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Patho 2 > Wrist Pathologies > Flashcards

Wrist Pathologies Flashcards

1
Q

Define De Quervain’s Tenosynovitis

A

Reactive thickening (inflammation) of the tendon sheath around EPB and APL

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2
Q

Prevalence of De Quervain’s Tenosynovitis

A

Tenosynovitis can be caused by unaccustomed movement, overuse or repetitive minor trauma of the thumb; May occur spontaneously (idiopathic)

The resulting synovial inflammation causes secondary thickening of the sheath and stenosis of the compartment, which further compromises the tendon.

The first dorsal compartment (APL & EPB) and the second dorsal compartment (ECRB) are most commonly affected.

The flexor tendons are affected far less frequently.

Overuse may involve eccentric lowering of the wrist into ulnar deviation with load, e.g.

  1. Lifting heavy dishes
  2. Painting
  3. Golf
  4. Hedge trimming
  5. Pruning
  6. Wringing activity

More common in women - 1.3% vs 0.5% (male)

More commonly reported in new mothers - the way they lift their babies involves eccentric ulnar deviation

Age most commonly 40s-50s

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3
Q

Pathology of De Quervain’s Tenosynovitis

A

The extensor retinaculum contains 6 compartments which transmit tendons lined with synovium

Inflammation of synovial sheaths of EPB & APL

Swelling of the sheaths and eventual thickening as swelling becomes organised

Adhesions may develop between tendon and sheath restricting normal tendon movement

Constriction of enclosed tendons = ‘stenosing tenosynovitis’

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4
Q

Clinical presentation of De Quervain’s Tenosynovitis

A

Pain on the radial side of the wrist that can be referred to the thumb

History of unaccustomed activity

Visible swelling over distal end of radius

Tendon sheath feels thick and hard

Tenderness most acute at tip of radial styloid

Weakness of grip

Aggravated by resisted thumb extension / abduction, or by stretching the affected tendons (Finkelstein Test)

Finkelstein’s Test

  1. Patient makes a closed fist with thumb tucked inside
  2. Passive ulnar deviation is performed maintaining the wrist in a neutral position
  3. Positive: reproduction of pain
  4. Negative: uncomfortable but not painful
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5
Q

Medical management of De Quervain’s Tenosynovitis

A

NSAIDs
Corticosteroid Injection Surgery

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6
Q

Physiotherapy management of De Quervain’s tenosynovitis

A

Splinting - calm symptoms however symptoms may reappear after splint removal; To rest the fingers and thumb for a period of 3 to 4 weeks.

Load Management - increase ability of tendon to w/stand load; gentle return to activity enouraged

Education - what the issue is, reduce activities aggravating symptoms

Exercises - strengthening of APB and EPL

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7
Q

Define Carpal Tunnel Syndrome

A

Median nerve is compressed where it passes through the carpal tunnel

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8
Q

Prevalence of Carpal Tunnel Syndrome

A

Most common peripheral nerve entrapment syndrome
1 in 10 people develop carpal tunnel at some point
Female>Male - more significant difference with increasing age

Younger presentations usually have coexisting pathologies

Risk factors:

  1. Diabetes (Type I and II)
  2. Menopause
  3. Hypothyroidism
  4. Obesity
  5. RA
  6. Pregnancy
  7. Family history
  8. Female>Male 8:1,
  9. Age 40-50, chances increase after this age
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9
Q

Causes of Carpal Tunnel Syndrome

A

Oedema, tendon inflammation, hormonal changes, cysts in the carpal tunnel, repetitive manual activity can contribute to nerve compression in this area

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10
Q

Prognosis of Carpal Tunnel Syndrome

A

Depends on severity of symptoms:
Mild to moderate – respond well to conservative (mild = 6 weeks ->referred to another physio for opinion)
Severe – more likely to require surgery

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11
Q

Clinical presentation of Carpal Tunnel Syndrome

A

Begins with intermittent nocturnal Pain, paraesthesia, anaesthesia in thumb & lateral 2½ fingers, that increases in frequency, then develops into waking hours

More severe cases – weakness of median nerve innervated muscles atrophy (thenar eminence wasting)

Whole hand may become affected and pain/aching may extend up into the forearm

Can progress to difficulty with fine motor tasks - as thenar eminence muscles weakened -> loss of thumb flexion, ABD, ADD, opposition

Difficulty fine motor tasks, gripping things, often drop objects.

