Wrist Hand Flashcards
What muscles go through carpal tunnel
Flexor pollicis longus
flexor digitorum superficialis
flexor digitorum profundus
Bunnell-Littler test
Intrinsic muscle tightness of the hand is indicated if PIP passive flexion range of motion is greater with the MCP flexed than with the MCP extended.
what is the best (or ‘safe’) position for splinting of the hand after injury for prevention of ligamentous and muscular shortening?
Wrist extended, MCP partially flexed, IP joint extended, thumb palmarly abducted.
Which of the following fractures have a high incidence of nonunion because of a threatened or tenuous blood supply
scaphoid
talus
odontoid
pinch grip test
This finding signifies entrapment of the anterior interosseous nerve, or weakness of the flexor pollicis longus, or a flexor tendon rupture.
Which flexor tendon zone, if injured, has the worst prognosis?
2
Flexed finger while patients hand is in resting position cause
disrupted extensor tendon
extended finger while patient hand is resting position cause
disrupted flexor tendon
fingers extend normally but overlap when flexed during patient flexing fingers toward palm
fracture with rotational deformity of finger
part or all of finger has different color or inability to sweat
digital nerve injury
blanching lasts more than 2 seconds with capillary refill
microvascular trauma
patient cannot distinguish two points at least 5mm apart
neurological compromise
patient cannot flex PIP while other fingers are extended
disrupted flexor digitorum superficialis
patient can not flex DIP while other fingers are extended
disrupted flexor digitorum profundus (jersey finger)
patient cannot extend joint or lacks extension at DIP
fracture of distal phalanx or rupture of extensor tendon (mallet finger)
patient has pain when shaking hands then attempts to pronate and supinate while examiner resists movement
pathology of distal ulnar joint or TFCC
tenderness at small bony prominence on the ulnar aspect of the palm in the area of the palmar crease
trauma to pisiform
tenderness with wrist flexion while palpating pisiform (hook of hamate is felt)
fracture of hook of hamate
where is triscaphe joint located
following the dorsal side of the second finger proximally, thumb will fall into recess
most commonly fractured wrist bone
scaphoid
hook of hamate fracture
- less common injury
- may occur when patient falls while holding an object and object lands between ground and ulnar side of palm
- may also be caused when bat hits ball or golf club catches the ground and hypothenar eminence is struck
most common ligamentous instability of wrist
- between scaphoid and lunate
- high degree of pain
- gap more than 3 mm
- wrist effusion and pain that is seemingly out of proportion to injury
Extensor zone 1 injury
- mallet finger
- disruption to extensor tendon over DIP joint causing flexion deformity
type 1 mallet finer
- closed fracture
- immobilization splint in extension or slight hyperextension for 8 weeks
- exercises start with blocking of profundus involving PIP active motion only
- after 8 weeks, if active extension is present, splinting only during sleep, work, athletics
type 2 mallet finger
- laceration at or proximal to the DIP with loss of tendon continuity
- simple suture through tendon alone incorporating the tendon and skin in same suture
- splint for 6-8 weeks
type 3 mallet finger
- deep abrasion with loss of skin, subcutaneous cover, tendon substance
- require immediate sot tissue coverage and grafting
type 4 mallet finger
- ## transepiphyseal plate fracture in children; hyperflexion injury with fracture of the articular surface; hyperextension injury wit fracture of articular surface with early or late palmar subluxation of distal phalanx
chronic mallet finger
- splinting is first line
- surgery is offered if conservative management fails
extensor zone 2 injures
- middle phalanx, result of laceration or crush injuries
- if extensor lag, repair is needed
- if active extension, splinting for 3-4 weeks
extensor zone 3 injuries
- boutonniere, disruption of central slip at PIP
- absent or weak extension of PIP is (+) positive finding
- splinting for 4-6 weeks of PIPJ in extension
- surgery for closed fractures when displaced avulsion fractures at base of middle phalanx, or axial and lateral instability of the PIPJ associated with loss of active or passive extension of joint
- reduce immobilization by 2 weeks in elderly
extensor zone 4 injury
- proximal phalanx injury
- splinting the PIPJ in extension for 3-4 weeks in non complete
- surgery + 6 weeks of splinting for complete laceration
extensor zone 5 injury
- almost always open and treated as human bites
- tendon repair is needed after irrigation
- splinting wrist in 30-45 degrees of extension and MCP in 20-30 degrees of flexion
extensor zone 6 injury
- may not always result in loss of extension at MCP
- surgery then splint 4-6 weeks in extension
- all fingers shoulder be splinted if extensor digitorum communis is involved
median nerve innervation
- pronator teres
- FCR
- Palmaris longus
- FDS
- lumbricals 1 and 2
AIN innervation (median nerve)
- FPL
- FDP to index and long finger
- pronator quadratus
recurrent branch of median n.
