wrist/hand

Question 1

acute management principles of loose hand/wrist

Answer 1

protect injury
control pain and inflammation
control/eliminate edema
restore full painfree ROM in entire kinetic chain
prevent ms atrophy
minimize detrimental effects of immob
scar management
maintain fitness

Question 2

Loose: midcarpal instability

Answer 2

insufficiency of the intercarpal ligaments, may not be symptomatic, and pt may be able to sublux and reduce the joint at will

clunk can be felt as distal row of carpals jumps back into place at end of ulnar deviation

Question 3

DISI

Answer 3

Scapholunate instability –(DISI –lunate migrates dorsally)
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

Question 4

VISI

Answer 4

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

Question 5

Loose: acute management

Answer 5

swelling following acute sprain, with degee of swelling corresponding to severity of injury

immob 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 thru out the day

after splint d/c: AROM, taping to provide support, decrease pain, strengthen

Question 6

exercise considerations for hypermobility/instability

Answer 6

functional oblique motion: from radial extenion to ulnar flexion

dart throwing motion: less scaphoid and lunate motion than during pure flex, ext

end range supination stressess the TFCC

Question 7

secondary consequence of instability

Answer 7

transient neuro (median n) symptoms due to compromise of carpal tunnel
- loss of the transverse carpal arch

Question 8

Loose: UCL sprain

Answer 8

skier’s thumb, gamekeeper’s thumb, break-dancer’s thumb

• apply force to stress UCL: tested at 0- and 30- degrees flexion

+ test is pain and extreme laxity
angulation 15 dg greater than uninvoluved side + 30-35 dg of motion - need surgery

risk of STENER lesion (torn UCL gets entraped beneath adductor pollicus aponeurosis)

Question 9

CMC OA: loose

Answer 9

distinguishing feature = loss of retroposition

splinting, stretch adductor pollicus, avoid adduction positions

Question 10

rheumatoid diseases/ family RA

Answer 10

chronic, progressive (flare-remitting), systemic, autoimmune

affects entire body; bilateral, symmetrical

acute stage: pain, swelling, warmth, limited motion (commonly: MCP, PIP, wrist jt)

Jt inflammation –> soft tissue damage –> ms weakness and imbalance –> pain, stiffness, jt damage, instability, deformity
- ulnar deviation of the MCP joints
- Boutonniere deformity
- swan-neck deformities of digits

Question 11

ulnar drift

Answer 11

happens in the MCP first then wrist

ulnar drift and palmar subluxation (pronation) due to damge to collateral ligaments and extensor mechanisms

ulnar deviation of hand due to weakening of capsuligamentous structures of the MCP and “bowstring effect” of extensor communis tendon

Question 12

causes of ulnar drift

Answer 12

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 tendonds

Question 13

boutonniere deformity (button hole)

Answer 13

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)

Question 14

intervention for boutonniere deformity due to sports trauma*

Answer 14

4 weeks in a splint that holds PIP jt in full ext, while allowing the DIP to flex

gentle AROM exercises can begin for flexion and extension of the PIP joint at 4-8 weeks, w the splint being reapplied b/w exercises

general strengthening usually begins at 10-12 weeks. for a return to competition an additional 2 months is required

Question 15

swan neck (recurvatum) deformity

Answer 15

flexed MCP and DIP
extended PIP

least functional of ALL deformities

contracture of instrinsics 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 mech

Question 16

what does swan neck lead to

Answer 16

an increaed extensor force across the PIP joint w 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 DIP joint

Question 17

intervention for swan neck

Answer 17

application of a small figure-of-8 splint that prevents the PIP joint from fully extending, while still allowing full flexion range

Question 18

RA interventions

Answer 18

stabilize the wrist

control inflammation

focus on joint system not isolate joints

patients with STIFF joints bc of scarring do poorly after soft-tissue surgery. Require aggressive and sustained therapy, often for 3-4 months

patients with joint LAXITY require careful intervention and control of ROM and the direction of motion by the use of splints for many months after surgery

Question 19

Stiff diagnosis

Answer 19

OA
post-immob
post-op
RA

Question 20

related pathologies and etiology of sympotms - stiff joint hypomobility

Answer 20

RA/JRA, DJD, trauma, dislocation, fx, surgery

contracture and adhesion post-immob

Question 21

post-fx/trauma: non op management protection phase

Answer 21

education the pt

reduce effects of inflammatino or synovial effusion and protect the area (frequent controlled movement to reduce contracture; grade 1-2 mob)

maintain soft tissue and joint mobility (passice, assisted, AROM, multiple angle ms setting exercises, tendon gliding exercises)

maintain integrity and function of related areas (elevate swelling

control pain and protect joints (splint, pt ed, activity mod)

Question 22

post-fx/trauma non op managment: controlled motion phases

Answer 22

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

Question 23

post-fx/trauma non op management - return to function phase

Answer 23

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

Question 23

indications for surgery - stiff wrist arthroplasty

Answer 23

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

Question 23

wrist arthroplasty - post op management

Answer 23

Immobilization
Exercise
*** Stability of the wrist takes priority over mobility (only 35 dg flex is needed)

Question 24

wrist arthroplasty - outcomes

Answer 24

pain relief

wrist and forearm ROM, strength, function

Question 25

total joint wrist arthroplasty - principles

Answer 25

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

Question 26

stiff wrist/hand management principles

Answer 26

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

Question 27

example of painful wrist

Answer 27

CTS (median n), AIN, pronator syndrom
- ulnar n entrapment (cubital tunnel or guyon’s tunnel)

DeQuervains tensosynovitis

RA

Question 28

tendinopathy - etiology and classificatoin

Answer 28

Reactive vs degenerative
- Inflammation present
- Onset and duration
-Tendinitis resolves more quickly
-Tendinosis can become more reticent to change

Load
-too much or too little load bearing capacity

• rest activity cycle
• decrased collagen integiry and vascular uspply w increased age

Question 29

principles of tendon loading

Answer 29

Progressive loading of tendon facilitates collagen synthesis
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

Question 30

carpal tunnel syndrome

Answer 30

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

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

pain 5/10 cut off

Question 31

presentation pattern of CTS

Answer 31

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

Question 32

CTS examination

Answer 32

Use Semmes-Weinstein monofilament testing
Use Phalen, Tinel, and carpal compression test

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

Question 33

CTS intervention*

Answer 33

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

Question 34

CTS intervention cont’

Answer 34

May perform manual therapy for the cervical spine and UE (mild to moderate CTS in the short term.)

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.

Question 35

DeQuervains tensosynovitis

Answer 35

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,

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
+ Finkelstein’s test
+ Eichoff’s test
+ WHAT test

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

Question 36

principles of tensosynovitis management

Answer 36

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