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
Loose CMC OA
Distinguishing feature = loss of retroposition
Destruction of joint to the point where use stability from static stabilizers and bone
Splinting, stretch adductor pollicis, avoid adduction positions
Try to get it back to more functional position
*stretching
*avoid adducted position
Splints (OTC)
Don’t cross MCP joint = can’t bend fingers = lose function
*immobilization would impact other joints
Rheumatoid diseases / family
Chronic, progressive (flare-remitting), systemic, autoimmune
Affects the entire body; bilateral, symmetrical
Acute stage: pain, swelling, warmth, limited motion (commonly: MCP, PIP, wrist joint)
Jt inflammation ➔ soft tissue damage ➔ muscle weakness and imbalance ➔ pain, stiffness, joint damage, instability, deformity
> Ulnar deviation of the MCP joints
> Boutonnière deformity
S> wan-neck deformities of the digits.
Ulnar drift
Ulnar drift happens in the MCP first then wrist = More distal to proximal - fingers first then ulnar deviation of wrist
Ulnar drift and palmar subluxation (pronation) due damage to collateral ligaments and extensor mechanisms = Alignment of extensors thrown off = bow like effect
Ulnar deviation of hand due to weakening of capsuligamentous structures of the MCP and “bowstring effect” of extensor communis tendon
Ulnar drift Causes:
\synovitis, weakening of radial collateral ligament, ulnar displacement of extensor tendons, contracture of ulnar side intrinsics, dysfunction of radial side intrinsics, ulnar displacement of flexor tendons
Boutonniere (“buttonhole”) deformity
Extended MCP and DIP, Flexed PIP
Rupture of central tendinous slip of the extensor hood
Common extensor tendon that inserts on the base of the middle phalanx is damaged (can also happen in sports: severe flexion of PIP or trauma to dorsal PIP ➔ damage to common extensor tendon)
Boutonniere (“buttonhole”) deformity
Intervention (due to sports trauma):
4 weeks in a splint that holds the PIP joint in full extension, while allowing the DIP joint to flex.
Gentle AROM exercises can begin for flexion and extension of the PIP joint at 4–8 weeks, with the splint being reapplied between exercises.
General strengthening usually begins at 10–12 weeks. For a return to competition, an additional 2 months is required.
Don’t pull on tendon until it heals slowly load tendon to help with remodeling and restore function
Tendons healing on bones = slow process
Hope extensor heals back downward = get function back
Swan neck (recurvatum) deformity
Flexed MCP and DIP, Extended PIP
Least functional of all deformities
Contracture of intrinsics or tearing of volar plate
Destruction of the oblique retinacular ligament of the extensor mechanism leads to posterior (dorsal) displacement of the lateral bands of the extensor mechanism.
Swan neck (recurvatum) deformity leads to:
an increased extensor force across the PIP joint with a resulting hyperextension of the PIP joint and chronic injury to the volar plate ➔ The extended position of the PIP joint stretches the FDS and FDP tendons. ➔ The pull on the FDP tendon causes a passive flexion of the DIP joint.
Over time volar plate gets more damaged as hyperextension increases
Swan neck (recurvatum) deformity Intervention:
Application of a small figure-of-eight splint that prevents the PIP joint from fully extending, while still allowing full flexion range.
Splint that lets you flex but not extend
Rheumatoid arthritis: Interventions
Stabilize the wrist!
Control inflammation
Focus on joint systems not isolated joints
Patients with stiff joints because of scarring do poorly after soft-tissue surgery. Patients in this group require aggressive and sustained therapy, often for 3–4 months.
Patients with joint laxity require careful intervention and control of the ROM and the direction of motion by the use of splints for many months after surgery.
