Wrist-Hand Conditions Flashcards
Carpal Tunnel Syndrome
What is the MOI?
Median nerve compression neuropathy
- this happens under the transverse carpal ligament at the wrist
Carpal Tunnel Syndrome
What is it also associated with?
With pregnancy, diabetes, trauma, tumor in the carpal tunnel
Carpal Tunnel Syndrome
What are the landmarks of the carpal tunnel?
On the palmar aspect which is bounded by scaphoid, trapezium, capitate, hook of hamate, pisiform and transverse carpal ligament
Carpal Tunnel Syndrome
What are the subjective findings?
- C/o of numbness in the median nerve, specifically tips of the first 3 fingers
- C/o of pain in the forearm and wrist
- Sx may wake up from pain
- Wrist flexion is uncomfortable
Carpal Tunnel Syndrome
What are the objective findings?
Thenar atrophy can be seen if it’s advanced
Carpal Tunnel Syndrome
What are the confirming/special test for a dx?
Phalen, tinel and carpal compression test
Plain radiographs can be done for bony abnormalities
EMG/NCS can help with differential dx
Carpal Tunnel Syndrome
What is the main intervention?
Splinting
tf that’s it???
De Quervain Tenosynovitis
What is the MOI?
Repetitive or unaccustomed use of the thumb
De Quervain Tenosynovitis
What structures are inflammed?
Extensor and adbuctor tendons of the thumb extensor pollicis longus and abd. pollic longus
De Quervain Tenosynovitis
What is the subjective findings?
Wrist pain on the radial side
Hard time grasping and gripping
De Quervain Tenosynovitis
What are the objective findings?
Possible swelling @ radial styloid process
Palpation = pain @ retinaculum of radial styloid
De Quervain Tenosynovitis
What are the special test done?
Finkelstein’s
WHAT test
Eichoffs
De Quervain Tenosynovitis
What is the primary goal of interventions?
reduce inflammation
prevent adhesions from forming
prevent recurrent tendonitis
De Quervain Tenosynovitis
If steroid injections are in play, where would it be injected?
Into the fibrous sheath of the first dorsal compartment
De Quervain Tenosynovitis
What can assist to decrease inflammation?
Electrotherapy and thermal modalities
De Quervain Tenosynovitis
What are some other interventions that PTs can focus on?
Gentle AROM for short periods –> isometric –> concentric
Grasping and releasing small things
Education on thumb spica splints
De Quervain Tenosynovitis
What is the overall prognosis of the dx?
getting treatments within 6 months have very good outcomes
90% of non-severe cases can have relief with conservative mangements
Duprytrens
What is the MOI?
Fibroproliferation disease of the palmar fascia
- usually genetic and environmental
- often self limiting
Overgrowth of connective tissues and scarring = fibroproliferation
Duprytrens
What population is affected more?
Males
Duprytrens
What are the interventions use?
- Surgical approaches (collage-nase clostridium histolyticum)
- injection and manipulation
- needle aponeurotomy
- percuatenous
- needle fasciotomy
- fasciectomy
A LOT OF CRAP NOT FOR US
What is the most common wrist injury for all age groups?
Fracture of the distal radius
Fractures
Colles Fx
Most comon type!!
Distal radius fx fragment - tilted upward (dorsally)
Fractures
Smith Fx
Distal fragments - tilted downward (volarly)
Fractures
Barton Fx
Intra-articular fx associated with sublux of the carpus (forward or back)
- also have a displaced articular fragment of the radius
Fractures
Chauffeurs Fx
Oblique fx through the base of the radial styloid
Fractures
Die-punch Fx
Depressed fx of the articular surface that is opposite the lunate or scaphoid bone
Fractures
What are the subjective findings?
Acute pain
tenderness
swelling
deformity of the wrist
hx of FOOSH
Fractures
What are the objective findings?
- swelling, deformity, discoloration around the wrist and distal radius
- may have associated skin injury and bleeding
- may have loss sensation in the median, radial or ulnar nerve
- possible decreased circulation to the hand
Fractures
What are the confirming tests?
imaging (hello obvious????) - AP and lateral
Fractures - Intervention
What are the conservative interventions with immobility?
AROM:
shoulder in all planes
elbow flexion and extension
finger flexion and extension
Fractures - Intervention
What must finger exercises include?
Isolated MCP flexion
complete flexion (full fist)
intrinsice minus fisting (MCP extension with IP flexion)
Fractures - Intervention
After immobilization, what is limited?
extenion and supination needs mobilization
Fractures - Intervention
After immobilization, what are initated?
AROM exercises of:
- wrist flexion and extension
- ulnar and radial deviation
Fractures - Intervention
When is PROM performed?
performed according to the MD protocol
- right away or after 1-2 week
Fractures - Intervention
What are some strenghtening exercises adapted?
AROM ex for wrist and forearm –> strength with light weights and tubes with putty for grip strength –> functional ex
Fractures
What is the prognosis?
Typically uncomplicated course
Occasional malunion or posttraumatic wrist arthritis
What is the most comon fractured carpal bone?
Scaphoid
Fractures of Scaphoid
What is the population that this mostly affect?
young male adults
Fractures of Scaphoid
Where does scaphoid span?
The distal and proximal rows of the carpals and consequently vulnerable to FOOSH
Fractures of Scaphoid
What are the subjective findings?
- Hx of a FOOSH type injury
- C/o of dorsal wrist pain (especially with gripping)
- Tender @ anatomical snuffbox
Fractures of Scaphoid
What are the objective findings?
- tender snuffbox
- decreased AROM of wrist
- Decreased grip strength
- normal neuro exam
Fractures of Scaphoid
What are the confirming/special test for dx?