- APB
- OP
- superficial head of FPB
ulnar nerve innervation
- FCU
- FDP to ring and little
superficial
- sensation
deep
- hypothenar muscles
- PAD
- DAB
- lumbricals III, IV
- AP
- deep head of FPB muscle
radial nerve innervation
- ECRL
PIN (radial)
- ECRB
- ECU
- ED
- EI
- EDQ
- APL
- EPB
- EPL
common sites of atrophy in hand
thenar and hypothenar eminences and intrinsic muscles between metacarpals and in the first dorsal web
claw hand
- hyper extension of the ring and small fingers MP joints with flexion of the corresponding IP joints
- ulnar nerve injury
ape hand
- loss of the ability to abduct the thumb away from the palm
- injury to median nerve or long standing CTS
ulnar drift
typically seen in RA
clubbing of nails
pulmonary or IBS
spoon nails
iron deficiency
raynauds disease
lupus erythematosus
Finkelstein test
- for De Quervain tendinopthy
- actively ulnar deviate the wrist over a table then passively flex the thumb across the palm
Eichoff test
- De Quervain tendinopathy
- hold thumb in fist and ulnar deviates
(less reliable than Finkelstein)
Intersection syndrome
- inflammatory condition occurring at the crossing paint between muscles of the first dorsal compartment and radial wrist extensor muscles.
Intersection syndrome complaints
- pain 2-4cm proximal to the wrist where the tendons of the first extensor compartment cross over the tendons of the second dorsal compartment
- more dorsal in the forearm than De Quervains
- may complain of a friction or squeaking sensation in the distal forearm when moving wrist and thumb
- test by resisting wrist extension
Scaphotrapeziotrapezoid joint arthritis test
- therapist applies pressure to scaphoid tubercle while radially and ulnar deviating the wrist
- result is positive when painful
Dorsal wrist syndrome (occult ganglion)
- tested with finger extension test
- place wrist and MP joint in flexion and resist long finger extension at MP joint
- pain in the 3rd and 4th dorsal compartment at wrist
Scaphoid Shift test
- test for SL instability or dissociation
- palpate scaphoid tubercle on the volar aspect of wrist and first passively ulnar deviates and slightly extends the patient wrist; then apply pressure on dorsal scaphoid tubercle, passively radial deviate and flex
- scaphoid with sublux
- suspect SL ligament injury with positive test and FOOSH injury
SL ballottement test
- patient’s arm pronated, examiner stabilizes lunate with thumb and index finger of one hand, grasps scaphoid with other hand
- moves scaphoid on lunate
- positive if pain and laxity or crepitus
Lunotriquetral (LT) ballottement test
- palpate lunate with one hand and pisotriquetral complex with other; move pisotriquetral complex while stabilizing lunate
- result is positive if maneuver recreates the patient’s pain and there is substantial laxity, clicking, crepitus
midcarpal instability
- examiner places patient’s wrist in neutral and forearm in pronation
- stabilize distal forearm and apply volar directed fore at capitate while applying an axially directed load to wrist, then ulnar deviate wrist
- positive if painful clunk occurs that reproduces the patient’s pain
ulnar fovea sign
- detects disruptions of the DRUJ ligaments from the fovea of the ulnar head or ulnotriquetral ligament injury
- with patients wrist and forearm in neutral rotation, examiner palpates soft spot between ulnar styloid, FCU tendon, volar surface of ulnar head, and pisiform
- positive test will reproduce the patient’s pain
TFCC load (compression) test
- patient pronates the forearm and makes a fist
- examiner ulnar deviates the patient’s wrist and appies an axial load through the wrist and uln
- examiner may apply additional load through TFCC by moving carpals on the ulna or rotating arm
pisiform boost test (ulnomenisaltriquetral dorsal glide)
- patient’s forearm in vertical position (elbow on table), and neutral, examiner pushes pisiform dorsally while translating the ulnar head volarly
- positive if test reproduces pain or excessive laxity of ulnomeniscotriquetral region
piano key sign
- DRUJ instability
- neutral rotation, stabilize radius and presses the ulnar styloid in a volar direction
- positive when pressure is released and ulna springs back up to its original position