Stiff Joint Hypomobility
Related Pathologies and Etiology of Symptoms
RA /JRA, DJD, trauma, dislocation, fracture, surgery
Contracture and adhesion post-immobilization
Stiff Post-traumatic/Post-fracture: Nonoperative Management
Management: Protection Phase
Educate the patient (e.g. length of symptoms, joint protection, activity pacing and modification; low but frequent repetition)
Reduce effects of inflammation or synovial effusion and protect the area (e.g. frequent controlled movement to reduce contracture; Grade I-II mobilization)
Maintain soft tissue and joint mobility (PROM, AAROM, flex/ext; pron/supin; multi-angle muscle setting)
Maintain integrity and function of related areas (shoulder, elbow exercise/activities; elevate if with swelling/edema)
Control pain and protect joints
Maintain joint and tendon mobility and muscle integrity
Stiff Post-traumatic/Post-fracture: Nonoperative Management
healing potential:
Closer it heals to thumb = better healing potential
Closer to ulna = worse potential to heal
Stiff Post-traumatic/Post-fracture: Nonoperative Management
Management: Controlled Motion Phase
Increase soft tissue and joint mobility
> Joint mobilization (non-thrust – grade I-IV)
> Manual stretching & self-stretching with weight; low intensity, long duration; dynamic splint
> Home instructions
Improve muscle performance and functional abilities
> Low load exercises in open and closed chain
> Control and coordination
> Muscle endurance + strength; involve other joints proximal to the elbow; progress to functional activities
Stiff Post-traumatic/Post-fracture: Nonoperative Management
Management: Return to Function Phase
Improve muscle performance
> Progress strengthening exercises; progress to simulate daily activities e.g. pushing, pulling, lifting, carrying, gripping
Restore functional mobility of joints and soft tissues (manual or mechanical stretching; joint mobilization)
Promote joint protection
> E.g. chronic RA modify high load activities
Stiff
Wrist Arthroplasty
Indications for Surgery:
Severe pain
Deformity causing imbalance of soft tissues
Subluxed/dislocated radiocarpal joint
Low demand UE functional needs
Bilateral wrist involvement and arthrodesis will not improve function
Anytime you replace a joint
*stability over mobility
Will NEVER get full ROM after a replacement
*too much motion is worse than too little motion
Stiff Wrist Arthroplasty
Postoperative Management
Immobilization
Exercise
*** Stability of the wrist takes priority over mobility (only 35 dg flex is needed)
Outcomes
> Pain relief
> Wrist and forearm ROM, strength, and function
Total joint arthroplasty – principles
Total joint arthroplasty is considered when all other management has been exhausted
Primarily for pain reduction
Full restoration of ROM is NOT expected
Quality of life measure
Stiff wrist/hand management principles
Restore ROM
Restore accessory motions, joint mobility
Restore strength
Consider that strength within the available range will be greater than strength available within the newly gained range
Strengthen through the full arc of motion!
Restore upper limb function
Task specific, work specific, sports specific
Painful (just a few examples)**
CTS (median n), AIN, pronator syndrome
Ulnar n entrapment (cubital tunnel or guyon’s tunnel)
DeQuervain’s tenosynovitis
RA
Tendinopathy – etiology and classification
Reactive vs degenerative
Inflammation presence:
Reactive Tendinopathy: Inflammation is present and contributes to the acute response. This inflammation can be addressed with rest, ice, and anti-inflammatory medications.
Degenerative Tendinopathy: Inflammation is less prominent. The focus is more on addressing structural changes and improving tendon health through rehabilitation and strengthening exercises.
Onset and duration
> Tendinitis resolves more quickly
> Tendinosis can become more reticent to change
Reactive Tendinopathy
result of acute overload or excessive mechanical stress on the tendon
acute tendon swelling and increased cellular activity
increased vascularity and a reactionary inflammatory response without significant structural changes in the tendon
Symptoms usually resolve relatively quickly with appropriate rest and reduction in stress
Degenerative Tendinopathy (Tendinosis)
Chronic overload or repetitive stress over time, often associated with aging or long-term use of the tendon
influenced by poor biomechanics or inadequate recovery
Characterized by a breakdown of collagen fibers, disorganized tendon structure, and an increase in non-inflammatory cells and matrix
Persistent pain, stiffness, and decreased functional capacity of the tendon
Tendinopathy – etiology and classification
Load
Too much load or too little load-bearing capacity
Rest-activity cycle - Tendon undergoing micro damage
metabolism undergoing to tendinoses
*lose mechanical properties
Decreased collagen integrity and vascular supply with increased age
Micro-Damage and Repair
Micro-Damage: Repetitive or excessive loading of the tendon leads to micro-damage in the collagen fibers. This damage is usually minor and is part of the natural cycle of tendon use and repair.
Repair Mechanism: Tendons have a limited capacity for self-repair. When subjected to normal, controlled stress, the tendon undergoes a repair process where damaged fibers are replaced and collagen synthesis occurs.
During rest, the metabolic processes focus on repairing the micro-damage and restoring tendon structure
Principles of tendon loading
Progressive loading of tendon facilitates collagen synthesis = High quality collagen synthesis - need progressive loading to get it
Tensile loading can be imparted with both active muscle contraction or passive stretching
Volitional activation can be isometric, concentric or eccentric
Follow the soreness rules
Tendons only work through tensile forces
*w/in tendon itself compression is not created
*only works by pulling
soreness during warm-up that continues:
2 days off, drop down 1 level
soreness during warm-up that goes away:
stay at level that led to soreness
soreness during warm-up that goes away but redevelops during session:
2 days off, drop down 1 level
soreness the day after lifting (not muscle soreness):
1 day off, do not advance program to the next level
no soreness:
advance 1 level per week or as instructed by healthcare professional
Painful Carpal tunnel syndrome (CTS)
Most common compression neuropathy
Carpal tunnel pressure on median nerve, may result from decreased tunnel space due to fluid retention (common during pregnancy, or infection, or renal dysfunction), gout, pseudo gout, can also decrease tunnel size, RA, collagen disorders, c-spine pathology, diabetes, hypothyroidism
Symptoms: Numbness, tingling, and pain in the thumb, index finger, middle finger, and part of the ring finger. Symptoms are often worse at night and can include weakness or clumsiness in the hand.
