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MSK > Wrist & Hand Complex > Flashcards

Wrist & Hand Complex Flashcards

1
Q

Colles Fracture

Description & Epi & Etiology

A

Distal radial fracture resulting in dorsal displacement
- Complications include compression neuropathy (most commonly the mediam nerve), CRPS, & arthritis

Epi:
- Fall on outstretched hand (FOOSH) - dorsal angulation

Epidemiology:
- More common in osteoporotic women
Low bone density - radius is most likely to fracture

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2
Q

Colles Fracture: S/S

(6)

A
  1. “Dinner fork” Deformity
  2. Dorsal wrist pain & tenderness
  3. Swelling - compression of median nerve
  4. May present with bruising
  5. May present with paresthesia (if median nerve is affected)
  6. Difficulty lifting & grasping
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3
Q

Colles Fracture: Intervention

2 Types

A

Medical Management:
Immobilzation:
- Stable: cast (thumb spica) - closed reduction = reduced it internally w/o Sx = reduces wound healing requirement & chanve of infection
- Unstable/ displaced: ORIF

PT Management (post-mobilization)
- Mobilization - everything above & below the fracture - everything except POR/SUP - could delay healing b/c bones are moving
- Strengthening - progressively INC ROM, begin applying load (unload - load)

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4
Q

Complex Regional Pain Syndome (CRPS)

Characteristics (2 Types) & Epi & Etiology

A

A chronic pain disorder caused ny sympathetic nervous system (SNS) malfunction & is characterized by pain that is out of proportion to the orginal insult or injury

CRPS Type I:
- Occurs after injuy to tissue - mm/tendon/ligament/bone
- Formerly known as Regional Sympathetic Dystrophy (RSD)

CRPS Type II:
- Occurs after injury to nerve
- Formerly known as Causalgia

Epi:
- F>M

Etiology:
- Unknown
- Symptoms usually develop in assocation with an injury to the affected area
Persistent pain that is severe - more than the injury itself

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5
Q

Complex Regional Pain Syndome (CRPS):
S/S

(6 + 6)

A
  1. Severe pain (commonly burning)
  2. Sensory abnormalities - allodynia &/or hyperalgesia
  3. Abnormal blood flow (vasomotor changes)
  4. Anormal sweating (sudomotor)
  5. Abnormal motor function - weakness, poor coordination, stiffness > HALLMARK (even before they have edema)
  6. Trophic changes
    - Colour changes (mottled, pink, red, cyanotic, or pale)
    - Temperature change (warm/hot or cold)
    - Edema - HALLMARK
    - Shiny taut skin
    - Abnormal hair or nail growth
    - In late stages, osteoporosis may develop
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6
Q

Complex Regional Pain Syndome (CRPS):
Clinical Course

3 Stages

A

Stage 1: Acute/ Reversible Stage
- Typically begins several days after injury or insidious over several weeks
- Characteristics: pain, hyperhidrosis (excessive sweating), warmth (vasodilation), erythema, rapid nail growth, edema in the distal extremity

Stage 2: Dystrophic or Vasoconstriction (ischemic) Stage
- Typically begins 3 months after the inital injury & lasts for 3-6 months
- Characteristics: burning pain, sympathetic hyperactivity, hyperesthesia excerbated bu cold weather, mottling & coldness, brittle nails, and osteoporosis

Stage 3: Atrophic Stage
- Typically begins 6 months - 1 year after injury & lasts for months or years
- Characteristics: pain either decreasing or becoming worse, severe osteoporosis, mm wasting & contractures
No manips - risk of fractures
Can be a long lasting, chronic condition

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7
Q

Complex Regional Pain Syndome (CRPS):
Interventions

A

PT Management:
1. Education
2. Mobility
Early ROM
Tendon gliding: table top> straight fist > claw ahnd > full fist & go through different mvmt of the hand
Nerve mobilization
3. Encourage ADLS MAJOR: use hand - encourage to use hand even if it hurts (as tolerable) - traini body to dampen response - no threat
4. Compressive loading: putting outstretched hand on table > progress to WB
5. Distraction
6. Desensitization: diff textures & feels to improve tolerance - soft > coarse (different sensory inputs)
7. Edema Control
Elevate
Compression
Retrograde massage
8. Modalites
TENS - sensory input & INC intensity - helps w/ training to tolerate more
US
Ice
9. Mirror Therapy: plastic changes in motor/sesnroy cortex - where it is “SMUDGED” - correlation b/t chronic pain & smudging in cortices
GMI (Graded Motor Therapy)
10 Aerobic activity: improves total body circulation & releases endorphins

