Stanbridge - T4 - TE2 - W8 - Wrist & Hand

Therapeutic Exercise II: The Wrist and Hand

• This course covers the structure and function of the wrist and hand, impairments, and therapeutic interventions.

Road Map

• Students will be able to identify wrist and hand structure and function.
• Students will be able to describe structural and functional impairments based on soft tissue lesions.
• Students will be able to implement therapeutic interventions for varying stages of recovery after tissue injury.
• Students will demonstrate exercise progressions to improve ROM, muscle performance, and functional use for non-operative and post-operative wrist and hand conditions.

Outline

• Structure & Arthrokinematics
• Gripping
• Joint Hypomobility
• Distal Radius Fracture
• Repetitive Trauma and Sprains
• Tendon Rupture-RA
• Carpal Tunnel Syndrome & Ulnar Nerve Compression
• Techniques for Musculotendinous Mobility

Structure and Function of the Wrist and Hand

• Joints of the wrist and hand
• Hand function
• Major nerves subject to pressure/trauma at the wrist and hand

Wrist and Hand - Function

• Wrist: final link of joints that position the hand for functional activities
• Hand: tool to control and manipulate the environment and express ideas and talents

Hand Bones

• 5 Metacarpals
• 14 Phalanges
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Trapezium
• Trapezoid
• Capitate
• Hamate

Joints of the Wrist

• Osteokinematic motions: flexion, extension, radial, and ulnar deviation
• Ligaments: ulnar and radial collateral ligaments, dorsal and volar radiocarpal ligaments, ulno-carpal ligaments, intercarpal ligaments
• Distal RU joint: not considered part of the wrist joint, but impairments here affect the wrist

Joints of the Wrist: Radiocarpal Joint

• Characteristics: distal radius, radioulnar disk, proximal surface of the scaphoid, lunate, and triquetrum

Joints of the Wrist: Midcarpal Joints

• Characteristics: 2 rows of carpals, distal surfaces of scaphoid, lunate, and triquetrum articulate with proximal surfaces of the trapezium, trapezoid, capitate, and hamate

Joints of the Hand: Carpometacarpal (CMC) Joints

• Carpometacarpal joint

CMC Joint of the Thumb

• Saddle joint

Muscles of the Wrist and Hand

• Intrinsic muscles
• Extrinsic muscles
• Complex function of the hand

Muscles of the Wrist and Hand: Length-Tension Relationships

• Position of the wrist controls the length of the extrinsic muscles of the digits
• To maximize grip strength: synchronous wrist extension with finger flexion lengthens extrinsic flexor tendons across the wrist, maintaining favorable length tension of the muscles
• For strong finger and thumb extension: wrist flexor muscles either stabilize or flex the wrist so the EDC, EI, EDM, or EPL muscles can function more efficiently.

Important Hand Function

• Cupping/arching hand: flexion of metacarpals and adduction of 5th MC improves grasp
• Flattening of hand: extension of the metacarpals releases objects
• Thumb CMC joint: allows opposition in prehension tasks
• Thumb MCP joint: reinforced by two sesamoid bones (volar surface) improves the leverage of the flexor pollicis brevis muscle

Gripping and Prehension Patterns

• Power grip: requires ulnar n. innervated muscles
• Spherical
• Cylinder
• Hook grip (PIP flexion)
• Precision grip: median n. innervated muscles
• Pad to pad
• Tip to tip
• Pad to side
• Combined grip: utilizes both lateral prehension
• Lateral prehension (intermediate) requires thumb adduction (ulnar nerve part power), CMC medial rotation (mimics a precision grasp), some flexion of IP joint of thumb, stabilization from remaining fingers & palm when force is needed; digits 1 & 2: precision, digits 3-5: power supplementation

Gripping and Prehension Patterns

• Power grip: ulnar n. innervated muscles (2 extrinsic flexors of the anterior forearm: FCU, 2 medial FDP)
• Precision grip: median n. innervated muscles (extrinsic muscles, finger & wrist flexors)
• HILA muscles: hypothenar eminence, interossei, lumbricals 1 & 2, adductor pollicis
• LOAF muscles of the hand: 2 lateral lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

Gripping and Prehension Patterns

• Lateral prehension
• Newer name for intermediate grip
• Requires thumb add (from ulnar n.- part power)
• Requires CMC medial rotation mimicking precision grasp
• Requires some IP flexion of thumb
• Requires stabilization from remaining fingers & palm when force is needed
• Digits 1 & 2: precision, Digits 3-5: power supplementation. Example: power needed to open a door versus the different grip to dip a tea bag

Joint Hypomobility

• Rheumatoid arthritis (RA): affects MCP, PIP, wrists. DIP, PIP, 1st CMC of hands

• Osteoarthritis (OA): affects DIP, PIP, 1st CMC of hands

• Hypomobility can occur from immobilization

Acute Stage Impairments: RA

• Pain, swelling, warmth, decreased mobility due to synovitis and tissue proliferation (MCP, PIP, wrists) and tenosynovitis and synovial proliferation.
• Progressive weakness and muscle imbalance (extrinsic & intrinsic muscles)
• General systemic muscular fatigue

