Wrist/Hand Flashcards
Distal row of carpal bones
Trapezium, trapezoid, capitiate, and hamate
Proximal row of carpal bones
Scaphoid, lunate, triquetrum, pisiform
Pisiform is a sesamoid for what tendon?
Flexor carpi ulnaris (FCU)
Most susceptible carpal bone to fracture
scaphoid
Most frequently dislocated carpal bone
Lunate
Kienbocks disease
Avascular necrosis (non-traumatic) of the lunate
Carpal described as the keystone of the transverse arch
Capitiate
Normal inclination of the distal articular radial surface
15-20°
Ulnar minus variance
Distal ulna is proximal to the ulnar surface of the radius
Ulnar positive variance
Distal ulna is distal to the ulnar surface of the radius
What ulnar variance is associated with Kienbock disease
Negative ulnar variance
Volar tilt of the distal raidus
15°
Loss is common post distal radius fx
Volar plate extension toward the proximal segement
Check reins
Heberden’s nodes
Osteophytes at the DIP joint
Bouchard’s nodes
Osteophytes at the PIP joint
What joints in the hand are the most commonly symptomatic joints involved with OA
DIP joints and thumb CMC
When MP joint immobilization is required, what is the optimal position for keeping ROM
MP flexion (70-90°), collateral ligaments are lax in ext and can become tight if immobilized in extension
LOAF muscles
L: lateral two lumbricals
O: opponens pollicis
A: abductor pollicis brevis
F: flexor pollicis brevis
LOAF muscles are innervated by which nerve?
Median nerve
Skier’s thumb
Acute disruption of the UCL of the thumb
Gamekeeper’s thumb
Chronic degenerative changes causing UCL disruption of the thumb
Stener lesion
Torn UCL (avulsion) is now seated superficial to the adductor aponeurosis
Tx for Stener lesion
Surgery (think Brett Farve)
2 strongest ligaments at the 1st CMC
Palmar oblique ligament and dorsoradial ligament
Motion of proximal row of carpal bones during radial deviation
Slight flexion and slides ulnarly
Motion of proximal row of carpal bones during ulnar deviation
Slight extension and slides radially
Piano key sign
Disruption of the ligaments supporting the DRUJ (causing excess ant/post ulnar translation)
Stabilize radius and press ulnar styloid volarly
Space of Poirier
Between distal and proximal “V”, very unstable (around lunate)
Mnemonic that describes # of tendons found within each of the 6 extensor compartments from radial to medial
221211
Extensor compartment #1
APL, EPB
Extensor compartment #2
ECRL, ECRB
Extensor compartment #3
EPL
Extensor compartment #4
ED, EI (extensor indicis)
Extensor compartment #5
EDM
Extensor compartment #6
ECU
2 tendons commonly involved with De Quervains
APL, EPB
aka #1 extensor compartment
Only wrist extensor muscle innervated PROXIMAL to the division of the radial nerve into PIN
ECRL
Extrinsic extensors of the wrist and hand are all innervated by what nerve? (exception of ECRL)
PIN
What extrinsic hand tendon rupture is common with distal radial fractures
EPL
Structure that connects ED tendons
Juncturae tendinae
What tendon uses the pisiform as a sesmoid bone
Flexor carpi ulnaris (FCU)
Goes around it to hook to 5th metacarpal
What muscle tendons run through the carpal tunnel
FDS (x4), FDP (x4), FPL
Chaism of Camper
Where the FDS splits into 2 slips (FDP passes through the chaism)
Finger flexor tendon sheath includes how many annular or cruciate regions
5 annular (O), 3 cruciate (X)
Which finger flexor annular pulleys are the most important
A2 & A4
Which finger flexor pulley is ruptured in 75% of rock climbers finger injuries
A2
Which finger flexor pulley is most common site for trigger finger
A1, can be released without significant deficits
Lumbrical muscles arise from what tendons
FDP
What muscles are significant contributors to the “intrinsic plus position”
Lumbricals, they help with MP joint flexion
Which lumbricals are unipennate and bipennate?