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8
Q

Immobilization: Warning Signs & Precautions

(5)

A
  1. Increase pain - CRPS
  2. Cast tightness - INC edema - S/S of CRPS?
  3. Cast looseness - not stabilizing segement
  4. Changes in surrounding skin colour/ sensation - could be CRPS &/or nerve/blood vessels that are compressed
  5. Increased swelling
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9
Q

Immobilizations: DOs & DONTs

6 + 2

A

DO:
1. Maintain ROM of joints above & below
2. Check skin integrity above & below cast
Inspecting for nerve/vessel/CRPS complications
3. Check capillary refill
4. Educate patient on how to reduce swelling - RICE
5. Educate patient on warning signs/precautions
6. Remove any tight jewellery

DONT:
- Stick things inside of the cast (ie stick to stratch)
Could develip an infection - cause skin abrasions
- Get the cast wet

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10
Q

Scaphoid Fracture

Description & Epi & Etiology

A

A fracture of the scaphoid bone
- The scaphoid bone is the most comonly factured carpal bone
- Complications include avascular necrosis, nonunion of fracture, and arthritis (< take load in a different way - could be excessive which leads to arthritis)
AVN - MUST be concerned about this - sometimes x-ray does not pick it up - may need a MRI or bone scan based on symptoms

Epi:
- Yound males (high risk activities)
- MVA - front on collison w/ hand on wheel

Etiology:
- Fall on outstretched hand (FOOSH)
Same MOI as Colle’s #
Older pop- weak radius - so radius is more likely to give whereas younger pop - radius is strong - not going to fracture so what gives is the scaphoid
- MVA (high force hyperextension)

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11
Q

Scaphoid Fracture: S/S

(4)

A
  1. Radial side wrist pain
  2. Tenderness in anatomical snuff box (EPl &EPB)
  3. May have swelling in anatomical snuffbox
  4. Pain w/ longitudinal compression of thumb - pressure is getting driven into scaphoid
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12
Q

Scaphoid Fracture: Intervention

2 Types

A
  1. Medical Management
    Immbolization
    - Stable: cast (thumb spica)
    - Unstable/displaced: ORIF
  2. PT Management (post-mobilization)
    - Mobilization - AROM/PROM, carpal mobilization if indicated
    - Strengthening
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13
Q

De Quervain’s Tendosynovitis

Description & Etiology

A

Painful inflammation of the sheath (synovium) surrounding the tendons of the 1st dorsal compartment (Abductor pollicis longus & Extensor pollicis brevis)

Etiology:
1. Chronic overuse: repetitive wrist & thumb mvmt
Ie. Golfing, carpentry, office work, gripping, wringing objects
2. Direct trauma (rare): blunt trauma to the radial styloid process

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14
Q

De Quervain’s Tendosynovitis: S/S

(5)

A
  1. Radial sided wrist pain (may extend proximal &/or distal along tendons
  2. Tenderness
  3. Swelling
  4. Worse w/ wrist & thumb movements: stretching & contraction of APL & EPB
  5. May have creptius
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15
Q

Special Test: Finkestein Test

A

Place thumb into closed fist & actively UD

(+) = pain

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16
Q

De Quervain’s Tendosynovitis: Interventions

A

PT Management:
- Activity modification
- Cryotherapy
- Splinting (thumb spica)
- Gradual stretching & strengthening (as tolerated)

Medical Management:
- NSAIDS - mixed result
- Corticosteriod Injections (Very effective) - more effective than PT
- Surgical release (rare) - release retinaculum

Generally do not respond well to PT

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17
Q

TFCC Tear

Description & Etiology

A

A tear in the ligamentous & cartilaginous structures of the TFCC resulting in ulnar sided wrist pain

2 Functions:
1. Helps stabilize the area
2. Transmit load across into ulna
IF affected: radius is oging to bear more load than it typically should

Etiology:
- Compressive loads to the wrist (especially while in ulnar deviation)
May be degenerative or traumatic
- Distal radial-ulnar fracture - disrupts TFCC function

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18
Q

TFCC Tear: S/S

(5)

A
  1. Ulnar sided wrist pain
  2. May have tenderness & swelling over dorsal ulnar aspect of wrist
  3. May have clicking w/ wrist movement
    HALLMARK - one of few wrist conditions w/ clicking
  4. Painful wrist extension & UD - compresing TFCC
  5. Pain on resisted wrist extension & UD - contracting & causing compressive forces = pain)
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19
Q

Special Test: TFCC Load Test
(Sharpey’s Test)

A

Procedure:
- Grab forearm & hand - apply a compressive load through wrist
- Placing pt in UD & move into different positions (EXT > FLEX)

