Wrist Pathologies Flashcards
Define De Quervain’s Tenosynovitis
Reactive thickening (inflammation) of the tendon sheath around EPB and APL
Prevalence of De Quervain’s Tenosynovitis
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.
- Lifting heavy dishes
- Painting
- Golf
- Hedge trimming
- Pruning
- 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
Pathology of De Quervain’s Tenosynovitis
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’
Clinical presentation of De Quervain’s Tenosynovitis
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
- Patient makes a closed fist with thumb tucked inside
- Passive ulnar deviation is performed maintaining the wrist in a neutral position
- Positive: reproduction of pain
- Negative: uncomfortable but not painful
Medical management of De Quervain’s Tenosynovitis
NSAIDs
Corticosteroid Injection Surgery
Physiotherapy management of De Quervain’s tenosynovitis
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
Define Carpal Tunnel Syndrome
Median nerve is compressed where it passes through the carpal tunnel
Prevalence of Carpal Tunnel Syndrome
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:
- Diabetes (Type I and II)
- Menopause
- Hypothyroidism
- Obesity
- RA
- Pregnancy
- Family history
- Female>Male 8:1,
- Age 40-50, chances increase after this age
Causes of Carpal Tunnel Syndrome
Oedema, tendon inflammation, hormonal changes, cysts in the carpal tunnel, repetitive manual activity can contribute to nerve compression in this area
Prognosis of Carpal Tunnel Syndrome
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
Clinical presentation of Carpal Tunnel Syndrome
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
Management of Carpal Tunnel Syndrome
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
Prevalence of distal radius #
Commonly occurs due to FOOSH
Types of distal radius #
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
Medical management of distal radius #
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
Physiotherapy management of distal radius #
Physiotherapy following period of immobilisation - involves manipulation to re-align #
Mainly to increase mobility, strength and function at wrist
Prevalence of Scaphoid #
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
Management of scaphoid #
Cast - period of immobilisation
Surgery - more severe cases require surgical fixation
Physiotherapy after immobilisation period - mainly to improve mobility, strength and function
Prevalence of OA
○ Most common form of arthritis, can develop in any synovial joint.
○ Most common in knees, hips and small joints of hand.
Medical management of OA
Corticosteroid Injection
Surgery - most severe cases; joint replacements (common), debridement
Physiotherapy management of OA
§ 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
Define Rheumatoid Arthritis (RA)
Systemic autoimmune disease (body’s immune system attacks the joint) characterised by inflammatory arthritis with extra-articular involvement
Pathology of RA
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
Prevalence of RA
○ 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
Risk factors of RA
Genetic Factors (non-modifiable)
Modifiable: Smoking, Air pollution (difficult to modify), Obesity, Low Vitamin D
Clinical Presentation of RA
○ 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
Medical management of RA
GOAL = symptom management Pharmacological management (key treatment) – Disease Modifying Anti-Rheumatic Drugs (DMARDs) Nutrition - help with symptom management
Physiotherapy management of RA
Appropriate exercise programme to maintain mobility, strength and function for as long as possible; also to manage flare-ups
Advice and education
Define Dupuytren Disease
Nodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis)
Pathology of Dupuytren’s Disease
- 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
Prevalence of Dupuytren Disease
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
Clinical features of Dupuytren’s Disease
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)
Medical management of Dupuytren Disease
Surgical Intervention is the mainstay of treatment; different levels of surgery depending on severity:
- Simple fasciotomy – early stage DD, contracted cord is cut through small incisions but not surgically removed – least invasive
- Fasciectomy – partial or total removal of the diseased palmar fascia including the contracted cord / nodule
- 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
- Amputation of the digits may be considered as a last resort
Physiotherapy management of Dupuytren Disease
Aimed at restoring mobility at finger joints
Pre-operative:
- Splinting
- Massage
- Passive stretching
- Active exercises
Main role is post-operative:
- Splinting - can be custom-made by hand therapists
- Passive stretching
- Active exercises
- Strengthening
- Functional activities
- Education and advice
- Oedema and scar management - really important because if scar begins to contract leads to recurrence
Prognosis of Dupuytren disease
Following surgery, prognosis is good initially
Recurrence is frequent
Early onset carries poorer prognosis
Proximal IP joint contractures soon become irreversible