ulnar compression test
- done to detect DRIJ inflammation or arthritis
- compress ulnar head into sigmoid notch of radius, this compression may be combined with forearm pronation and supination
- positive if pain
bunnell-littler test
- used to examine the length of hand intrinsic muscles
- examiner holds patients wrist in extension and MP joint of test finger in hyperextension and measures passive PIP joint flexion
- examiner then flexes MP joint and reassesses PIP joint flexion
- result is positive for intrinsic tightness if PIP joint motion increases with MP joint in flexion
Allen test
- for vascular disorder or arterial occlusion
- pt opens and closes fist several times and then make a tight first
- examiner simultaneously compresses both radial and ulnar arteries at the wrist
- open hand, should be white and blanched
- examiner releases one artery and observes blood flow back into hand and repeats entire process for other artery
- positive when hand does not revascularize or is sluggish
tests for function of hands
- functional dexterity test
- nine hole peg test
- perdue pegboard
- jebsen-taylor hand function test
semmes-weinstein monofilaments values
- 2.83 normal sensation
- 3.61 diminished light touch
- 4.31 diminished protective sensation
- 4.56 loss of protective sensation
- 6.65 untestable
two point discrimination
- measure of innervation density
- normal 2PD is less than 6mm
first sensory modality to be affected in compression neuropathies
innervation threshold
vibratory sensation
Tinel sign for CTS
tap over the median nerve at the carpal tunnel
tinel sign for compression at the superficial sensory branch of radial nerve
tap radial styloid
phalen test for CTS
extend the patient’s elbow and allow the wrist to flex and fingers to extend for 60 seconds
OK sign for AIN lesion
- have patient make OK sign
- look for IP joint flexion of thumb and DIP joint flexion of index finger
- positive if patient brings the pulps of their thumb and index fingers together rather than tips
froment sign
- for ulnar lesion
- hold index card or sheet of paper using key pinch
- test is positive if IP joint of thumb flexes indicating use of FPL muscle to compensate for weakness or loss of AP and FPB
intrinsic plus posture
MP flexed 70-90, IP joints in full extension
tenolysis
surgical removal of adhesions limiting tendon excursion that have formed after flexor or extensor tendon repair
- complications of tendon rupture, degradation of neurovascular system, worsening symptoms
- considered after 3 months of no improvements
most frequent fractured bone in body
distal phalanges of digits
most common fracture of metacarpals
Boxer fracture
MC neck fracture on small finger
Bennett fracture
- fracture dislocation
- triangular portion of bone is avulsed from ulnar side of MC base
- injury occurs from excessive abduction forces combined with an axial load at first CMC joint
- the avulsed fragment is the attachment site of the palmar oblique ligament (stabilizer of the MC to trapezium)
- the remaining MC subluxes in a proximal and dorsal direction by deforming force of the APL
Rolando fracture
- occurs at base of thumb MC
- has two or more fragments on the articular surface
UCL disruption
- hyperextension with radial deviation at the thumb MP joint
- acute injury is skiers thumb
- gamekeepers thumb is chronic and has UCL laxity
Stener lesion
- describes a UCL that has retracted proximally and dorsally to where it may now be laying over the adductor aponeurosis
grade 1 collateral ligament injury
- produce excessive tensile stress but does not disrupt the continuity of the ligament
- stable through full AROM
grade 2 collateral ligament injury
- partial disruption of the ligament
- immobilization for 2-4 weeks in a gutter orthosis with involved IP joint in full extension
grade 3 collateral ligament injury
- complete ligament rupture as well as an injury to the volar plate or dorsal capsule
- must be immobilized
scaphoid frature
- dull deep radial sided wrist pain
- may be produced on direct palpation of the scaphoid in the anatomical snuffbox at the SL joint line or on scaphoid tubercle
- if initial radiographs are negative, immobilize in thumb spica with repeat imaging in 2 weeks
triquetrum frature
