Wrist pathologies Flashcards
Scaphoid fracture
DD
- Scapholunate instability
- Lunate necrosis (keinbock’s disease)
PE
- pain snuff box
- x ray
- UD to RD
Tx
- conservative cast thumb 6-8 wks tubercle
- waist= increased displacement to need surgery
- proximal pole= increased risk of arterial comp so likely surgery
1st OA
Symptoms
- Crepitus
- pain MC joint
- Gradual onset
PE
- obs movement +/- atrophy
- grind test
Tx -can splint not wrist ROM reduction -NSAIDs -rest -AROM, isometrics, resisted ABD A & E= heat, avoid pinching
DeQuervain’s tenosynovitis
DD
Degenerative thickening of the extensor retinaculum and tendon sheath of the APL and EPB tendon (run either side of snuff box). Decreases space for tendon gliding and leads to mechanical impingement.
DD
- OA first CMC
- Wartenburg syndrom
- ECRB/L tendinopathy
- FCR tendinopathy
Complains of
- pain with ulnar deviation
- clenching wrist
- pulling from radial side
PE
- swelling
- palpation localised tenderness and pain at base of thumb
- clenching wrist, ulnar dev, resisted contraction ABL and EPB
- Finklesteins
Mx
- A & E
- REST
- ADL modifications
- AROM, tendon glides
- Pain management
- thermoplastic rigid forearm splint 2 weeks
Px: 6-12 wks resolve
Dorsal radial sensory nerve (wartenburg’s)
caused by compression of bracioradialis tendon and the extensor carpi radials longus tendon in pronation of hand
Numbness, tingling and pain over dorsal radial aspect of hand
PE
-tinel’s (pins and needles)
Skier’s thumb
PE
- tender over ulnar thumb MP joint
- pinching strength
- UCL stress test
Mx:
Conservative 1 & 2= thumb spica splint hand based 6 wks
-flex & ext AROM 3-4 per day at 3 wks
-6 wks= gentle Prom, lateral and palmer pinch strengthening
Surgical G3
Post: hand based spica splint 6 wks
2wks AROM, then ROM and strengthening at 4 wks. RTS 6 wks modified splint
Scapholunate injury
DD
- Scaphoid #
- Lunate #
- TFCC tear
Tenderness over joint
Watson’s test
Tx:
1: immobilise and therapy= splint, dart throwing motion, wrist isometric, FCR, avoid weightbearing/ grip strengthening
2: Surgical pinning
3: open repair, fusion
Proprioception training
Dorsal wrist ganglion
-in scapolante joint fluid filled cyst
ERCL/ECRB tendinopathy
tendinopathy grading:
1: pain during exercise that may go with warming up or be present a short while later.
2: Pain during exercise that does not subside but does not interfere with ADL
3: pain starting to limit physical activities and ADL
4: Pain interfering with ADL and consistent not constant
Reactive: overload
Degenerative: failed healing –> cellular changes and neovascularisation
PE
- pain and tenderness
- local swelling
- pain resisted wrist ext
- pain after repeated mvmt with stiffness after period of rest
Mx:
- deload
- address biomechanics
- ADL mod
- grad reload to facilitate healing
Dorsal radioulnar joint instability
Extreme pronation and ext /degenerative
DD
-TFCC tear
PE
- Palpation: between radius and ulna
- pain pronation/ supination
- snapping or subluxation of ulna
- Ballottment test/ Piano key : glide radius and ulna P/A, A/P in various ranges of supination/pronation
- pain or excess mobility
Mx:
- Splinting elbow cast 6 wks
- strengthening & ROM
TFCC
FOOSH
DD
- ECU tendinopathy
- Ulnar styloid fracture ‘
- DRUj arthritis
PE
- palpation og distal to ulna head and proximal triquetrum
- AROM limited by pain
- TFCC load test (clicking, pain, snapping)
- TFCC integrity test
- Press test (push up from chair)
Mx:
- splint 2-3 wks
- painfree ROM, avoid agg activities, strength
- RTS 6 wks
Extensor carpi ulnari subluxation
DD
- ECU tendinopathy
- DRUJ instability
- TFCC tear
PE
- subluxes in volar and ulnar direction not dorsal
- palpation between ulna and base of 5th, mild swelling
- dislocated supination
- relocates w/ pronation
- Wrist in sup flex–> palpable snap +
Mx:
Immobilisation w forearm in pronation and radial deviation
ECU tendinopathy
Overuse
PE:
- pain ulnar side distal ulnar and 5th MC
- pain resisted wrist ext/ulnar deviation
Mx:
- deload
- addres biomechanics
- ADL modification
- gradual reload
Carpal tunnel syndrome
Median nerve compression
DD
- Pronator teres syndome
- cervical radiculopathy
- Diabetic peripheral neuropathy
Complains of:
- pins and needles, numbness and pain in fingers
- Night pain
- dead hand or loss of circulation
- dry skin, swelling, colour changes
- loss of sensation
- Sense of congestion or finger swelling
PE
- Wasting of thenar eminence
- weakness and loss of dexterity in hand
- reduced strength in thenar (pinch/gripping), APB power
- Sensibility tests
- Tinnels
- Phalens
- reverse phalanx
- durkans (30 sec hold)
- durkans + wrist flex
Mx:
- work and ADL mod (awk wrist positions, prolonged repeated grip, vibrations and force
- night splinting
- nerve and tendon gliding
- oedema control