(+) = pain or hear a click

20
Q

Special Test: Press Test

A

Procedure:
- pt pushes up from a chair (“dip”)

(+) = pain

21
Q

TFCC Tear: Intervention

A

PT Management:
- Activity modification
- Bracing (widget) - less bulky & restricts mvmt primarily at the wrist
- Cryotherapy
- Progressive strengthening & mobility exercises when able to tolerate
Begining = immobilization (quite extensive period) - less PT indicated in the beginning

Medical Management
- NSAID
- Corticosteriod injection
- Surgery - debridement & repair - tighten ligaments

22
Q

Peripheral Neuropathy: MM Innervations

A

Median - 2 LOAF
- Lumbricals 1 & 2
- Opponens pollicus
- Abductor pollicis brevis
- Flexor pollicus brevis

Ulnar - MAFIA
- Medial lumbricals - 3 & 4
- Adductor pollicus
- Flexor digitorum profundus & flexor digit minimi
- Interossei mm
PAD = Palmer interossei - ADDuction
DAB = Dorsal Interossei - ABDuction
- Abductor digiti minimi & opponens
Hypothenar mm = flexor digiti minimi, abductor digiti minimi, opponens digiti minimi, and palmaris brevis

Radial - BEAST
- Brachioradialis
- Extensors (of wrist)
- Anconeus
- Supinator
- Triceps

23
Q

Hand Deformities D/T Nerve Lesions

2 + 1 + 1

A

Median Nerve:
Ape hand (Low lvl lesion)
- Thumb is ADDucted - inability to abduct or oppose the thumb
- Thumb is held in the same dorsal-ventral plane as D2-5
True deformity

Hand of Benediction
- Inability to flex D1-3
- D1-3 remain in extension when attempting to make a fist, only seen when actively attemptnig to flex digits (Not a true deformity)

Ulnar Nerve:
Claw Hand
- Hyperextension of MCP & flexion of IP joints of D4-5
- Does not matter if they are closing or opening fist - fingers will stay in that position
- True Deformity = mm are going unopposed

Radial Nerve:
Wrist Drop
- Inability to extend the wrist or the MCR joints of the hand
- mm of flexion are unopposed by mm of EXT
- Anatgonist are pulling into one direction

24
Q

CTS

Characteristics && EPI

A

A condition caused by localized compression of the median nerve as it passes through the carpal tunnel

Most common condition & neuropathy

Carpal Tunnel:
- A narrow passageway for tendons & the median nerve on the volar side of the hand, created by the carpal bones (floor) & the flexor retinculum (roof)
- Contents:
9 tendons total: tendon of flexor pollicus longus, 4 tendonds of flexor digitorum profundus, four tendons of flexor digitorum superficialis
Median nerve
All flexor tendons

Epi:
- F>M

25
Q

CTS: Etiology (RF)

4+ 7

A
  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
26
Q

CTS: S/S

(6)

A
  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)
27
Q

Special Tests: CTS

(8)

A
  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)
28
Q

CTS: Interventions

2 Types

A

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

29
Q

Postoperative Management for Carpal Tunnel Release Surgery

(4)

A
  • 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
30
Q

Postoperative Management for Carpal Tunnel Release Surgery:
Maximum & Moderate-Minimum Protection Phases

A

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)

31
Q

Double Crush Syndrome

(2)

A

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

32
Q

Ulnar Tunnel Syndrome

Characteristics

A

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

33
Q

Ulnar Tunnel Syndrome:
Etiology

(5)

A
  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
34
Q

Ulnar Tunnel Syndrome:
S/S

(3)

A
  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
35
Q

Ulnar Tunnel Syndrome: Special Tests

(5)

A
  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 (-)
36
Q

Ulnar Tunnel Syndrome: Interventions

A

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

37
Q

Gamekeeper’s (Skier’s) Thumb

Description & Etiology

A
  • 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

38
Q

Gamekeeper’s (Skier’s) Thumb:
S/S

4

A
  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
39
Q

Special Test: Thumb UCL Laxity or Instability Test

A

Valgus stress test (Gr.1-3)

40
Q

Thumb UCL Laxity or Instability Test:
Intervention

A

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)

41
Q

Thumb Carpometacarpal Osteoarthritis

Description & Epi & Etiology

A

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

42
Q

Thumb Carpometacarpal Osteoarthritis:
S/S

(6)

A
  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
43
Q

Special Test: Grind Test

A

Axial compressionn while rotating

(+) = pain

44
Q

Thumb Carpometacarpal Osteoarthritis:
Interventions

A

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

45
Q

Finger Deformities

(8)

A

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

MSK (13 decks)

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