Wrist & Hand Complex Flashcards

Question

CTS: Etiology (RF) | 4+ 7

Answer 1

1. Typically, insidious onset 2. Repetitive hand movements (typing, assembly line work) 3. Vibrations (power tools) 4. Assocaited conditions: - RA & other inflammatory conditions - Colles' fracture - inflammation & swelling > compress - Lunate subluxation - move forward & encroaches on the space - Hypothyroidism - excess fluid retention - Pregnancy (typically seen in 2nd trimester) - excess fluid retention *likely to see bilaterally w/ excess fluid conditions* - DM - excessive fluid retention - Obesity - 2 reasons: tissue crowding the area (larger) & water retention

Answer 2

1. Paresthesia & pain in median nerve distribution of the hand 2. Worse w/ sustained or repetitive wrist movement 3. Nocturnal numbess & pain (INC at night) 4. Relieved by "flicking" wrist 5. Weakness & cluminess in hand DEC grip strength Frequently dropping things 6. In severe cases: atrophy of thenar eminence & first 2 lumbricals (essentially all mm innervated by it)

Answer 3

1. Tinel's Test: palpate carpal bones (palmer & dorsally - flex/ext wrist to landmark) 2. Phalen's test: wrist flexion w/ compression 3. Reverse Phalon's - prayer pose 4. Carpal Compression Test: pressing hard on carpal bones to reproduce S/S 5. Resisted APB: only mm exclusively innervated by the **ulnar nerve** (MMT) 6. ULTT median nerve bias: decreased excursion on affected side 7. Nerve conduction velocity test: can show false (-) - often misses CTS but can also have false (+) 8. Electromyography (EMG)

Answer 4

PT Management: - Activity modification - Splinting wrist in neurtal position = NOT stretched or compressed - Mobility Techniques Nerve mobilization Tendon-gliding exercises (gentle) Joint mobilization (if there is restricted joint mobility) - Improve mm performance (no provocation of symptoms) Gentle multi-angle mm setting Progress to resistance & endurance Fine-finger dexterity Medical Management: - NSAID - Corticosteriod injections - Carpal Tunnel release surgery - cut the flexor reticulum to create space

Answer 5

- Wrist may be immobilized for **7 to 10** days post-op in slight **extension** with the fingers free to move - When allowed splint may be removed for therapy - AVOID active wrist **flexion** past neutrral & **finger flexion** w/ wrist flexed during the first **10 days** post-op - May have pain in thenar & hypothenar eminences as a result of release & flattening of **palmar arch** **This is known as PILLAR pain**

Answer 6

**Maximum Protection Phase** Interventions: 1. Patient education 2. Wound management 3. Control of edema 4. Control of pain 5. Active tendon-gliding exercises 6. Nerve-gliding exercises 7. Upper-extremity exercises - Active finger & thumb mvmt in all directions w/ the wrist stabilized in moderate wrist extension - Active wrist extension - Active radial & ulnar deviation of the wirst w/ the in slight extension - Pronation & supination of the forearm - All elbow & shoulder movemet **Moderate & Minimum Protection Phase:** - Sutures are usually removed around post-op day 10-12 - Return to full activity by **6-12 weeks** - Residual impairments may include weakness, sensory deficits, persistent edema, limited ROM, hypersensitivity, and pain Interventions: 1. Scar tissue mobilization 2. Progressive stretching & joint mobilization 3. Progressive strengthening Begin isometrics 4 weeks post-op Grip & pinch exercises 6 weeks post-op 4. Dexterity exercises 5. Sensory re-education (ie desenitization)

Answer 7

Nerve compression at more than one site along the same nerve Proximal compression or pathology of a nerve is suggested to increase vulnerability of a nerve at a distal point

Answer 8

A condition caused by localized compression of the ulnar nerve as it passes through Guyon's canal - Also known as Guyon's canal syndrome Guyon's Canal - A semi-rigid can created by the connection between the pisiform bone & the hook of the hamate - Also known as the Pisohamate canal