Lumbricals (radial to ulnar):
I-II = unipennate
III-IV = bipennate
Action of the dorsi interossei (DI)
finger abduction
Action of the palmar interossei (PI)
finger adduction
Action of the lumbricals
MP flexion
The lateral bands of the extensor mechanism sit dorsal or volar to the axis of rotation
dorsal
Boutonniere deformity
PIP flexion, DIP extension
Swan-neck deformity
PIP extension, DIP flexion
What causes boutonniere or swan-neck deformities
Disruption of the bands (triangular ligament, transverse retinacular ligament)
Ulnar nerve travels through the cubital tunnel and then between the heads of what muscle?
FCU
Guyon canal
Ulnar tunnel between the pisiform and hook of hamate
Only muscle that is a primary hand or wrist motor innervated by the radial nerve?
ECRL
Self report measures for wrist and hand
DASH, QuickDASH, Carpal Tunnel Questionnaire (CTQ)
Claw hand can indicate damage to which nerve
Ulnar nerve
Ape hand can indicated damage to which nerve
Median, or can be from long standing CTS
Ulnar drift is caused by what condition
Rheumatoid arthritis
Objective assessment for scars
Vancouver Scar Scale
Dry skin in hand/forearm can indicate damage to what structures?
Peripheral nerve lesion
Clubbing of nails can be due to
Pulmonary OR inflammatory bowel disease
Spoon nails can be due to
Iron deficiency, Raynauds, or Lupus
Best methods to measure edema or atrophy
Volumetry (preferred) and circumferential
Both are reliable
Lister’s tubercle
Anatomic process on the dorsum of the radius that functions as a pulley to the EPL
Bossing of CMC joints
Excessive bone growth on back of hand
Dupuytren’s contracture
Abnormal thickening of tissues in the palm of the hand
If wrist/hand PROM exceeds AROM by >10° there is likely what?
Weakness or tendon adhesions
Jersey finger
Avulsion of the FDP tendon
Kapandji scale
Measure of thumb CMC joint opposition
(0-10, 10 = good)
Finkelstein test
For De Quervain’s
Ulnar deviation (no thumb unless need more provocation)
Eichoff test
Thumb in palm and passively ulnarly deviate wrist
Which De Quervain’s test is better: Finkelstein vs Eichoff
Finkelstein (less false positives)
Intersection syndrome
- What it is
- Symptoms
Result of repetitive friction at the junction in which the tendons of the #1st extensor/dorsal compartment cross over the #2nd, creating a tenosynovitis
- Symptoms: Pain 2-4cm proximal to wrist, friction or squeaking in distal forearm w/ movement of wrist and hand, pain with resisted extension
Test for scaphotrapeziotrapezoid (STT) jt arthritis
Pressure to scaphoid tubercle while radially/ulnar deviating the wrist
No evidence on accuracy
Finger extension test
- Used for
- Method
To diagnose occult dorsal wrist ganglion
- Wrist and MP jts in flexion and resists long-finger ext
- sign is pain
Test has 100% sensitivity
Scaphoid shift test
Tests for SL instability
Passively ulnar deviate and slight ext, put dorsal pressure on scaphoid tubercle, passively radially deviate and slight flexion
- Pain or clunk = positive test
Is the Scaphoid shift test enough to conclude SL instability?
No, use in combo with hx of wrist trauma (FOOSH)
Up to 1/3 of patient have false + due to ligament laxity
SL ballottement test
Move scaphoid volarly/dorsally, lunate is stabilized
+ = pain, laxity
Lunotriquetral (LT) ballottement test
Move pisotriquetral complex dorsally and volarly, lunate is stabilized
+ = pain, laxity, clicking, crepitus
Midcarpal instability test
Volar force at capitate while applying an axially directed load to the wrist, then ulnar deviates the wrist
+ = painful clunk
NOTE: test is not good
Ulnar fovea sign
Pressing the examiner’s thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon
- Detects foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries
+ = pain
Is the ulnar fovea sign good?
