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Phty3120 UL FINAL > Wrist pathologies > Flashcards

Wrist pathologies Flashcards

1
Q

Scaphoid fracture

A

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
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2
Q

1st OA

A

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
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3
Q

DeQuervain’s tenosynovitis

A

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

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4
Q

Dorsal radial sensory nerve (wartenburg’s)

A

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)

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5
Q

Skier’s thumb

A

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

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6
Q

Scapholunate injury

A

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

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7
Q

Dorsal wrist ganglion

A

-in scapolante joint fluid filled cyst

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8
Q

ERCL/ECRB tendinopathy

A

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
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9
Q

Dorsal radioulnar joint instability

A

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
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10
Q

TFCC

A

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
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11
Q

Extensor carpi ulnari subluxation

A

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

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12
Q

ECU tendinopathy

A

Overuse

PE:

  • pain ulnar side distal ulnar and 5th MC
  • pain resisted wrist ext/ulnar deviation

Mx:

  • deload
  • addres biomechanics
  • ADL modification
  • gradual reload
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13
Q

Carpal tunnel syndrome

Median nerve compression

A

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

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14
Q

FCU tendinopathy

A

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
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15
Q

Ulnar nerve compression

A

-Guyon’s canal

  • FCU, FDP weakness
  • Muscle weakness Hypothenar, dorsal and palmar interossei, lumbrical of 3rd and 4th finger

DD
-Carpal tunnel syndrome

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16
Q

Pisiform OA

A

Crepitus

location of pain

17
Q

Hook of hamate fracture

A

2cm distal and centrally from pisiform

x-ray

18
Q

Mallet finger

A

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
19
Q

Intrinisic tightness

A

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

20
Q

Extrinsic tightness

A

Ax = flex MCP and extend IPs, then Extend MCP and extend IPS. If can’t extend IPS 2nd time then extrinsic tightness

21
Q

Oblique reticular ligament tightness

A

Ax = lack of DIP flexion when PIP extended compared to when it is flexed

22
Q

Acute central slip injury

Boutonnieres deformity

A

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
23
Q

PIP dislocation

A

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

24
Q

Phalangeal #

A

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
25
Q

Trigger finger

A

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
26
Q

Metacarpal #

A

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

27
Q

Distal radial #

A

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,

28
Q

Complex regional pain syndrom

A
  • 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
29
Q

RA

A

-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

30
Q

Nerve lesion

A 
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
31
Q

Nerve lesion Mx

A 
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

Phty3120 UL FINAL (4 decks)

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