Can have transient symptoms from compression
Fluid going through the tendon as well
*helps with lubrication and protection
*general amount - not much space in wrist - lots of swelling = no ability to expand
Half of CTS cases related to:
repetitive and cumulative trauma in the workplace; extreme positioning of fingers and wrist, forceful and repetitive loading, especially of finger flexors can provoke CTS
Wrist in more opposition ——> chronic compression
There is a fat pad
*but not a lot of protection here
*nerve can become easily compressed
Painful
Carpal tunnel syndrome (CTS)
symptoms:
Numbness pattern:
Volar thumb, index, long, radial ½ of ring
Pain :
Nocturnal pain/numbness
Motor weakness pattern:
Thenar muscles, esp APB, OP, FPB (superficial head) lumbricals 1 & 2
in late stages more severe, visible atrophy
OTHER:
Dropping objects
*Lose grip strength - tell tale sign!!
CTS (Examination)
Use Semmes-Weinstein monofilament testing
Use Phalen, Tinel, and carpal compression test
Clinicians should assess and document patient age (older than 45 years), whether shaking their hands relieves their symptoms, sensory loss in the thumb, the wrist ratio index (> 0.67), and scores from the Boston Carpal Tunnel Questionnaire- symptom severity scale (CTQ-SSS) (> 1.9).
The presence of more than 3 of these clinical findings has shown acceptable diagnostic accuracy.
Use Purdue Pegboard Test or the Delon-modified Moberg pick-up test
Do not use lateral pinch strength testing as outcome measure (surgical or non-surgical)
Do not use grip strength to assess <3 mo. change post surgery
May assess grip strength and 3-point or tip pinch strength to compare with norms
CTS (Intervention)
Recommend a neutral-positioned wrist orthosis worn at night for short-term symptom relief and functional improvement for individuals with CTS seeking nonsurgical management.
**Avoid sustained flexed wrist posturing
Do not use low-level laser therapy
Do not use thermal ultrasound (mild-moderate CTS)
Do not use iontophoresis (mild-moderate CTS)
Do not use magnets
May perform manual therapy for the cervical spine and UE (mild to moderate CTS in the short term.)
FROM THE CPG - night splint to wear at night
*keeps you from flexed position so you don’t compress the median nerve even more
There is conflicting evidence on the use of neurodynamic mobilizations for mild to moderate CTS.
May use a combined orthotic/stretching program in individuals with mild to moderate CTS who do not have thenar atrophy and have normal 2-point discrimination. Clinicians should monitor those undergoing treatment for clinically significant improvement.
Double Crush Syndrome Overview
peripheral nerve is compressed or irritated at more than one location along its path, such as at both the cervical spine and the carpal tunnel
Painful DeQuervain’s tenosynovitis
50+ usually, can be younger
Progressive stenosing tenosynovitis affecting the tendon sheaths of the first dorsal compartment of the wrist
Entrapment of the tendons due to thickening of the sheaths, Sheath around tendon, gets thick = tendon can’t slide nicely through
*over time gets stuck
*sheath gets so thick = tendon can’t go through
*tendon shortens over time
Compression increases with ulnar deviation
Severe pain with wrist ulnar deviation and thumb flexion and adduction, and with thumb extension and abduction
Crepitus may be present
Painful DeQuervain’s tenosynovitis positive tests
+ Finkelstein’s test
+ Eichoff’s test
+ WHAT test
Painful
DeQuervain’s tenosynovitis positive tests
s/sx
APL and EPB tendons
Overuse, repetitive tasks, overexertion of the thumb or radial/ulnar deviation of the wrist predisposing factors
c/o gradual onset of dull pain in the region of the radial styloid and wrist which can radiate proximally into the forearm and distally into the thumb
Pain and swelling at the base of the thumb, which can worsen with thumb movements or gripping. There may be tenderness in the first dorsal compartment
Pronator Syndrome
Affected Nerve: Median nerve.
Symptoms: Similar to CTS but can also include pain in the forearm. Pain and symptoms are often exacerbated by pronation of the forearm and can also involve sensory and motor dysfunction.
Cause: Compression of the median nerve by the pronator teres muscle or other structures in the forearm.
Anterior Interosseous Nerve (AIN) Syndrome
Affected Nerve: Anterior interosseous nerve, a branch of the median nerve.
Symptoms: Motor symptoms only, including weakness or paralysis of the flexor pollicis longus, flexor digitorum profundus (to the index and middle fingers), and pronator quadratus. There is typically no sensory loss.
Principles of tenosynovitis management
Principles of severity and irritability
Protection and relative rest if severe and highly irritable
Progression based on response to loading
Tendon glides within its sheath
Synovial fluid
Promote the mobility of the tendon within its container
Promote bathing the tendon in the synovial fluid
Tendon gliding -> Gentle AROM
Splints (OTC)
Thumb splints
*designed to prevent flexion from occurring
*strains EPB
*minimize and utilize from contractile standpoint
