wrist and hand soft tissue injuries Flashcards by Aoife O'Connor

what is the MOI of a wrist sprain?

-falls on flexed or extended wrist or contusions
-overload injury seen in gymnasts/ weight lifters

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what structures of the wrist could be included in wrist sprains?

-collateral ligaments
-scapholunate ligament - grade I, II or III
- may also have tears of the triangular fibrocartilage complex on ulnar side (TFCC)

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What are the symptoms of wrist sprains?

-pain
-swelling
-weakness in the wrist
-popping or slipping inside the wrist
-symptoms can get worse with activity, such as gripping, squeezing and lifting

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what are the physical signs of a wrist sprain?

-tenderness over specific wrist ligaments
-swelling
-loss of ROM
-weakness
-certain positive special tests

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what is the TFCC?

-lies between the ulna and carpus
-major stabiliser of the wrist
-common side of ulnar wrist pain
-injured with ulnar deviation with compression eg gymnastics, diving etc

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what are the signs and symptoms of a TFCC tear?

-pain on ulnar side of wrist - associated with pronation and ulnar deviation mvt
-tender on ulnar aspect on palpation
-pain on resisted extension & ulnar deviation
-reduced & painful grip strength
-press test is positive

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what does the conservative management of a TFCC tear involve?

-relative rest
-protecting brace /splint
-strengthening - isometric and grip strength
-ROM / manual therapy - but with caution if unstable

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what does the surgical management of a TFCC tear involve?

-excision of torn cartilage under arthroscopy
-ulnar shortening - if it longer than radius and can impinge on radius

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what can happen to the wrist after a grade 3 ligament sprain?

carpal instability

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what carpal bone is the key bone for carpal stability?

-the scaphoid

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what is the most common carpal bone instability?

scaphoid-lunate instability

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what are the signs & symptoms of carpal instability?

-pain
-decrease in ROM
-clicking sensation
-increase in mobility on accessory motion testing
-tenderness on palpation
-decrease in grip strength

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how is carpal instability managed?

-if sprain only, with no dislocation then managed as a usual ligament sprain
-if minor subluxation- may reduce spontaneously, otherwise reduced in surgery

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what is the role of the physiotherapist in wrist ligament sprains /. carpal instability ?

-activity modification
-splinting (OT)
-pain management - NSAIDS, meds
-strengthening exercise
-proprioception exercises

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what are examples of good strengthening exercises for wrist instability ?

-flexor carpi radialis, extensor apri radialis etc
-avoid exercising extensor and flexor carpi ulnaris
-isometric in acute stage
-progression to concentric and eccentric through range

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why is it not recommended to exercise the ECU and FCU?

as it can increase the scaphoid lunate distance

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what is skiers / gamekeepers thumb?

-rupture of the ulnar collateral ligament of the thumb

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what is the MOI of skiers thumb?

fall on the outstretched thumb

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what are the symptoms of skiers thumb?

-pain & swelling at the base of the thumb
-pain using the thumb for pinching and gripping, opening jars, cars and door handles

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what are the physical signs of skiers thumb?

-tenderness along the UCL
-instability & discomfort with stress testing of the ligament thumb in extension
-x rays to out rule avulsion fracture

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how is skiers thumb managed conservatively?

-casting/ splinting the wrist and thumb for several weeks

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what does the surgical treatment of skiers thumb involve?

-repair of the torn ligament with reattachment to the bone
-period of immobilisation

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what is De Quervain’s tenosynovitis?

-inflammation of the APL and EPB tendons as they pass through their synovial sheath at the level of the radial styloid

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what kind of injury is De Quervains Tenosynovitis?

overuse injury - ulnar deviation, thumb abduction

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what kind of sports do we see De Quervains tenosynovitis in?

-rowers -ten pin bowlers

what are the signs and symptoms of De Quervains tenosynovitis?

-pain along the APL and EPB tendons -tenderness on palpation -crepitus - cracking noises etc -thickening along the tendon -difficulty gripping -resisted thumb extension & abduction reproduced pain -pain on stretching

what is Finkelstein's test?

test involves ulnar deviation of the wrist with the thumb adducted in the palm

what does a positive Finkelstein's test?