Yes, comparable to MRI for detection of ligament injury of the DRUL or ulnotriquetral
TFCC load test
Pronation, ulnar devation, make a fist, axial load
+ = pain
Pisiform boost test
Tests for ulnomeniscotriquetral region issues
Push pisiform dorsally and ulna volar
+ = Pain and laxity
Tests for CMC arthritis
- Pressure shear test (AP/PA of 1stMC on trapezium)
- CMC grind test (axial load and rotate)
Both are good SN/SP, shear just slightly better overall
UCL stress test
Valgus force on 1st MP joint at 0° and 30° of flexion
+ = >35° laxity or >15° vs other side
Bunnell-Littler test
Test intrinsic muscle length
MCP extended, PIP flexed, then MCP flex
+ capsule tightness = If PIP ROM doesn’t change
+ muscle tightness = PIP ROM increases w/ MCP flexion
Clinical tools to assess dexterity and functional testing of the wrist/hand
1) Functional dexterity test
2) Nine-Hole Peg Test
3) Purdue Pegboard
4) Jebsen-Taylor Hand Function Test
If suspect sensory deficits which is better: Monofilaments or 2 point discrimination
Start with monofilaments for touch threshold (affected w/ vibratory loss PRIOR to loss of 2PD)
Normal 2 point discrimination (2PD)
Less than 6mm
OK sign
Test for AIN lesion, unable to do so if damaged (tear drop shape)
Froment sign
Test for ulnar nerve lesion - unable to use AP and FPB, ends up using FPL for thumb IP flexion
Tendon injuries in the hand are worst post-op outcomes if in what zone?
Zone II (between insertion of FDP and heads of MC’s)
Is prolonged immobilization post-tendon repair good or bad?
Bad, early mobilization without load is recommended to limit tissue adhesions
Post-operative protocol for flexor tendon repair
Early stages (3-4wks) - application of cast (wrist in slight flexion, MP jts in 50-60° flexion)
Intermediate stage (4wks) - Progress to neutral orthosis, begin PROM finger flex and AROM finger ext
1-2 wks post-immobilization can start AROM
Late stage (4-6wks) - orthosis di/c, being gentle isolated jt blocking exercises
8wks - add light resistance
10-12wks - add heavy resistance (>10#)
Should tendon glides or edema/stiffness control be done first in tx?
Edema/stiffness control BEFORE glides
Place-hold exercise
Fingers passively put in flexion and then pt asked to hold position
Use is questionable due to high stress/snap put on tendon from lax to active
Zone I finger/hand repairs tend to only include which tendon?
FDP
T/F: Tendon gliding concerns are less in zones III and IV
True, no finger pulleys
Mallet finger disruption is in which zone?
Extensor zone I
Extensor tendons have how many zones
8 (+ thumb)
I-VIII and TI-IV
Flexor tendons have how many zones
5 zones (I-V)
Chronic mallet finger can turn into what condition/deformity?
Swan-neck deformity, especially in hypermobile individuals
What can develop if there is a loss of balance of flexors and extensors
Boutonniere deformity
Disruptions to the triangular ligament, lateral ands, and/or central slip cause the lateral bands to migrate which direction (dorsal/volar)
Volar, if volar to axis they become flexors instead of extensors (aka loss of balance of flexors & extensors)
Amount of motion that is helpful for tendon nutrition post-extensor repair in zones V & VI
Index/middle:
Ring/small:
Index/middle: 30-45°
Ring/small: 40-50°
Tenolysis
When should it be done?
