MSK Exam Questions

• Orthopedic treatment includes wrist and hand conditions discussed in section 3
• Including common conditions such as Carpal Tunnel Syndrome, etc

Carpal Tunnel Syndrome

• Compression or entrapment of the median nerve as the nerve passes through the carpal tunnel represents an inflammatory response and impaired nerve transmission
• Decreased tunnel size, bony changes, ganglion/cyst, or dislocation cause compression
• Repetitive Strain Injury (RSI), systemic conditions like diabetes, hypothyroidism, and pregnancy, and scar tissue from a cut flexor retinaculum increase the size of components running through tunnel causing compression
• Compression is caused by a combination of the above, such as RA with edema
• MOI with external noxious pressure influence from wearing shoulders and backpacks, watches, gloves, bracelets, splints
• Internal hypertoned muscles, structural abnormalities, trauma, overuse (RSI), poor limb positioning while sleeping, or systemic conditions
• Contributing factors include systemic conditions, Vitamin B6 deficiency, inherited, females>males populations, and work related activities
• Nocturnal neurological symptoms (numbness, tingling, pain, weakness) is the telltale sign
• Unilateral distribution more common in the dominant hand along the median nerve
• Palmar Fascia may feel like it is tearing with deep/achy pain at the anterior forearm
• Can cause possible weakness
• Self-relief achieved by shaking, massaging, or opening and closing the hand
• Atrophy of thenar muscles leads to clumsy movements, weakness with precision, and weak grips
• Palmar Cutaneous branch of the median nerve not affected as it runs superficially over the carpal tunnel
• Symptoms in palm and fingers indicate possible pronator teres and carpal tunnel compressions
• Symptoms in palm and not in fingers indicates Compression at pronator teres and not carpal tunnel
• Symptoms in fingers and not in palms indicates Compression at carpal tunnel and not pronator teres
• Special tests include Phalen's, or Flexion Ligamentous Stress Test, Reverse Phalen's, or Extension Ligamentous Stress Test, Tinel's, and Pronator Teres Syndrome Test to rule out
• Differential diagnosis: C6 - C7 Radiculopathies (spinal), Thoracic Outlet Syndrome (TOS), Pronator Teres Syndrome, and Double Crush Syndrome (nerve entrapped at 2 sites on its pathway)
• Treatment includes message therapy and wrist splinting in a neutral position
• Medication with oral anti-inflammatories, steroid injection, or Vitamin B6
• Transection of Flexor Retinaculum has many complications

Dupuytren's Contracture

• The condition is an idiopathic contracture of the palmar fascia
• Palmar fascia absorbs pressure and increases the stability of hand and has 3 directions: Longitudinal (superficial), Transverse (deep), and Vertical (attaches the two layers)
• Palmaris Longus flexes at the wrist and hand and inserts into the fascia
• It is absent in 20% of the population
• Occurrence is possible via FCU
• Etiology is idiopathic, has correlation with epilepsy, prolonged immobilization of hand, alcoholism, and diabetes
• Begins with shortening and fibrosis, proliferation of fibroblasts, nodular formation, and contracture
• No inflammation
• It is spontaneous and affects the skin and fascia and not muscle, tendon or joint
• Recurrent trauma is not the cause, but can occur following an injury
• Contributing factors include Hyperkyphosis, TOS, RSD, increased SNS firing, Lateral Epicondylitis, and Adhesive Capsulitis
• Palmar fascia symptoms include tender, thickened, nodular, visible dimpling, and puckering
• Leads to MCP and IP flexion that affects the 4&5 digits
• Wrist flexor hypertonicity and a decreased AROM of IP's
• Gradual onset/progression, often becomes bilateral
• Onset typically around 30 years old in men, and 45 years old in women
• Differential diagnosis: Trigger Finger; nodules near tendons
• Treatments inculde cortisone injections, heat and stretching, splints, surgical incision, amputation, palmar fascia removal, and skin grafts
• A massage focuses on forearm flexors, palmar fascia and palmaris alongus, FCU, carpals, metacarpals, PIPs, DIPs, and contrast hydro therapy aiming to decrease SNS, pain, HT, TrP, fascial restriction, and adhesions as well as maintain/increase ROM and improve circulation/tissue health.

