Wrist and hand pathology/management Flashcards
Instability Etiologies:
Microtrauma
Macrotrauma
Other
Microtrauma
Gymnasts: Repetitive stress on the joints from intense training and high-impact activities can lead to instability.
Weight lifters: Heavy lifting can strain and potentially damage stabilizing structures around joints.
Manual therapists: Repeated manipulation and physical demands can cause joint stress over time.
Secondary instability
*injury from macro trauma and
instability from micro trauma
Capsule gets more and more stretched - repetitive motion leads to instability
Macrotrauma
FOOSH (Fall On Outstretched Hand): A common cause of joint instability due to sudden, forceful impact. Any significant trauma can potentially cause joint instability.
Other Factors
Neurological: Conditions affecting neuromuscular control can lead to joint instability due to impaired proprioception or motor control.
Rheumatoid arthritis: Chronic inflammation can weaken and damage the stabilizing structures around joints.
Hypermobility syndromes
Lack of tone - bigger problem in shoulder = less bony stability more soft tissue from muscle
Hypermobility syndromes:
Ehlers-Danlos Syndrome: A connective tissue disorder that often leads to joint hypermobility and instability.
Marfan’s Syndrome: A genetic disorder that affects connective tissue and can result in joint laxity.
We should know about it if they have it
*affects soft tissue extensibility
*we can’t “fix” it
*they don’t have stability from CT -> joint issues over time
Beighton score items:
Passive Extension of the Little Finger: The examiner checks if the little finger can be extended backward beyond 90 degrees. (1 point for each hand)
Passive Extension of the Thumb: The examiner checks if the thumb can be placed against the forearm. (1 point for each hand)
Elbow Hyperextension: The examiner checks if the elbows can extend backward beyond 10 degrees. (1 point for each elbow)
Knee Hyperextension: The examiner checks if the knees can extend backward beyond 10 degrees. (1 point for each knee)
Forward Flexion of the Trunk: The patient is asked to bend forward with straight knees and try to touch the floor with their palms. (1 point if they can touch the floor)
Beighton Score Interpretation:
The total score is out of 9 points.
A higher score indicates greater joint hypermobility.
Score of 4 or more: Suggests significant joint hypermobility and may indicate a hypermobility syndrome, such as Ehlers-Danlos Syndrome.
Score of 6 or more: Often used as a threshold for diagnosing hypermobility syndromes in some guidelines.
3 Pillars of stability
Bony, neuromuscular, capsuloligamentous
Bony Stability:
contribution of the bone structure and its alignment to joint stability
Proper anatomical fit and congruence of the joint surfaces help in maintaining stability
If bones are not in right place - they won’t fit nicely in puzzle = NO arch
Neuromuscular Stability:
role of muscles, tendons, and the nervous system in providing joint stability
ability of the muscles to contract and support the joint as well as the role of proprioception and neuromuscular control
Extrinsic m. = for the wrist = provide compression where
bones fit together = maintain arch
*line of pull is mostly compression
Capsuloligamentous Stability:
contribution of the joint capsule and ligaments to joint stability
provide passive support and restrict excessive movements
*proximal row ligaments = usually most devastating to wrist stability** scapholunate (more commonly injury)
Stability of the wrist:
Shape of carpal bones -> transverse carpal arch
Intrinsic muscle (interossei and lumbricals) activity to maintain the arch
Compressive loading from extrinsic muscles
Ligamentous constraints: the most important factor for wrist stability
> palmar radiocarpal ligaments
> dorsal radiocarpal ligaments
> intercarpal ligaments
Loose Instability: Wrist sprain
MOI: FOOSH, trauma, taking weight through the hand, very common!