Answer 9

1. Trauma: FOOSH w/ or w/o # of hook of the hamate 2. Chronic pressure: cycling *Especially going downhill = leaning forward & CoG is forward & putting a lot of pressure through the wrist* 3. Space-occupying lesions: ganglion cyst 4. Extended use of crutches - constant pressure & compression 5. Higher risk amount cyclist, baseball catchersm karate players, and use of jackhammers

Answer 10

1. Paresthesia & pain in ulnar nerve distribution of hand 2. Motor weakness of mm inervated by ulnar nerve DEC Grip strength Fatigue w/ repetitive or sustained activities 3. In severe cases: claw hand & atrophy of hypothenar eminence

Answer 11

1. Froment's Sign (ulnar nerve palsy) 2. Guyon canal compression test 3. Tinel's test over Guyon's canal 4. ULTT ulnar nerve bias 5. Nerve conduction velocity test - lots of false (-)

Answer 12

PT Management: - Activity modifcation - **Cock-up** Splint - puts wrist into extension - Ergonomic & padded equipment & tools - ie padded handlebars & gloves - Frequent changes of hand positions on handlebars - limit prolonged stress - Nerve mobilization Medical Management: - NSAID - Corticosteriod injections - Cuyon's canal release surgery

Answer 13

- Sprain of the ulnar collateral ligament (UCL) of the thumb - Occurs with a **valgus** force is applied to the MCP joint of the thumb Etiology: - Occurs when a valgus force is applied to the MCP joint of the thumb - **FOOSH w/ thumb sticking out** - Commonly seen in gamekeepers (killing rabbits), skiers & volleyball players

Answer 14

1. Pain & tenderness at base of thumb on ulnar side of the MCP joint 2. Pain with movement - worse with abduction & extension 3. Decreased pinch & grip strength 4. Swelling & discolouration at base of thumb

Answer 15

Valgus stress test (Gr.1-3)

Answer 16

PT Management: - Activity modification - Splint MCP in slight flexion - Gentle ROM as tolerated - Strengthening (theraputty) Medical Management: - Surgicial repair (complete tear or dosplaced avulsion fracture)

Answer 17

Osteoarthritis of the CMC of the thumb **Most common form of OA in the hand** Epi: - F>M - Advanced age Etiology: - Repetitive movements - Joint injury

Answer 18

1. Pain at base of thumb (CMC) 2. Worse at night, w/ changes in weather & w/ overuse *Changes in barometric pressures in the atmosphere* 3. Tenderness at CMC 4. Decreased pinch & grip strength 5. Muscle wasting at thenar eminence - disuse b/c of pain 6. Possible instability (sublux or dislocation) - May lead to hyper-extension deformity of MCP - Joint space narrowing = space dec so ligaments are no longer taut & lose effectiveness in restaining mvmt

Answer 19

Axial compressionn while rotating (+) = pain

Answer 20

PT Management: - Activity modification - Splinting - temporary immobilization - Larger grip handles = less stress - AROM w/in tolerable limits - Strengthening Wax + ICE = analgesic affect Medical Management: - NSAIDS - Corticosteriod injection - 1st CMC Athroplasty - remove trapezium bone & relaced it w/ something else - 1st CMC Athrodesis - fuse bones - reduce ROM but DEC pain

Answer 21

Dupuytren's Contracture - Contractures of the plantar fascia - Fixed flexion deformity of the MCP & PIP joints - Usually seen in **D4-D5** - Skin is often **adherent to the fascia** Typically seen in males Dx through S/S - see an outline on palmar side Sx - splint in EXT afterwards Trigger Finger - Thickening of the flexor tendon sheath (Notta's nodule) *Nodule is going through a narrowed (thickened) canal* - Results in tendon sticking, catching, or locking when attempting to flex the affected finger - More common in **D3-D4** - Often associated with RA- d/t inflammation Mallet Finger Deformity - Flexion of the DIP at rest - flexor tendon is unopposed - Due to **rupture** or avulsion of the extensor tendon at its insertion in the distal phalanx from **hyperflexion** injury - Typically treated by splinting the DIP straight for 6-8 weeks Bouchard Nodes - Osteoarthritis enlargement of the PIP on the dorsal surface Heberden Nodes - Osteoarthritic enlargement of the DIP on the dorsal surface Swan Neck Deformity Boutonnere Deformity Ulnar Drift