- possible axial compression
- often not visible on PA and lateral radiographs - so get a scaphoid or oblique view
Fractures of Scaphoid
What is the current opinion of interventions?
conservative is controversial
- no agreement on the optimum position for immobilization
Fractures of Scaphoid
What is the current management?
Currently immobilization»_space;
Fractures of Scaphoid
After immobilization, how should interventions be addressed?
Capsular pattern of the wrist!!
AROM exercises for:
- wrist flexion and extension
- radial and ulnar deviation
Do as early as possible after immobilization with PROM as well
Gamekeepers (Chronic) or Skier (Acute)
What structure is injured?
Ulnar collateral ligament
Gamekeepers (Chronic) or Skier (Acute)
What is the MOI?
Injury or repetitive use
disrupted ligament = instability of MCP joint
Decreased functioning for pinching and opposition
Gamekeepers (Chronic) or Skier (Acute)
What is the subjective findings of the acute phase?
Pain and swelling @ ulnar side of MCP joint
Gamekeepers (Chronic) or Skier (Acute)
What is the subjective findings of the chronic phase?
C/o of pain, weakness or loss of stability
Gamekeepers (Chronic) or Skier (Acute)
What is the objective findings?
- local tenderness and swelling @ ulnar side of MCP joint
- pain or lots of motion with valgus stress test of UCL
- impaired MCP joint flex and ext
- Decreased pinching strength = instability or acute pain
Gamekeepers (Chronic) or Skier (Acute)
What is the confirming/special test to determine dx?
MCP stability tested in full extension and @ 30deg of flexion
allows to stress the accessory collateral liament and UCL
Gamekeepers (Chronic) or Skier (Acute)
How long does grade 1 and 2 immobilized?
In a thumb spica cast for 3 weeks + splinting for 2 weeks
Gamekeepers (Chronic) or Skier (Acute)
When is AROM initiated?
Flexion and extension exercises start @ 3 weeks –> strengthening @ 8 weeks
Gamekeepers (Chronic) or Skier (Acute)
What is avoided for the first 2-6 weeks?
to avoid any abduction stress to the MCP
Gamekeepers (Chronic) or Skier (Acute)
How are grade 3 tears treated?
any tears and displaced bony avulsions are treated surgically and immobilized
Gamekeepers (Chronic) or Skier (Acute)
What is the postsurgical rehab involving?
thumb spica cast or splint for 3 weeks + 2 weeks of splinting
rehab is then like grades 1 and 2
Except during active flexion and extension
OA of the thumb
What is the common population affected?
More common women
- usually around after 40 y.o
OA of the thumb
What is the possible hx to point you to OA?
Past fx or other injuries to the joint = more likely to develop
OA of the thumb
What are the sx?
This a long one
- Pain with gripping or pinching
- swelling and tender @ base of thumb
- aching discomfort after long use
- loss of strength with gripping or pinching
- out of joint look
- bump over the joint
- limited motion
OA of the thumb
What is ligament reconstruction?
stabilizes the CMC joint by taking off a portion of the damanged ligament then replacing it with a their own wrist flexor tendon
OA of the thumb
Who can benefit from a ligament reconstruction?
adults with no cartilage loss where the sx result from joint laxity
OA of the thumb
What are the pros of ligament reconstruction?
people with very early or pre-arthritis experience for good to excellent pain relief
OA of the thumb
What are the cons of ligament reconstruction?
the procedure stabilizes the joint BUT doesn’t repair the damaged cartilage or bone
OA of the thumb
What is the most comon surgery?
Ligament reconstruction and tendon interposition (LRTI)
OA of the thumb
How is the LTRI procedure performed?
the arthritic joint surface removed and then replaced with tendon that keeps the bones separated
- surgeons will take off part of the trapezium
OA of the thumb
Who does LTRI help with?
Helps adults with mod to severe arthritis with pain and hard time pinching or gripping
OA of the thumb
What are the pros of LTRI?
By removing the whole trapezium takes out the arthritis coming back
OA of the thumb
What is the success rate of LRTI?
96% success rate
last at least 15-20 years
OA of the thumb
What are the cons of LRTI?
Has a long and painful recovery
- 4 weeks of wearing a thumb cast
- decreased pinch strength
OA of the thumb
How is the total joint replacement (TJR) procedure completed?
removes all or part of the damanged thumb joint and replaces it with an artificial implant
OA of the thumb
Who can benefit fom TJR?
Metal joint replacements are an option for older patietns with few functional demands since it will fail with heavier use
Spacers = lower fail rates but higher complication rates
OA of the thumb
Who are spacers reserved for?
For younger or very active adults with more advanced disease
OA of the thumb
What are the pros of TJR?
Less invasive surgery (since no grafting) with a faster recovery and rehab
some impants can be done without taking off trapezium to preserve healthy tissues and improve strength
OA of the thumb
What are the cons of TRJ?
Spacers have high complication rates for some patient’s that includes bone damage, persistent pain and inflammation
OA of the thumb
What is the procedure method for fusion?
takes pain away by fusing bone together
- creating a socket by hallowing out the thumb’s MT bone –> shaping the trapezium into a cone that fits inside the socket
- a metal pin holds bones together to keep alignment and prevent movement while bones fused
OA of the thumb
Who can benefit from fusion?
- Younger, active patients who have posttraumatic arthritis or physically demanding jobs
- people with RA
- those who have done thumb surgery but no sx relief
OA of the thumb
What are the pros of fusion?
makes a stable, pain free thumb that can grasp and pinch
OA of the thumb
What are the cons of fusion?
Has relatively high complication rate
- can damage nearby joint and causes loss of mobility in the CMC joint
- ability to lay the palm flat and put the fingers and thumb together in a cone shape
