters carpal tunnel.
positive test=reproduction of symptoms of paresthesia along median nerve distribution
Median nerve compression test
indicates CTS
PT holds pt’s hand and places thumbs directly over course of median nerve through flexor retinaculum- applying pressure for 30 seconds.
positive test=reproduction of pain, paresthesia, or numbness distal to site of compression in the distribution of the median nerve
ulnar nerve special tests
Froment’s sign
Froment’s sign
indicates ulnar nerve lesion
ulnar nerve innervates adductor pollicis*
when pt attempts to lateral pinch an object (paper) IP joint will flex but adductor pollicis won’t fire, compensation of flexor pollicis longus
special tests for intrinsic muscle tightness
1: Bunnell-littler test
2: ORL test
Bunnell-Littler test
indicates intrinsic muscle tightness
start with wrist in neutral and perform test.
repeat with wrist in flexion and extension (may indicate extrinsic muscle tightness)
positive test=increased PIP flexion with MCP flexion
- clinically you see limited PIP flexion; could be due to: intrinsic muscle contracture, extensor digitorum tendon, capsular restriction
- when you passively extend the MCP jt you are tightening the intrinsics; flex the PIP jt then compare to PIP jt motion as you flex the MVP jt. If PIP motion increases, the restriction is from tight intrinsics
ROM loss due to capsular tightness
- flexing the wrist and MCP joints puts the extensor digitorum on stretch; from this position flex the PIP joint to its limit
- repeat with the wrist and MCP joint extended; if the PIP joint restriction remains unchanged regardless of wrist and MCP joint position the limitation is likely capsular
DIP ROM loss
DIP flexion ROM may be limited due to:
- tight oblique retinacular ligament
- capsular tightness
to test for oblique retinacular ligament tightness perform the Bunnell-Littler test one joint distally. if passive DIP jt flexion is limited as the PIP is passively extended, but DIP flexion increases as the PIP is flexed, the test is positive for ORL tightness
Joint mobilizations for radiocarpal/midcarpals
distraction dorsal glide ventral glide radial glide ulnar glide
joint mobilizations for 1st CMC
distraction dorsal glide palmar glide radial glide ulnar glide
joint mobilizations for MCP, DIP, PIP
distraction dorsal glide palmar glide radial glide (MCP only) ulnar glide (MCP only)