Surgical removal of adhesions limiting tendon excursion
Used if no improvement with therapy in 3 months
Complications of tenolysis
Tendon rupture, degradation of the neurovascular system, worsening symptoms/function
4 stage tendon gliding
1) open hand
2) Hook fist (IP flexion)
3) Straight fist (DIP ext)
4) Full fist
Rehab post-tenolysis
Immediately: AROM, place-and-hold, 4 stage tendon gliding
2wks post-op: Jt blocking exercises
May use orthotic for comfort and to prevent adhesions
6 wks post-op: resistance (gentle)
Most frequently fractured bone in the body
Distal phalenx (Tuft fx)
Tuft fx
Distal phalenx fx, often comminuted
Healing involves short term immobilization (2-3wks), often heals with fibrous union vs ossification
6-8wk min immobilization if avulsion fx
Boxer fx
Fx of the 5th metacarpal neck from punch w/ closed fist
Flexed position of up to 70° is okay because 5th ray is very mobile and deformity doesn’t affect function
Bennett fx
Triangular portion of bone if fx at base of thumb MC, requires surgery
Rolando fx
2 or more pieces of bone fx at base of CMC jt
More complicated vs Bennett fx, can lead to gripping issues
What precaution must be taken when buddy taping a finger?
Can exacerbate PIP jt effusion
When is surgery indicated in PIP jt sprains?
If the jt cannot be stabilized using non-surgical tx OR those that are unstable at angles >25° flexion
Long-term consequences of a scaphoid nonunion
SNAC wrist (scapho-nonunion advanced collapse), may ultimately result in complete carpal breakdown
Pain with gripping, weight bearing through hand, TTP over medial carpals
Consider hook of hamate fx (not usually seen on standard XR, need carpal tunnel viewe)
Can cause distal ulnar neuropathy
DISI pattern
Dorsal intercalated segmental instability, scapholunate angle >60°
Lunate instability - lunate is pulled into extension
VISI pattern
Volar intercalated segmental instability
Scapholunate angle <30°
Lunate instability - lunate is pulled into flexion
Normal scapholunate angle
30-60°
SL disassociation symptoms/signs
Symptoms:
- Pain @ radial side of wrist at rest and w/ activity
- Decreased grip
- Pain w/ weight bearing
Signs:
- TTP scaphoid tuberosity/waist/SL jt line
- Laxity w/ ballottement test
- Possible + scaphoid shift test
- XR findings
Compare outcomes of non-surgical vs surgical repair of distal radius fx
Same, although grip strength is BETTER in surgical group
Colles fx
Distal radius fx with hyperextended wrist
VOLAR angulated distal fragment
Smith’s fx
Distal radius fx w/ flexed wrist
DORSAL angulated distal fragment
Indications for surgery of distal radius fx
Significant loss of radial height or excessive dorsal angulation
Best surgical option for distal radius fx
Volar plate
Most appropriate rehab interventions for non-surgical distal radius fx in elderly low demand patients
Wrist work in combo with home evaluation for balance and fall assessment
What ligament injuries occur in 1/3 of distal radius fx’s
SL and LT
What tendon rupture/damage can occur commonly post-distal radius fx
EPL
AROM of wrist can start how soon post-ORIF in distal radius fx’s:
- Extra-articular
- Intra-articular
- Non-surgical cast immobilization
- Extra-articular (1-3wks)
- Intra-articular (4-6wks)
- Non-surgical cast immobilization (5-6wks)
Common substitution pattern for lack of forearm supination
Humerus adduction and shoulder ER
Is formal PT vs independent HEP indicated in uncomplicated fractures?
Good outcomes with independent HEP
HOWEVER,
Pt’s >60y/o or w/ complications or co-morbidities did better with formal therapy supervision
What condition puts you more at risk for symptomatic dorsal ganglion cysts
Generalized ligament hyperlaxity
Common around SL region and scapholunate instability is commonly associated with the cysts
How to differentiate between a ganglion cyst and tenosynovitis lump?
