wrist/hand Flashcards
acute management principles of loose hand/wrist
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
Loose: midcarpal instability
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
DISI
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
VISI
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
Loose: acute management
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
exercise considerations for hypermobility/instability
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
secondary consequence of instability
transient neuro (median n) symptoms due to compromise of carpal tunnel
- loss of the transverse carpal arch
Loose: UCL sprain
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)
CMC OA: loose
distinguishing feature = loss of retroposition
splinting, stretch adductor pollicus, avoid adduction positions
rheumatoid diseases/ family RA
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
ulnar drift
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
causes of ulnar drift
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
boutonniere deformity (button hole)
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)
intervention for boutonniere deformity due to sports trauma*
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
swan neck (recurvatum) deformity
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
what does swan neck lead to
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
intervention for swan neck
application of a small figure-of-8 splint that prevents the PIP joint from fully extending, while still allowing full flexion range
RA interventions
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
Stiff diagnosis
OA
post-immob
post-op
RA
related pathologies and etiology of sympotms - stiff joint hypomobility
RA/JRA, DJD, trauma, dislocation, fx, surgery
contracture and adhesion post-immob
post-fx/trauma: non op management protection phase
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)
post-fx/trauma non op managment: controlled motion phases
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
post-fx/trauma non op management - return to function phase
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
indications for surgery - stiff wrist arthroplasty
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
wrist arthroplasty - post op management
Immobilization
Exercise
*** Stability of the wrist takes priority over mobility (only 35 dg flex is needed)
wrist arthroplasty - outcomes
pain relief
wrist and forearm ROM, strength, function
total joint wrist arthroplasty - principles
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
stiff wrist/hand management principles
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
example of painful wrist
CTS (median n), AIN, pronator syndrom
- ulnar n entrapment (cubital tunnel or guyon’s tunnel)
DeQuervains tensosynovitis
RA
tendinopathy - etiology and classificatoin
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
principles of tendon loading
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
carpal tunnel syndrome
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
presentation pattern of CTS
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
CTS examination
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
CTS intervention*
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
CTS intervention cont’
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.
DeQuervains tensosynovitis
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
principles of tensosynovitis management
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
