Wrist and Hand STI Flashcards
types of hand injuries
Ligament Sprains- Wrist, Skiers thumb
dorsal tendinopathy
tenosynovitis - De Quervain’s, Trigger finger
nerve entrapments - ulnar, median
finger injuries - Mallet Finger, PIP joint sprain, Rupture of FDS and FDP
dislocation - MCP, PIP
common sources of injuries in dorsal region of hand
Fracture Carpal bone of distal radius
Extensor Tenosynovitis
Ganglion
ligament sprain
common sources of injuries in volar region of hand
Ligament Sprain
Carpal Tunnel Syndrome
Fracture Carpal bone of distal radius
common sources of injuries in ulnar region of hand
Ligament Sprain
TFCC tear
Ulnar nerve Compression
Flexor Carpi ulnaris Tendinopathy
common sources of injuries in radial region of hand
De Quervain’s Intersection syndrome Scapholunate Dissociation Flexor Carpi Radialis Tendinopathy * Missed scaphoid #
generis common sources of pain in hand
Ligament Sprain
Inflammatory Arthritis
Fracture Carpal bone of distal radius
common sources of injuries in thumb
Skiers thumb
Avulsion fracture
Osteoarthritis
Bennett’s fracture
causes of wrist sprain
Falls on flexed or extended wrist or contusions
Overload injury seen in gymnasts/ weightlifters
what structures are included in wrist sprain
Collateral ligaments
Scapholunate ligament
signs of wrist sprain
Tenderness over specific wrist ligaments.
Swelling, loss of motion, and weakness.
Certain special tests are suggestive of specific ligament injuries
symptoms of wrist sprain
Pain, swelling, or weakness in the wrist.
Can occasionally be a sense of ‘popping’ or ‘slipping’ inside the wrist.
Symptoms generally worse with activity, such as gripping, squeezing, and lifting.
triangular fibrocartilage complex (TFCC) location
Lies between the ulna and carpus
function of TFCC
Takes 20% of compressive load of the wrist
ulnar wrist pain is indicative of
TFCC tear
causes of TFCC tear
ulnar deviation with compression e.g diving, gymnastics, racket sports
signs and symptoms of TFCC tear
Pain on ulnar side of wrist –associated with pronation and ulnar deviation movements
Tender on ulnar aspect on palpation
Pain +/-Clicking sensation with wrist movement esp. Flexion /extension in ulnar deviation
TFCC load test: axial compression and ulnar deviation
Pain on resisted extension and ulnar deviation
Reduced and painful grip strength
conservative management of TFCC tear
Relative rest Protecting bracing /splint Strengthening’ Isometric. Grip strength, ROM/ Manual therapy? Caution with high grades if unstable
surgical treatment of TFCC tear
Excision of torn cartilage under arthroscopy
Ulnar shortening – if it is longer than radius and can impinge on radius
(Ulnar Impaction Syndrome)
cause of carpal instability
from a Grade 3 ligament sprain to any of the carpal ligaments
what carpal bone is key to carpal stability
scaphoid
most common carpal instability
scaphoid-lunate instability-may lead to dislocation
what other carpal bone is also commonly injured
capitate
signs and symptoms of carpal instability
Pain increase ROM 2 pain ‘clicking sensation’ increased mobility on accessory motion testing e.g. Kaltenborn decreased grip strength Tenderness on palpation Positive Scaphoid Shift (Watson) test
management of carpal instability if sprain only
with no dislocation, then managed as a usual ligament sprain
management of carpal instability if minor subluxation
may reduce spontaneously. Otherwise reduced with traction and immobilised to allow healing
surgery if detected early
strengthening exercises for carpal instability for what muscles
Esp FCR, ECRL and APL muscles
Isometric in acute stage
Progression to conc/ecc and through range
‘Dart throwing movement’
exercises to avoid with carpal instability and why
Avoid exercising Extensor and Flexor Carpi Ulnaris (ECU/FCU)- can increase the Scaph-lunate distance
cause of skiers thumb
Rupture of the Ulnar Collateral Ligament of the Thumb
Caused by fall on the outstretched thumb
grades of skiers thumb
I-tearing of fibres with no loss of continuity
II-partial tear
III-complete rupture
symptoms of skiers thumb
Pain and swelling at the base of the thumb
Pain using the thumb for pinching and gripping, opening jars, car door handles, etc.
signs of skiers thumb
Tenderness along the UCL
Instability and discomfort with stress testing of the ligament-thumb in extension. Apply abduction (valgus) stress to the MCP joint
X-rays to out-rule avulsion fracture
non operative treatment of skiers thumb
Casting/Splinting the wrist and thumb for several weeks
de quervains tenosynovitis source of pain
Inflammation of the APL and EPB tendons as they pass in their synovial sheath at the level of the radial styloid
cause of de quervains tenosynovitis
Overuse injury –ulnar deviation, thumb abduction
signs and symptoms of de quervains tenosynovitis
Pain along APL and EPB tendons Tenderness on palpation Crepitus Thickening along tendon Difficulty gripping Finklestein’s test
finkelstein test
The test involves ulnar deviation of the wrist with the thumb adducted in the palm.