- most common cause is FOOSH with hand landing in hyperextension and ulnar deviation
fracture of hook of hamate
- occurs as a result of a compressive force transmitted through the base of the palm or shear force during active torque of the wrist(tennis racquet, baseball bat, golf club)
- pain with gripping and when weightbearing through palm
- can cause distal ulnar neuropathy
static instability pattern
- signs include abnormal gap between individual carpal bones, alteration in shape or appearance of individual bones, and loss of smooth appearing arcs across the midcarpal and radiocarpal rows
symptoms associated with the most common of carpal instability patterns
- pain on radial side of wrist at rest or with movement
- complaints of decreased grip strength
- pain with attempts of wrist and hand weight-bearing activities
- tenderness to palpation over the scaphoid tuberosity, waist, or SL joint line
- laxity of the SL joint with ballottement test
- possibly a positive scaphoid shift test
- radiographic evidence
colles fracture
- extraarticular fracture occurring 1.5-2 inches proximal to articular surface of distal radius with angular displacement dorsally
- MOI is FOOSH with wrist in hyperextension and forearm supination
smith fracture
- fall onto flexed wrist and pronated forearm, results in volar angulated distal fragment
rupture of EPL
- can be a late complication of nonsurgical treatment of distal radius fracture
- can be due to irritation across fracture fragments and necrosis from a hematoma that develops in the third extensor compartment
ganglion cysts
- most common soft tissue mass in the wrist and hand
- no known cause but could be repetitive microtrauma
- 2.9 time greater odds of ligament laxity
- 70% arise from SL ligament or SL articulation
- volar are less common, arise from scaphotrapezial joint or radiocarpal joint
- can adhere to radial artery or cause ulnar/median nerve compression
dupuytren disease
- a fibroproliferative disease of the digital and palmar fascia
- begins as a palpable nodule or mass in the palm at the level of the distal palmar crease
- cords form and shorten and thicken and eventually cause joint flexion contractures at MP or PIP joints
- can be attributed to both genetic and environmental factures
- typically male
De quervain tendinopathy
- tendon entrapment
- impaired tendon gliding under a thickened retinaculum in the first dorsal extensor tendon compartment of the wrist (APL and EPB)
- more common in women than men
- common in later stages of pregnancy and lactation
presentation of de quervain tendinopathy
- complaints of pain in first dorsal compartment
- tenderness upon palpation
- finkelstein and eichoff tests and resisted thumb tension
factors associated with poor outcomes with de quervains
- metabolic syndrome, hypothyroidism
- use of growth hormone
- hx of trigger finger or CTS
- extensor tendon triggering
- presence of psych factors
trigger finger
- occurs due to size mismatch between a swollen flexor tendon and thickened A1 pulley
- women>male
median nerve injury
Proximal injury
- motor loss in pronator teres, FCR, palmaris longus, FPL, FDP (index and long), lumbricals 1/2, FBP (superficial) APB, and OP
Distal injury
- preserves funtion of forearm, wrist flexor, extrinsic finger flexor,
- weakness of opposition, pinch
ulnar nerve injury
high injury
- sensory loss in volar and dorsal surfaces of small and ring finger
- motor loss in FCU, FDP (ring and small), hypothenar, dorsal and palmar interossei, lumbricals to the ring and small fingers, AP, and FPB (deep head)
Lower injuries
- spare sensation on the dorsal ulnar aspect of the hand due to branching of the dorsal branch of the ulnar nerve in the forearm
lesions proximal to ulnar tunnel
- sensory loss in ulnar aspect of the hand (volar only, and motor loss in hand similar to high lesions
lesion of deep branch distal to bifurcation
- normal sensation but lose motor function of intrinsic muscles
radial nerve injuries
- associated with humeral shaft fracture or elbow dislocation
- proximal to radial head affect anconeus, brachioradialis, all wrist, thumb and finger extensors
- sensory loss in radial side of hand including dorsal aspect of thumb, index, and long fingers