Tenosynovitis cyst will move during tendon excursion, ganglion cyst does not move
3 Treatment options for ganglionic cysts
1) observation
2) aspiration (usually w/ steroid injection)
3) surgical excision
Indications for surgery for Dupuytren disease
MP contracture >30°
or
PIP contracture of >20°
Known demographics/risk factors for dupuytren disease
Male, northern European, increased age
Evidence on use of rehab for tx of dupuytren disease
Limited and inconclusive, surgery is usually main tx
Rehab management of patients following a fasciectomy for dupuytren disease
Typically NO-TENSION technique
T/F: De Quervain Tendinopathy is a tendon entrapment issue (aka tenovaginitis - inflammatory thickening of the fibrous sheath containing one or more tendons)
True
De Quervain Tendinopathy is common in which populations?
Women (especially late stage pregnancy or lactation periods)
Levels of estrogen receptor expression correlated to disease activity (1 study)
Is imaging needed for De Quervain Tendinopathy
Not usually, unless to rule out other things
Recommendations for rehab of De Quervain Tendinopathy
Corticosteroids & orthosis
Trigger finger
Commonly around MP jt or distal palmar crease around the A1 pulley
Can be nodule proximal to A1 pulley sheath
Non-operative treatment for trigger finger typically include:
What are the only evidence based interventions?
ROM and tendon gliding, modalities, orthosis, or steroid injection.
Only interventions with evidence include orthoses and injection
What stage (early/late) of trigger finger responds well to orthosis
Early/mild - orthosis in extension
What stage (early/late) of trigger finger responds well to orthosis PLUS cortisone injection
Late
Rehab considerations for post-cortisone injection to treat trigger finger
Avoid physical activity/overload to affected part for 3 wks to allow tendon healing to avoid tendon rupture
Neuropraxia:
- Prognosis
- Healing time
- Cause
- Clinical signs/symptoms
- Prognosis: GOOD
- Healing time: Hrs to 3 months (post-removal of compression)
- Cause: Formation of endoneurial edema
- Clinical signs/symptoms: Sensory dysfunction, NEG TInel, EMG normal
Axonotmesis:
- Prognosis
- Healing time
- Cause
- Clinical signs/symptoms
- Prognosis: GOOD
- Healing time: Occurs almost immediately
- Cause: axon damage (non to connective tissues around it - endo/peri/epineurium)
- Clinical signs/symptoms: Sensory & motor deficits, POS+ TInel, EMG decreased nerve conduction
Neurotmesis:
- Prognosis
- Healing time
- Cause
- Clinical signs/symptoms
- Prognosis: BAD
- Healing time: Does not heal without surgery
- Cause: Laceration
- Clinical signs/symptoms: Complete functional loss
Axonal regeneration and remyelination begins how soon post-repair of a nerve injury?
As early as 2-3 wks
What are the order of return for sensation post-nerve repair
1) PAIN
2) Vibration, proprioception, motor function
Rate for axonal regrowth
1mm/day
Outcomes of nerve repair better for young or old?
Young!!
NOTE: Adults will have some sort of deficit, likely due to brain reorganizing tasks as soon as it notices a deficit
Presentation of median nerve traumatic injury -
PROXIMAL
Sensation: deficits in volar thumb-radial 1/2 of ring finger
Motor deficits: PT, FCR, PL, FDP (index/middle), FPL, LOAF muscles (lat lumb, OP, APB, FPB)
Presentation of median nerve traumatic injury -
DISTAL
Sensation: deficits in volar thumb-radial 1/2 of ring finger
Motor deficits: Weakness of LOAF muscles (thenar eminence) causing difficulty with opposition and pinch
Ulnar nerve bifurcates at Guyon’s canal into which nerves?