Prolonged and intense symptoms.

Uni or bilateral - Dominant hand tends to be worse affected.

May be unable to differentiate between hot and cold.

Aggs - physical activity

Eases - hanging arm over side of bed & shaking hand

Assessment:

Observe and palpate for tenderness, swelling, warmth, discolouration.

Sensation testing of fingers, thumb, palm using gentle touch or pin-prick is suggestive of the condition if numbness, i.e. Positive.

Hot and cold sensation testing may reveal deficiencies if positive too.

Thenar eminence muscle strength tests may reveal weakness and atrophy here may be observed. Resist thumb actions of flexion, abduction and opposition.

Tinel’s sign – tap sharply over the median nerve on the anterior aspect of the wrist (sharp tingling in fingers is positive for the condition).

Phalen’s test active flexion of the wrist(s) for up to 1 minute (sharp tingling in thumb and fingers is positive for the condition).

Differentiate with cervical spine pathology

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12
Q

Management of Carpal Tunnel Syndrome

A

Education – lifestyle modification
Load management
Splinting – night time; calm symptoms during sleep
Exercise
Corticosteroid Injection - if conservative measures are not working
Surgery - if conservative measures are not working

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13
Q

Prevalence of distal radius #

A

Commonly occurs due to FOOSH

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14
Q

Types of distal radius #

A

Colles’ Fracture – most common – extra-articular (# occurs out of joint capsule), dorsally displaced distal radius fracture; associated with dinner fork defomity

Smith’s Fracture – extra-articular, anterior displacement of distal radius

Barton’s Fracture – intra-articular fracture with associated dislocation of the RCJ

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15
Q

Medical management of distal radius #

A

Splint
Casts
K-Wires - for fixation (lasts 4-6 weeks) - inserted into bone and hook remains outside of body, allowing for wires to be removed later
Surgery - MUA

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16
Q

Physiotherapy management of distal radius #

A

Physiotherapy following period of immobilisation - involves manipulation to re-align #

Mainly to increase mobility, strength and function at wrist

17
Q

Prevalence of Scaphoid #

A

Most commonly fractured carpal bone (70% of carpal bone #)
Often from a FOOSH
Waist (80% scaphoid #) > Prox Pole > Distal pole (least at risk)
Proximal pole has poor blood supply -risk of AVN
Risk of non-union (5%)
Pain over anatomical snuffbox
Approx 25% initial scaphoid # not seen in X-ray - if in doubt patient wrist will be immobilised and X-ray repeated in 10-14 days later when its more visible

18
Q

Management of scaphoid #

A

Cast - period of immobilisation
Surgery - more severe cases require surgical fixation
Physiotherapy after immobilisation period - mainly to improve mobility, strength and function

19
Q

Prevalence of OA

A

○ Most common form of arthritis, can develop in any synovial joint.
○ Most common in knees, hips and small joints of hand.

20
Q

Medical management of OA

A

Corticosteroid Injection
Surgery - most severe cases; joint replacements (common), debridement

21
Q

Physiotherapy management of OA

A

§ Exercises for mobility and strength
Hydrotherapy - different form of exercises in hydrotherapy pool; warmer (34oC) than standard pool, providing therapeutic affect; buoyancy of pool also provides a therapeutic affect
Manual therapy
Education

22
Q

Define Rheumatoid Arthritis (RA)

A

Systemic autoimmune disease (body’s immune system attacks the joint) characterised by inflammatory arthritis with extra-articular involvement

23
Q

Pathology of RA

A

Synovium is infiltrated by immune cells.
Fibroblasts and inflammatory cells lead to osteoclast generation resulting in bone erosion and loss of joint integrity.
Systemic inflammation and autoimmunity in RA begin long before the onset of joint inflammation