-pain over radial styloid

what does the management of De Quiervains tenosynovitis?

-relative rest / activity modfication -POLICE -ROM / strength -resting splint -steroid injection -electro modalities for healing eg lasers

what is intersection syndrome?

bursitis where APL and EBP tendons cross over the ECR tendons

what are the signs & symptoms of intersection syndrome?

-tenderness dorsally on the radial side of the wrist -selling and creptis (proximal to site of De Quervains)

what does the management of intersection syndrome involve?

-similar to DE Q - activity modification, POLICE etc -surgery is rare

what is carpal tunnel syndrome?

-compression of the medial nerve as it passes through the carpal tunnel

what are the causes of carpal tunnel syndrome?

-inflammation and swelling within the carpal tunnel or reduction of the size of the tunnel -trauma eg fractured distal radius -repetitive strain keyboard use -repeated gripping

what conditions is carpal tunnel syndrome associated with?

-pregnancy -obesity -RA -diabetes

what are the symptoms of carpal tunnel syndrome?

-aching, burning sensation with P&N's in median nerve distribution -symptoms can cause person to wake at night -loss of sensitivity if hand -clumsiness

what is important to rule out with carpal tunnel syndrome?

-cervical spine referral -thoracic outlet syndrome - brachial plexus

what would a neurological exam demonstrate with a patient suffering from carpal tunnel syndrome?

-loss of sensation -may or may not have reduced strength in median nerve distribution

how is carpal tunnel syndrome managed?

-reduce swelling and pressure on the nerve -if overuse, address eg ergonomics - keyboard position etc -restore ROM if reduced -night / resting splint -manual therapy - median nerve mobilisation -NSAIDS / corticosteroid injection -acupunture

what are examples of special tests for carpal tunnel syndrome?

-phalen's test -tinel's test -neural tissue provocation test of median nerve

what is ulnar nerve entrapment?

-when the ulnar nerve is compressed as it crosses the wrist at the tunnel of guyon

what can cause ulnar nerve entrapment?

-trauma - fracture at wrist -FCU tendinitis at pisiform -cyclists -using crutches or walking sticks -may occur with cubital tunnel syndrome

what are the signs and symptoms of ulnar nerve entrapment?

-may not complain of pain -p&n's over the ring and little fingers -loss of sensation at the tip of the little finger -management is similar to carpal tunnel syndrome

what is duputyren's contracture?

-thickening and contracture of the palmar fascia

what is the aetiology of duputyren's contracture?

-unknown -middle aged men - common -progressive and recurring

what does the management of Duputyren's contracture involve?

-corticosteroid injection - some benefit -splinting, stretching , ultrasound etc

what are ganglion cysts?

swelling on ganglion

where can ganglion cysts be seen?

-FCR tendon sheath -digital extensors -roof of the first dorsal compartment

what does the treatment of ganglion cysts involve?

-rest -splinting -surgical excision if unsuccessful

what is mallet finger?

-avulsion of extensor mechanism (tendon)

what is the MOI of mallet finger?

-can occur with basketball, cricket and baseball

what does Mallet finger result in?

- flexion deformity of DIP

how is a mallet finger managed?

-splinting for 6-8 weeks with mallet splint

what is trigger finger?

-tenosynovitis of the flexor policies longus or other deep flexor tendon -overuse injury

what kinds of people is trigger finger common in?

-musicians -gardeners -construction workers -activities involving repetitive gripping

what are the symptoms of trigger finger?

-pain in finger -sensation of catching or triggering of the involved digit -the finger may actually lock in flexion or extension -symptoms are usually worse in the morning and improve during the day

what are the signs of trigger finger?

-tenderness along the flexor tendon sheath, especially at the A1 pulley in the palm -nodule may be felt moving under the pulley with finger mvt -locking or catching is classic

what does the management of trigger finger involve?

-NSAIDS -corticosteroid injections -physio intervention is not useful

what functions does FDP have?

-flex the wrist flex the MCP -flex PIP -flex DIP

what does the MOI of a rupture of the FDP involve?

-forceful hyperextension of DIP joint with FDP in maximal contraction -eg sudden jerk of rope, such as starting a lawnmower or retraining an animal on lead