Advanced Stage: RA

• Joint capsule weakens
• Cartilage destruction
• Bone erosion
• Altered muscle tension leads to joint instability, subluxations, and dislocations.
• Deformities: ulnar subluxation of carpal bones causes radial deviation of the wrist, ulnar drift of fingers, swan neck deformity, boutonniere deformity, zig-zag deformity of the thumb

Joint Hypomobility: OA

• Due to age and repetitive joint trauma, post-traumatic arthrosis from fracture or fracture dislocation
• Acute Stage Impairments: achiness, stiffness decreasing with movement; swelling, warmth, restricted/painful motion with stressful activities or trauma.; thumb CMC: accessory hyper-mobility
• Most ligaments are taut with thumb in abduction, extension and opposition; balance forces of muscles needed for thumb pinch.
• Advanced Stages: Initial capsular laxity (hypermobility and instability); progresses to contractures and limited motion; Joints become enlarged; subluxation (common at 1st CMC), General weakness: grip strength; Poor endurance, pain with pinching & gripping.

Joint Hypomobility: Post Immobilization

• Decreased ROM & joint play
• Firm end feels and pain with overpressure
• Tendon adhesions due to inflammation in the tendon or its sheath
• Decreased muscle performance, weak grip strength, decreased flexibility & endurance

Joint Hypomobility - General Management : Acute Phase

• Patient education
• Pain management
• Splinting (to stretch adductors and maintain CMC abduction—most effective in the earlier stages of disease)
• Activity modification (external support may be needed)

Joint Protection in the Wrist & Hand

• Respect pain
• Maintain strength and ROM
• Balance activity level and rest
• Avoid deforming positions or one position for prolonged periods.
• Avoid using strong grasping activities that facilitate deforming forces, especially lateral pinch

Joint Hypomobility - General Management : Acute Phase

• Maintain joint & tendon mobility and muscle integrity
• PROM, AAROM, AROM (aquatic therapy as well; non-stressful, NWB exercise)
• Tendon gliding
• Multiple-angle muscle setting (address common muscle impairments of APL, APB and opponenses m to stabilize the CMC joint)
• Isometrics in correct arch of pinch position; AVOID lateral pinch strengthening

Other areas to address causing median nerve symptoms

• Cervical radiculopathy
• Thoracic outlet syndrome
• For the forearm; a. Pronator teres syndrome (motor median n & palmar cutaneous n), b. Anterior interosseous nerve syndrome
• Digital nerve compression- bowler's thumb
• Neuropathy (systemic)
• Tenosynovitis (RA)
• Complex regional pain syndrome
• Double crush injury: nerves in a double crush injury can develop symptoms at other areas along its course as well as in the primary site; nerves have lessened ability to withstand distal compression when irritated proximally

CTS (Carpal Tunnel Syndrome)

• Confined space containing the median nerve and the extrinsic finger flexor tendons
• Dorsal border: carpal bones
• Ventral border: transverse carpal ligament

CTS- Etiology

• Synovial thickness & scarring in the tendon sheaths (tendinosis)
• Irritation/inflammation of tendons (tendonitis)
• Due to; repetitive or sustained wrist flexion, extension or gripping
• Overuse or cumulative trauma syndrome
• Swelling due to local trauma (fall/blow to wrist: carpal fracture, distal radius fracture, carpal dislocation)
• Swelling due to OA, RA, diabetes, pregnancy
• Compressive forces from equipment usage or vibrations against the carpal tunnel

CTS- Examination (Subjective)

• History of risk factors
• Sensory changes in the hand
• Consistent with median nerve distribution
• Nighttime paresthesias

CTS- Examination (Clinical Findings)

• Atrophy of thenar eminence
• Ape hand posture
• Thenar muscle weakness
• Positive Phalen's test
• Loss of 2-point discrimination
• Positive Tinel's sign
• Electrophysiological studies (nerve conduction, electromyography) help with differential diagnosis

Surgical Management for CTS

• With failure of conservative treatment
• Surgical decompression involving transection of transverse carpal ligament
• Increase volume of the carpal tunnel
• Scar tissue excision

CTS- Post-operative Management

• Maximum Protection Phase (Pt education, wound management, splint use, control edema/pain. Mobilization: PROM of joints, tendon mobilizations)
• Moderate-minimal protection phases (Address residual impairments, scar tissue mobilization, Progressive stretching/joint mobilizations, Grip/pinch exercises, Dexterity, sensory stimulation/sensory re-education)

Ulnar nerve compression in Tunnel of Guyon

• Etiology: irritation of ulnar nerve in the tunnel between the hook of the hamate and pisiform.
• Sustained pressure: prolonged handwriting/cycling
• Synovial inflammation: repetitive gripping of the 4th and 5th fingers (knitting, tying knots, using pliers/staplers)
• Trauma: falling on ulnar border of wrist, hook of hamate fracture
• Space-occupying lesion: ganglion, ulnar artery aneurysm