Positive if reproduces the pain over radial styloid
management of de quervains tenosynovitis
Relative rest/ Activity modification POLICE ROM/Strength Resting Splint Steroid Injection Electro modalities for healing (e.g. laser/US)
intersection syndrome
irritation and swelling of radial side of wrist
source of pain in intersection syndrome
Bursitis where APL and EPB tendons cross over the ECR tendons
cause of intersection syndrome
May be due to friction as they exert tension in different directions or due to De Quervains tenosynovitis
signs and symptoms of intersection syndrome
Tenderness dorsally on the radial side of the wrist
Swelling and crepitus (usually proximal to site for De Quervain’s)
Differential DX: De Quervain’s
management of intersection syndrome
similar to de quervains
source of pain in carpal tunnel syndrome
Compression of the median nerve as it passes through the carpal tunnel
cause of carpal tunnel syndrome
inflammation or swelling within the carpal tunnel or reduction of the size of the tunnel
activities that cause carpal tunnel syndrome
Trauma (fractured distal radius), repetitive strain-keyboard use, repeated gripping, excess vibration from heavy machinery
symptoms of carpal tunnel syndrome
Aching, burning sensation with P+N’s in median nerve distribution.
Symptoms can wake at night and can be eased by vigorously shaking/rubbing the hand.
Loss of sensitivity and dexterity of hand
‘Clumsiness’
what nerves must be ruled out in carpal tunnel syndrome
Cervical Spine ( nerve root) Thoracic Outlet Syndrome (brachial plexus)
tests for the carpal tunnel syndrome
Phalen’s test
Tinel’s test
Neural Tissue Provocation Test of Median Nerve
phalens test
Hold wrist in maximum flexion x1 minute to compress the nerve. Positive if p+n’s are reproduced within 3 mins
tinels test
Tap the nerve over the flexor retinaculum. Positive if p+n’s are reproduced in the radial 3 digits
Neural Tissue Provocation Test of Median Nerve
Tests the sensitivity of the brachial plexus and median nerve
aim of management of carpal tunnel syndrome
to reduce swelling and pressure on the nerve
management of carpal tunnel syndrome
If overuse, address e.g ergonomics- keyboard position, regular movement
If reduced ROM (e.g. post fracture)-restore ROM
Night/resting splint
Manual therapy: joint/median nerve mobilisation
NSAIDs /Corticosteroid injection
ulnar nerve entrapment causes
Trauma (fracture at wrist) FC Ulnaris tendinitis at pisiform. Cyclists (handle bar palsy), Using crutches/walking stick May occur with Cubital Tunnel Syndrome (ulnar nerve entrapment at elbow)
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
ulnar nerve entrapment causes weakness in what muscles
flexor carpi ulnaris flexor digitorum profundus. palmaris brevis, lumbricals hypothenar interossei muscles
duputyrens contracrue
Insidious thickening and contracture of the palmar fascia
Readily observed and palpable in the palm
location of duputyrens contracture
Usually effects the 4th or 5th digits or both
aetiology duputyrens contracture
Unknown Common Middle-aged men Familial Progressive and recurring Often bilateral
management of duputyrens contracture
Corticosteroid injection of some benefit
Collagenase injection
Conservative Treatment-Splinting, stretching, ultrasound, laser - relatively ineffective, No evidence.
ganglions
Synovial cyst communicating with the joint space
way to diagnose ganglion
palpation
cause of ganglions
Most frequently from FCR tendon sheath, digital extensors, roof of the first dorsal compartment
treatment of ganglions
rest, splinting; surgical excision if unsuccessful
mallet finger
Avulsion of extensor mechanism (tendon)
cause of mallet finger
: Can occur with basketball, cricket, baseball
what must be out ruled when diagnosing mallet finger
fracture of distal phalanx
treatment of mallet finger
Splinted for 6-8 weeks with mallet splint
Physio to restore ROM and strength after immobilisation
trigger finger source of pain
Tenosynovitis of the FPL or other deep flexor tendon
cause of trigger finger
Overuse injury
May have painful nodules
trigger finger is common in..
Common in musicians, gardeners and construction workers due to repetitive gripping
trigger finger is associated with
RA/ Diabetics
signs of trigger finger
Tenderness along the flexor tendon sheath, especially at the A1 pulley in the palm.
A nodule may be felt moving under the pulley, with finger motion.
Locking or catching is classic.
symptoms of trigger finger
Pain in the finger. Often a 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.
treatment of trigger finger
Important for physio to identify
BUT physio intervention not useful
NSAIDS
Corticosteroid injection
Surgical release of tendon
rupture of flexor digitorum mechanism of injury
: Forceful hyperextension of DIP joint with FDP in maximal contraction
FDP function
flexes the wrist, MCP , PIP and DIP joints
in what finger does rupture of flexor digitorum profundus mostly occur
in ring finger
FDP rupture treatment
surgery