May have visible swelling
Pain at extremes of wrist motion
Pain with RI in most directions
Tender to palpation at joint line or over carpals
Differ. Dx- r/o fx, especially the scaphoid and lunate
Wrist is small - a little bit of swelling = can impact all motions
fracture vs sprain tenderness:
*Tend to palpation = over ligament uncomfortable (kind of hurts), pinpoint over bone for fracture (pass out/throw up)
*Wrist sprain = hurts, can move don’t want to / fracture = natural thing to not move = something is wrong
Loose Distal radio-ulnar joint instability (DRUJ)
Pain with pronation/supination
h/o fall, or impact sports, racquet sports
Increased laxity between the distal radius and ulna
Identified with (+) piano key test or radioulnar ballottement
Piano key – ulnar meniscal triquetral instability
Ballottement (def) – a palpatory technique for detecting or examining a “floating” object in the body
MOI
*FOOSH, impact sports
Think football someone running into you and you put your hands up
Racquet sports - violent supination/pronation or rotational force
Loose triangular fibrocartilage complex (TFCC) disruption
Fall on supinated outstretched hand or due to chronic repetitive rotational loading
c/o medial wrist pain just distal to ulna = Does not travel, but can refer upward the length of the ulna
Pain increases with end range pronation/supination, and forceful gripping
*stability of wrist, extrinsic m. contribute to compression
*co-contract = compression of joint & ulnar deviation (position of power) - TFCC is loaded a little bit more
May have painful clicking w/wrist motion = *fibrocartilage area
Tenderness localized to dorsal anatomic depression distal to ulnar head
(TFCC) disruption
Acute Management:
Long-arm cast or splint fitted with the elbow in 90 degrees of flexion, and the forearm and wrist in ulnar deviation and extension for 6 weeks, if the TFCC is unstable
*stabilize up = rotation is occurring = pronation and supination needs to be limited so things heal - If just wrist is splinted - rotation will still occur at elbow
UE treatment proximal kinematic chain
After cast removal
> A/AAROM first emphasis on flexion/extension initially (straight plane), followed by pronation/supination, radial/ulnar deviation
> After 2 weeks can start strengthening if asymptomatic
If identified after the initial healing phase – bracing, strengthening, surgery
Loose Carpal Instability Multi-link structure – Zigzag effect
Mobile proximal row “intercalated” between 2 rigid structures
Can get rotational collapse
Lunate most frequently dislocated- can dislocate dorsally (DISI scapholunate instability) or volarly (VISI-lunotriquetral instability)
**named for when lunate ends up
When you flex
*scaphoid flexed
*triquetirum extends
*Lunate stays put
= keeps them together
If scapho-lunate ligament ruptures
= no counterbalance = lunate goes with triquetrium into extension
Loose Scapholunate Instability (DISI)
lunate migrates dorsally
**Named based on what happens in flexion
FOOSH, with forces transmitted through the wrist in extension and ulnar deviation
Weakness with grasping objects
chronic vague wrist pain
+ tenderness over scaphoid and/or lunate
+ laxity between the scaphoid and lunate
+ scaphoid shear test
+ Scaphoid (Watsons) shift test
Loose Lunate triquetral instability (VISI)
Second most common instability (VISI- lunate tilts ventrally)
Similar signs and symptoms to scapho-lunate instability, except for location
+ Ballotment test (lunotriquetral instability) Reagan’s Test
Loose Mid carpal instability
Insufficiency of the intercarpal ligaments, may not be symptomatic, and pt may be able to sublux and reduce the jt at will
Clunk can be felt as the distal row of carpals jumps back into place at the end of ulnar deviation
Between proximal and distal row
*shearing them on each other
Loose Acute management principles
Protect injury
Control pain and inflammation
Control /eliminate edema
Restore full painfree ROM in entire kinematic chain
Prevent ms atrophy
Minimize detrimental effects of immobilization
Scar management if needed
Maintain fitness
*some grade III’s can heal depending on where it is
Loose Acute management swelling:
Swelling follows acute sprain, with degree of swelling corresponding to severity of injury
*swelling is a secondary problem
Pulling fluid out = more worried about chronic
*not in first 48 hours
Don’t drain joints early on - do if it impacts ROM and function
***Fluid is not the problem, what causes the fluid is the problem
Loose Acute management splinting:
Immobilize the joint- custom or off the shelf splint that allows fingers to move, holds wrist in 10 degrees of extension
Mild sprain splint for 3-5 days, longer for moderate to severe sprain ice throughout the day,
After splint d/c : AROM, taping to provide support, decrease pain, strengthening
Times where you can move joint farther but swelling is the limiting factor
*not the ligament itself
Don’t give NSAIDs early on - don’t knock down inflammatory process in first 48 hours
*want the natural healing process to occur
Loose Hypermobility/Instability
Exercise considerations
We work in diagonal 3D planes not straight planes
Functional oblique motion from radial ext (RD and ext) to ulnar flexion (UD and flex)
Dart-throwing motion – less scaphoid and lunate motion than during pure flex-ext
Stress reduced in the scapholunate interval
End range supination stresses the TFCC
Secondary consequence of instability
Transient neuro symptoms due to compromise of the carpal tunnel
> Loss of the transverse carpal arch
compression or irritation of the median nerve within the carpal tunnel
Symptoms of Carpal Tunnel Syndrome
Numbness: Especially in the thumb, index finger, middle finger, and part of the ring finger.
Tingling: Often described as a “pins and needles” sensation in the affected fingers.
Pain: May radiate up the arm or occur at night.
Weakness: Difficulty with fine motor tasks or grip strength.
Loose UCL sprain
Skier’s thumb, gamekeeper’s thumb, break-dancer’s thumb
UCL sprain- apply force to stress UCL; tested at 0- and 30-degrees flexion
+ test is pain and extreme laxity
Angulation 15 degrees greater than uninvolved side =30-35 degrees of motion- need for surgery
Risk of Stener lesion (torn UCL gets entrapped beneath adductor pollicis aponeurosis
complete rupture of UCL = possible of ends to get stuck under
*surgery is recommended for this reason
*if not in right some = won’t heal right = chronic instability
Loose UCL sprain management
Protect injury
Control pain and inflammation
Control /eliminate edema
Restore full painfree ROM in entire kinematic chain
Prevent ms atrophy
Minimize detrimental effects of immobilization
With thumb = you can wear just thumb splint
*not up to elbow
Limit valgus essentially = prevent it from going backwards