Ulnar Nerve Compression in Tunnel of Guyon - Examination

• Possible atrophy of hypothenar eminence and intrinsic muscles
• Partial claw hand posture of the fourth and fifth digits
• Intrinsic muscle weakness (HILA muscles)
• Restricted mobility of extrinsic finger flexor and extensor muscles
• Possible adhesions, restricted mobility of pisiform
• Pain and paresthesia in the distribution of the ulnar nerve.
• Positive Tinel's sign over Tunnel of Guyon

Weakness in Ulnar Innervated Intrinsic Muscles

• Affects key pinch and grip strength. Example: Froment's sign

Ulnar N./Tunnel of Guyon: Functional Limitations

• Decreased grip strength
• Fatigue in hand with repetitive/sustained activities
• Inability to use the 4th and 5th digits for spherical/cylindrical power grips
• Decreased ability to perform a provoking activity (knitting, etc.)

Ulnar Nerve Compression in Tunnel of Guyon - Claw Hand Posture

• Extensor digitorum muscle unopposed
• No lumbrical extension of IP's
• FDP and FDS overpower Ext D.
• IP flexion occurs

Injury at Tunnel of Guyon-Sensory Changes vs Cubital Tunnel

• Sensory changes spare the medial aspect of the wrist/hypothenar area, dorsal medial aspect of hand/dorsum of the medial 1 1/2 digits are innervated by palmar and dorsal sensory branches of the nerve that arise proximal to the wrist

Ulnar N. Compression in Tunnel of Guyon- Non-operative Management

• Protect the nerve
• Patient education
• Joint mobilization
• Ulnar nerve mobilization
• Improve muscle performance

Ulnar N. Compression in Tunnel of Guyon - Non-operative Management

• Protect the nerve
• Rest using cock-up splint/protect areas with decreased sensitivity
• Education (activity modification, avoid pressure to base of palm, posture, home exercise program)

Ulnar N. Compression in Tunnel of Guyon- Post-operative Management

• Surgical release of the ulnar tunnel performed after failure of conservative treatment
• Progressive paralysis
• Long-standing muscle wasting
• Clawing of digits.
• Wrist immobilized for ~3-5 days
• PROTOCOL

Ulnar N. Compression in Tunnel of Guyon - Post-operative Management

• Same as carpal tunnel surgery: wound protection, control inflammation/swelling, prevent adhesions, ROM exercises, improve muscle performance, grip strength, scar mobilization, ulnar nerve mobilization, further include flexibility exercises, progress toward patient-specific functional strengthening and endurance exercises, sensory stimulation and discriminative sensory re-education

Review- Questions

• What are the causes of ulnar nerve entrapment at the Tunnel of Guyon?
• What should you educate your patient on for nonsurgical management in the acute phases of this pathology?
• What are the general guidelines for post surgical management of this pathology?

Important Considerations for Application of Exercise for the Wrist and Hand

• Allow the fingers to relax when strengthening wrist musculature
• If one muscle is weaker, the wrist should be guided through the range to minimize the stronger muscles’ action.
• Progress to controlled patterns requiring wrist stabilization for functional tasks: repetitive gripping, picking up/releasing objects, and opening/closing a jar lid.

Important Considerations for Application of Exercise

• Incorporate the entire upper extremity
• Imbalance from weak intrinsic muscles leads to a claw hand
• The wrist must be stabilized for extrinsic hand musculature to be effective
• Manipulating small objects requires use of thumb in opposition to index and middle fingers

Techniques for Musculotendinous Mobility

• Tendon gliding and tendon blocking exercises
• Scar tissue mobilization for tendon adhesions

Exercise Techniques to Increase Flexibility and Range of Motion

• General stretching techniques (wrist flexors, extensors, radial and ulnar deviators)
• Stretching techniques of intrinsic and multi-joint muscles (finger flexor and extensors, finger abductors and adductors)
• Self stretches (lumbricals, adductor pollicis)

Wrist Strengthening Exercises

• Varying options: add a long piece of putty for resistance; do against resistance (manual or TheraBand)

Review - Questions for the Wrist and Hand

• Why is tendon gliding important?
• With what pathologies learned in this chapter can tendon gliding be used?

Road Map

• At this time, students should be able to identify important aspects of wrist and hand structure and function.
• Describe structural and functional impairments that occur based on types of soft tissue lesions.
• Implement therapeutic interventions to treat impairments and functional limitations in the wrist and hand related to stages of recovery after tissue injury.
• Demonstrate exercise progression to develop and improve ROM, muscle performance, and functional use for non-operative and postoperative wrist and hand conditions.

This quiz covers various aspects of hand gripping mechanics, focusing on the intrinsic muscles involved in different types of grips. It emphasizes the roles of specific muscles and nerves during rehabilitation exercises, particularly after injuries. Test your knowledge on grip types, muscle innervation, and post-repair expectations.