1) Superficial sensory branch
2) Deep motor branch
Presentation of ulnar nerve traumatic injury -
HIGH
Sensation: deficits in volar/dorsal 1/2 ring and small finger
Motor deficits: FCU, FDP (ring and small finger), hypothenar, dorsal/palmar interossei, medial lumbricals, AP, FPB (deep head)
Presentation of ulnar nerve traumatic injury -
LOW (proximal to ulnar tunnel)
Sensation: ONLY volar ulnar aspect of hand (dorsal sensory split posteriorly before wrist)
Motor deficits: Same as high except for NO FCU and FDP
Presentation of ulnar nerve traumatic injury -
LOW (distal to ulnar tunnel/bifurcation - DEEP Branch)
Sensation: None (hint: deep motor branch)
Motor deficits: hand intrinsics
Presentation of ulnar nerve traumatic injury -
LOW (distal to ulnar tunnel/bifurcation - SUPERFICIAL Branch)
Sensation: Volar-ulnar aspect of the hand
(hint: superficial sensory branch)
Motor deficits: Not common, can be some in palmaris brevis
What injuries are commonly associated with radial nerve injuries
Humeral shaft fx or elbow dislocations
Presentation of radial nerve traumatic injury -
PROXIMAL to bifurcation
Sensation: Radial side of hand including dorsal thumb/index/middle
Motor deficits: Anconeous, brachioradialis, all wrist/thumb/finger extensors (“Wrist drop”)
Presentation of radial nerve traumatic injury -
DISTAL to bifurcation = Superficial sensory branches
Sensation: Radial side of hand including dorsal thumb/index/middle
Motor deficits: NONE
Presentation of radial nerve traumatic injury -
DISTAL to bifurcation = PIN
Sensation: NONE
Motor deficits: all wrist/thumb/finger extensors (can have some wrist extension (strong radial deviation) d/t ECRL branching off nerve prior to bifurcation)
Radial nerve bifurcates in forearm into which 2 nerves
1) PIN
2) Superficial sensory nerve
Good or bad: use of ice on nerve repairs?
Controversial - if applied at or distal to repair = slows nerve conduction and may harm insensate tissues
2 phases of Sensory re-education
- When to start
- brief overview
Phase 1: Starts immediately, maintain cortical hand map in the brain, use mirror therapy
Phase 2: Starts after touch localization is present, performs shape/texture/object identification
Which should happen first: Desensitization vs sensory reeducation
Desensitization
Carpal Tunnel Syndrom CPR:
1) Shaking hands for symptom relief
2) Wrist-ratio index greater than .67
3) Symptom Severity Scale score >1.9
4) Decreased thumb sensation
5) Age greater than 45 years
How to assess the severity of nerve compression in carpal tunnel syndrome?
Tinel’s sign, sensory threshold testing, and 2PD
If inconclusive = electrodiagnostic studies can be helpful
Is PT indicated in post-op carpal tunnel release?
No, unless there’s complications
When is surgery indicated in carpal tunnel syndrome?
When severe or failure to improve after non-surgical management
Surgery results are good in majority of patients post-CTR
Ulnar tunnel syndrome involves what canal?
Guyon Canal
Are CTS and UTS related?
Not directly, BUT high percentage (85%) of people with idiopathic UTS ALSO had CTS
Symptoms of ulnar tunnel syndrome
Pain, N/T, weakness in ulnar distribution of hand, may have clawing (ring/small fingers), intrinsic muscle wasting, atrophy in thumb web space
Does UTS cause a + Allen’s test?
It can be + if there is arterial involvement
Is surgery or non-surgical management better for UTS?
In mild cases WITHOUT motor loss = PT
In cases WITH motor loss = Surgery
Is PT common post-UTS release?
No, unless there are complications
Is PT indicated in post-op radial nerve release?
No, unless there are complications
What is the first sign of nerve regeneration (test-wise)?
+ Tinel’s test
Then progress to pin prick and 2PD
Of all types of scaphoid fractures (displaced, unstable, proximal pole, waist or mid-pole fx) which is least likely to require surgical fixation?
Waist or mid-pole
D/T prevalence of non-union or delayed union, unstable and displaced are an absolute MUST. There is limited vascularity at the PROXIMAL pole of the scaphoid leading to need for surgical fixation
Post-ORIF distal radius fx with volar plate (2wks), what should be the goal of PT?
Achieve full tendon excursion and a full fist
Yes, A/PROM is important, but finger mobility is MOST