- Surgical: decompression- wound management, early ROM, avoid heavy lifting for 4 wks, no splint
Px:
-surgery highest benefits 6-12 mths and highest likelihood of recovery
FCU tendinopathy
Same all tendinopathy
PE:
- palpation most prominent tendon of ulnar polar surface of the wrist
- pain on resisted flex and radial deviation
- pain after repeated movements and stiffness after periods of rest
Ulnar nerve compression
-Guyon’s canal
- FCU, FDP weakness
- Muscle weakness Hypothenar, dorsal and palmar interossei, lumbrical of 3rd and 4th finger
DD
-Carpal tunnel syndrome
Pisiform OA
Crepitus
location of pain
Hook of hamate fracture
2cm distal and centrally from pisiform
x-ray
Mallet finger
Avulsion of ext tendon
Forced DIP flex with resisted ext
DD
- Jersey finger
- FDS rupture
PE:
- palpation
- inability to extend DIP
Mx:
- Splint 0-6 wks in 5-15 H-ext 24/7
- PIP free unless swan neck for 6-7 wks
- ROM of other joints
- After 6-8 wks gentle active flex and wean from splint
Intrinisic tightness
Ax = extend MCP and Flex DIP, then slightly flex MCP and flex dip. IF you can now do it then there is tightness
Can’t do claw, but can do fist
Extrinsic tightness
Ax = flex MCP and extend IPs, then Extend MCP and extend IPS. If can’t extend IPS 2nd time then extrinsic tightness
Oblique reticular ligament tightness
Ax = lack of DIP flexion when PIP extended compared to when it is flexed
Acute central slip injury
Boutonnieres deformity
Inability to extend PIP
Mx: -splint into full ext so tendon heals -6 wks grade; AROM night splinting between exercises -7 wks if flex loss, start passive PIP flex
PIP dislocation
Collateral ligament injury
Avulsion # +/-
Volar plate rupture +/-
PE:
- painful palpation
- swelling
Tx: -control oedema (coban) -splint in ext at night -Kinda stable: immobilise 10-20 flex for 4 wks unstable: surgery Early active flex and ext is important
RTP: buddy strap
Phalangeal #
Xray
movment
Tx:
- Immobilise 4 wks ext
- AROM stability permits
- Oedema control (coban)
- buddy strap
Distal phalanx
- usually crush #
- pain and swelling
- if affects 30% intraarticular joint space, surgery required
Trigger finger
flexor tendon trapped in A1 pulley fo flexor tendon sheath mechanical catch–> friction–> inflammation
- Painful straightening with a catch
- locking and jamming
Mx: -splint t restrict MCP flex, IP free, 2-3 weeks Full PROM daily Oedema control Education Pain management
Metacarpal #
MC neck common
3-5 week healing, Rx based on head, neck, shaft or base
Boxer’s # (volarly displaced head)
-Oedema control and splint to facilitate reduction and prevent MCP extension stiff
Metacarpal neck #
-Hand based brace, MC head supported volarly
-Gentle AROM
-Wean from splint after 4-6 weeks
-Buddy strap
Distal radial #
Foosh
Colles# - non articular
Smiths # - reverse colles with volar displacement
Barton’s # - displaced, unstable articular subluxation with carpals
PE
- swelling
- tender
- loss of wrist motion
- x ray
Mx:
Conservative
-immobilise for non-displaced fracture
Surgery
Get good reduction – maintain good reduction – early motion as stability allows – oedema control (elevation and compression) hand ROM, shoulder and elbow ROM, wrist mobilisation as heals
Complications -malunion =pain stiffness OA CTS TFCC tears EPL rupture CRPS type 1
Manual
-PROM, AROM,
Complex regional pain syndrom
- vasomotor dysfunction
- allodynia
DD
- Compartment syndrome
- RA
- Carpal tunnel syndrome
3 phases:
Acute: pain, swelling, red, sweating, heat, stiffness
Sub acute: continued pain, stiffness, organised oedema, decreased redness
Chronic: very stiff, reduced pain
Mx: -Reduce pain and swelling Improve function and mobility Reduce stress Gentle active exercises Mirror therapy Functional use Shoulder and elbow ROM
RA
-MP ulnar drift
-Boutonniere and swan neck and mallet
Reduce inflammation
Maintain stability and mobility
Acute: rest, position to prevent contracture, gentle ROM, cold therapy, education
Subacute: exercise as tolerated, heat, joint protection/splinting
Chronic: joint protection, strength exercises, educating and splinting
Joint protection = respect pain, avoid deforming positions, avoid prolonged positions and use stronger joints when possible, use adaptive equipment
Nerve lesion
Low level medial - Weak: FPB, FO, lumbricals 1 and 2, APB - Ape hand - Can’t oppose thumb - Can’t chuck pinch - Decreased power grip - Sensation affected Low level ulnar - Weak: ADM, FDM, ODM, interossei, 4th and 5h lumbricals, AP, FPB - Claw hand - Loss of lateral pinch (Froment’s sign) - Decrease power grip - Flattened MC arch Low radial - ED or EPL High median - FCR High ulnar - FCU High radial - ECRB and ECRL
Nerve lesion Mx
Splint in flexion for 3-4 weeks until sheath strengthens AROM of other joints After 3 weeks gradual AROM Prevent joint contracture Sensory re-education