DeQuervain's Syndrome

• It is the Tenosynovitis of Abductor Pollicis Longus and Extensor Pollicis Brevis tendon sheaths
• MOI with RSI, ulnar deviation and radial deviation, and forceful gripping
• S&S include associated RSI symptoms over radial side of wrist/hand and thumb
• Difficult, lending the slide through the sheath of APL & EPB tendons
• Testing increases symptoms, Tenosynovitis, and Tenderness
• Repetitive ulnar deviation can irritate the tendons and is very painful
• Massage therapy has some contradictions including no frictions, but has goals to Decrease SNS, Decrease pain, HT, TrP, Decrease fascial restriction, Decrease adhesions in tendon sheath (MFR, ice), Maintain/increase ROM, Mobilise hypomobile joints, and Stretch shortened muscles
• Tissues require focus of forearm extensors, Intrinsic hand muscles, Deep distal 4 (APL, EPB, EPL, EI), carpals, and forearm flexors
• Caution working over anatomical snuff box because it can irritate radial nerve

Rheumatoid Arthritis

• Autoimmune disorder causing chronic, destructive inflammation to multiple joints and connective tissue of the body
• Etiology is idiopathic and autoimmune in nature
• Gradual onset age, 25-50 years, or activation with injury to joint surfaces
• Not caused by trauma
• Synovial membrane of the joints thickens, Synovitis, boney changes, and fibrosis result in ankylosis
• Surrounding structures also affected i.e., muscle imbalances, tendon ruptures, and joint subluxation
• Signs and symptoms include symmetrical affect small joints mostly
• Has a tendency to be systemic and includes pulmonary and renal systems
• Typical deformities include Ulnar drift, Boutonniere, and Swan Neck deformities
• Diagnosis with X-ray + lab testing for rheumatoid factor
• AM stiffness for one hour or longer and involves at least 3 joints for 6 weeks
• Symptoms include symmetrical swelling and the development of nodules
• PADS and DUBS develop
• Commonly Bilateral
• Taping, bracing, and orthosis helps in reducing severity to begin rehab or to prevent exacerbation
• Intrinsic hand muscle function, especially lumbricals is most indicated
• if strengthening exercises emphasizes the extrinsic hand muscle function, it is likely to increase or lead to the onset of ulnar drift
• Techniques include Joint distraction, stretching, and massage
• It is best to perform only pain-free gentle ROM
• A medical doctor or hand specialist provides advice on tools that will make ADLs easier to perform

1st CMC OA

• Etiology common in older aduts
• Long-term degenerative process; it causes pain and relative instability of the 1st CMC (due to capsular laxity) which may predispose to UCL of the thumb injury
• Is a degeneration of Articular Cartilage where Calcium progress to subchondral bone.
• Osteoarthritis causes thickened and lax capsules
• Pain in the area of the anatomical snuffbox especially with thumb movement which is worse in the morning or after sitting for prolonged periods, responds well to heat
• Caused by Activities, and is more painful with compression, forceful gripping/pinching, radial deviation.
• Signs include thenar contracture, reduced thumb abduction, decreased CMC ROM, intrinsic muscle atrophy/weakness (from disuse), MCP UCL pain/dysfunction
• To counter this do exercises strengthening thumb abductors & extensors
• Treatment includes Remove provoking movements (with Radial deviation) for a period of time,
• May provide stability when the ULC is strained
• This allows stabilization with taping, bracing, CMC orthosis
• Thenar muscle MFR, stretching into abduction, with massage
• Joint distraction along with Hand exercises that focus on functional strengthening of dorsal interosseous muscle and other intrinsic hand muscles
• Pain-free gentle ROM such as a thumb rolling exercise

Radius Fractures

• Colles Fracture is a transverse fracture of the radius proximal to the wrist where fragments of the radius displace dorsally
• FOOSH is etiology, common in elderly patients
• The radius can have malunion (difficult to reduce)
• Median nerve becomes involved
• Reflux Sympathetic Dystrophy (RSD) and Carpal Tunnel Syndrome (CTS) are main complications
• S&S = “Dinner Fork” deformity
• Galeazzi Fracture is a Fracture of the radius and Dislocation of the DRU joint
• It has a MOI caused by FOOSH with rotation
• Ulnar nerve lesion is the main complication
• Scaphoid bone is the most commonly fractured carpal