24
Q

Prevalence of RA

A

○ Most prevalent in North America and Northern Europe
○ Female > Male - 2-3:1
○ Prevalence increases with age
○ Paediatric population – RA = Juvenile Idiopathic Arthritis; Idiopathic = occurs spontaneously or w/out a known cause
○ Polyarthritis of small joints of hands – PIP, MCP, RCJ
○ Other commonly affected joints – elbows, shoulders, hips, knees, ankles, MTP

25
Q

Risk factors of RA

A

Genetic Factors (non-modifiable)

Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D

26
Q

Clinical Presentation of RA

A

○ Insidious (gradual) onset over a period of months
○ Joint stiffness in the morning
○ Fatigue
○ Deformity (formed overtime due to bone erosion and loss of joint integrity)
○ Pain
○ Weakness and restricted mobility in affected joints
○ If Cx is involved it can lead to cervical instability between C1 and C2 - affecting dens and surrounding ligts = reducing stability

27
Q

Medical management of RA

A 
GOAL = symptom management 
Pharmacological management (key treatment) – Disease Modifying Anti-Rheumatic Drugs (DMARDs) 
Nutrition - help with symptom management
28
Q

Physiotherapy management of RA

A

Appropriate exercise programme to maintain mobility, strength and function for as long as possible; also to manage flare-ups
Advice and education

29
Q

Define Dupuytren Disease

A

Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis)

30
Q

Pathology of Dupuytren’s Disease

A
  • Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis) resulting in;
  • Flexion contracture of the MCP and PIP joints leading to loss of function
  • Occurs slowly, typically progresses over the course of several years; normally affects 4th and 5th fingers but can affect others
  • Commonly begins with thickening of the skin, then bands (palpable at first; only visible over time) of fibrotic tissue form in the palmar area caused by fibroblast proliferation causing collagen deposits, leading to contracture of palmar fascia (aponeurosis)
  • Eventually leading to the affected fingers being pulled into flexion.
  • Typically occurs bilaterally
31
Q

Prevalence of Dupuytren Disease

A

An inherited autosomal dominant trait

Most common in people of Northern European descent

Males > Females - difference becomes less with increasing age

Average age of onset 60, incidence increases with increasing age

Onset at an early age usually means aggressive disease

Environmental Factors – alcohol intake, smoking, manual labour, low body weight / BMI, use of anticonvulsant drugs

Associated with diabetes, epilepsy, HIV, adhesive capsulitis, cancer

32
Q

Clinical features of Dupuytren’s Disease

A

Nodular thickening, palm

Gradually extends distally

Involves ring &/or little finger

Pain, seldom marked

Bilateral, 1 more than other

Palm is puckered, nodular & thick

Flexion deformities at MCP & PIP joints

Dorsal knuckle pads may be thickened (Garrod’s pads)

33
Q

Medical management of Dupuytren Disease

A

Surgical Intervention is the mainstay of treatment; different levels of surgery depending on severity:

  1. Simple fasciotomy – early stage DD, contracted cord is cut through small incisions but not surgically removed – least invasive
  2. Fasciectomy – partial or total removal of the diseased palmar fascia including the contracted cord / nodule
  3. Dermofasciectomy – removes all diseased tissue, also removes overlying skin and fat, then required a full thickness skin graft to cover the surgical site – severe, recurrent Dupuytrens
  4. Amputation of the digits may be considered as a last resort
34
Q

Physiotherapy management of Dupuytren Disease

A

Aimed at restoring mobility at finger joints

Pre-operative:

  1. Splinting
  2. Massage
  3. Passive stretching
  4. Active exercises

Main role is post-operative:

  1. Splinting - can be custom-made by hand therapists
  2. Passive stretching
  3. Active exercises
  4. Strengthening
  5. Functional activities
  6. Education and advice
  7. Oedema and scar management - really important because if scar begins to contract leads to recurrence
35
Q

Prognosis of Dupuytren disease

A

Following surgery, prognosis is good initially

Recurrence is frequent

Early onset carries poorer prognosis

Proximal IP joint contractures soon become irreversible

Patho 2 (30 decks)

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