Scaphoid Fracture

• Scaphoid is the most commonly fractured carpal bone; common in young adults with missed diagnosises of sprains
• If there is pain felt after trauma, is likely to be from a broken bone
• Radiographs are hard to read and does not show up after an injury right away
• Usually shows several weeks later when soft tissues start to calcify
• Poor blood supply adds in healing and delayed bone repair
• MOI: FOOSH injury with Radial deviation leading to Signs & Symptoms:
• Causing pain on radial side esp (w/ RD + EXT), and light swelling
• Local tenderness can persist in the anatomical snuffbox
• Medical treatment is difficult without surgical intervention
• Casting/immobilization provides 2-4 weeks of splints
• Avascular necrosis, delayed union or non-union, and Post traumatic DJD main complications

Post-fracture Reflex Sympathetic Dystrophy:

• Reflex sympathetic dystrophy syndrome (RSD) is a disorder that involves more constant and lasting pain, usually after a fracture trauma, show signs after injury or stroke
• It has been seen with central origin pain syndromes
• The level and amount of pain is significantly worse than the original injury
• It most commonly follows a Colles' fracture

Lunate Dislocation

• It occurs when the displaced and ancient lunate
• MOI = Palmar dislocation of the lunate from a FOOSH injury with wrist hyperextension, leading to lunate compression and carpal tunnel
• Symptoms include a swollen wrist with painful extension of fingers and wrist and possible median nerve symptoms
• It requires powerful medical intervention when reducing, that are pressure by surgery for more serious case
• Major medical concern if their is necrosis or median nerve damage of palsy
• Assessment of AROM shows decrease flexion/extension
• PROM there will be a reduced extension from carpal tunnel
• RROM there will weakness + extension of the wrist
• The easiest way is to use Merphy's sign to tell if the 3 mc is even

Trigger Finger

• A trigger finger is a result of tendons thicken and develops nodules
• It is a Digital tenovaginitis/ tenosynovitis, with a restriction along the tendon
• Its restriction on the tendon makes extension and flexion more difficult
• Causing "sticking" of the tendon for the finger thats affected, with an increasing lack of tension
• In minor cases you only need flexion to create extension
• Progression can result in it being difficult to extend actively and requiring assistance
• Progressing to requiring assistance to extend ginger passively
• Its idiopathic in nature but is associated with RA, as well as other forms conditions
• Main issues are finger/thumb stiffness and pain
• Can make fingers audibly snap, and require assistance with motion
• Best way is tape or splint that gives support to MCP
• Direct work isnt helpful, may stim exter function
• Always avoid over stretching
• Best cases are self resolving, NSAIDS aid but do not make it worse

Skier's Thumb/Gamekeepers Thumb

• Ulnar Collateral Ligament Sprain of the 1st MCP Joint
• The MCP joint sits between a highly mobile saddle joint (CMC) and a rigid hinge joint (IP) making it more vulnerable to forces being used on it
• Can lead to UCL of the thumb by acute trauma
• Radial deviation of the thumb, results in a secondary instability from chronic bone changes
• Occurrences fall from ski poles, baseball players catching, hockey
• Best to Strengthen thumb opposition and esp
• Signs and Symptoms involve ulna pain, and difficulty pain with pinching
• Medical: Surgery is need for full rupture, protect joint
• Strengthen exercises of the thumb, with stability taking precedence over mobility

FPL Tenosynovitis

• Tendition sheath of this area creates the “radial bursa” in the wrist with flexion
• This often becomes “irritation prone” and may need surgery if it gets in the way
• The A1 tissue is most commonly affected, this can trigger load bearing
• Pain increases with concentric Rrom
• Is movement of the tendon wthin The sheath is problem and that its normally caused by repeated thumb use, such as gripping, rock climbing, or texting
• Wont be able to perform in general MMT due to pain
• With massage skin rolling is helpful and to avoid frictions with irritated sheath

TFCC Injury

• TFCC injuries are one of the most common causes of ulnar wrist pain
• Caused form external extension or a rotational injury.
• Main issues are ulnar pain, weight resistance
• Often from extreme pronation and extreme ulnar deviation
• No external Ademia
• Treatment: joint stabilisation compression joint for proper wrist function .
• Medical: Active treatment plan and ROM exercises will relieve pain
• Not for mobilisation
• Joint motion: External rotation, external extension.