AD I Wrist Hand Study Guide.docx

Wrist and Hand Examination 9/20/2023 Starting your Evaluation Your hand evaluation is like others Past medical history and subjective information Outcome scales DASH, UEFI, CTSSS Patient Goals Aggravating and relieving factors Duration of symptoms Functional level PLOF vs. Current Observation Hand r...

Wrist and Hand Examination 9/20/2023 Starting your Evaluation Your hand evaluation is like others Past medical history and subjective information Outcome scales DASH, UEFI, CTSSS Patient Goals Aggravating and relieving factors Duration of symptoms Functional level PLOF vs. Current Observation Hand relationship to body posturing Hands supinated, guarding, adducted or flexed fingers? Ease of movement compensatory patterns DO they use ulnar side vs. digits Resting position extension, flexed, abducted Normal tenodesis With active wrist extension, fingers going into passive flexion to facilitate normal gripping. With active wrist flexion, fingers should go into passive extension Assess for atrophy Atrophy Thenar or hypothenar (flat looking) Can indicate nerve injuries Intrinsic wasting Deformities rotational, angular, nodes, nerve injuries Herberden’s node (seen in OA) Bouchard’s nodes (seen in OA) Examination Peripheral pulse palpation radial and ulnar arteries Surface temperature involved vs. uninvolved sides Edema (pitting or brawny) Degree of swelling mild, moderate, severe The effect on ROM Dorsal hand edema results in wrist flexion MP hyperextension PIP and DIP flexion Thumb adduction Circumferential measurement as a figure 8 Volume displacement methods Capillary refill apply pressure to pulp of nail and compare to contralateral side Should take about 2 seconds, anything more than 2-3s is abnormal Range of Motion Active and Passive Assess joints above and below **Wrist flexion occurs more at the midcarpal joint (30 degrees RC, 40 degrees) mid carpal) ** **Wrist extension occurs more at the RC vs mid carpal (20 degrees mid carpal and 40 degrees RC)** Full extension 0 degrees Hyperextension + Extensor lag - When PROM is greater than AROM, the active limitation is called a lag Assess end-feel Assess joint play Strength Testing Standard MMT testing Break test of the joints above and below the pathological joint MMT the pathological joint Grip testing Dynamometer usually test 3-4 grips and test against uninvolved side Bell curve Pinch testing Tip to tip checking anterior interosseous nerve also (governs flexor pollicis longus) 3 jaw chuck Checks deep ulnar nerve (thumb adduction) Lateral pinch key grip assessing deep ulnar nerve Neuro Screen DTRs Biceps C5/6 Brachioradialis C6 Triceps C7 Abnormal UMN signs Hoffman’s test assess UMN signs by flicking the DIP of the middle finger and you would see abnormal response of flicking of thumb into thumb flexion Inverted supinator test abnormal brachioradialis test where you repetitively tap the tendon and get long finger flexor and thumb flexor rapid response (almost like clonus) Clonus forceful extension of the wrist eliciting clonus repsonse Myotomes UE Dermatomes Standard UE with close attention to hand Sensation testing Semme’s Weinsten (OT’s/ continued ed courses) Special Tests Ligament, capsule, and joint instability Axial load (TFCC) TFCC load axial compression with ulnar deviation, reproducing ulnar sided pain or clicking UCL of thumb valgus stress test of MCP joint, assessing gapping of ulnar side of joint Watson (scaphoid shift) assess integrity of scaphoid Tendon and muscles Finkelstein test Sweater finger sign rupture of FDP so unable to fully flex DIP Bunnel- littler MCP intrinsic tightness test, so individual will have greater IP joint ROM with MCP in flexion than extension ORL test for retinacular ligament tightness DIP flexion limited by ORL tightness Circulation Allen test Often performed with TOS Pulses Neurological dysfunction Carpal tunnel compression test Phalen’s and reverse Phalen’s Tinel sign Froment sign AIN tip to tip/ “ok” sign If they cannot, it is positive ULTT ULTT 1A and 1B median, AIN ULTT 2 radial ULTT 3 Ulna Carpal Tunnel CPR Shaking hands for symptom relief Wrist ratio index greater than 0.67 (comparing AP to ML: AP/ML in CM) Symptom severity scale score greater than 1.9 Reduced median sensory field of digit 1 Age greater than 45 years Palpation Ulna styloid TFCC Scaphoid Capitate CMC of thumb Tendons trigger finger Carpals Thenar/hypothenar eminence Guyan’s canal Common Hand Conditions 9/20/2023 Fractures Presentation Pain/tenderness Edema Decreased ROM Deformities Loss of function Diagnosis History Physical manifestations X-ray/scans Role of therapist Improve ROM Decrease pain Edema management Scar management Orthosis Patient education Energy conservation Joint protection ADLs Discharge planning Evaluation of fractures Past medical history History of present illness sate of injury and date of surgery AROM Pain Edema Sensation Functional performance Important to view X-rays before and after a reduction Fracture management Reduction The restoration of a fractured bone to its normal anatomical position Stable fractures are those in which muscular forces are not likely to displace the fracture Appropriate for treatment with closed methods Closed Includes LAC, SAC, orthoses, slings, pins, and braces Open Internal fixation (ORIF) can involve plates, screws, and/or rods Warranted if fragments are displaced and/or comminuted External fixation when there is concern about bone length Supply traction to the bone Arthroplasty Joint replacement Arthrodesis Occurs when the joint is fused Fracture blisters occur in areas where there is little soft tissue between the bone and skin Occur over the fracture site, resulting from edema Wrist Fractures Colles’ Most common fracture of the distal radius Common in post-menopausal women, usually a FOOSH injury Dinner fork deformity is the common finding Produced by dorsal displacement of the distal fracture fragments Smith’s Fall onto a flexed wrist of a direct blow to the back of the wrist Fracture of the distal radius where the distal fragment is displaced volarly Less common General Guidelines for Fracture Care Goals: Early Phase 0-6 weeks Reduce edema Elevation Gentle AROM Retrograde/ MEM Light compression Wound/skin Scar mobilization Light ADL’s/functional activities Minimize stiffness AROM, tender glides, blocking Gentle PROM to digits Support reduction of fracture Orthosis wrist support (dorsal or volar) Facilitate ROM Wrist (if able) tenodesis, antigravity? Do not encourage reliance on extensor digitorum for extension Challenging to regain wrist extension and forearm supoiantion Forearm rotation Elbow Shoulder Goals: Middle Phase 6-8 weeks Continue to work on increasing ROM If PROM is ok’d AAROM, PROM Grade I joint mobilization Maitland, Kaltenborn Begin gentle strengthening Scar control Increase functional use activities to increase ROM and strength Stretch If ok’d by MD Dynamic orthosis Goals Late Phase 8-12 weeks Maximize ROM Joint mobilization if needed PROM, stretch Promote strength Grip, pinch Wrist Forearm, elbow Shoulder Return to PLOF ADLs, work Orthopedic Options: ORIF Indications Significant articular displacement Colar comminution Metaphyseal-diaphyseal extension Plating Volar plating preferred but… May irritate tendons Rupture of FPL Colar locking plates provide improved support to bone Dorsal plating Extensor tendon irritation and rupture Bone graft is complicated or complex Volar Locking Plates Early Referral Begin day 11-14 Review op not and X-rays Initial evaluation Wound care Dressing change provide light compressive dressing to decrease edema Immobilize with volar wrist support (with wrist in slight extension) clam shell if ordered Gentle AROM Tenodesis, blocking Check for FPL adherence Blocking FPL Opposition Pain assessment, control Edema, wound, skin, scar Monitor ulnar sided wrist pain TFCC or DRUJ Consider widget once orthosis is discontinued Weeks 2-4 Function is priority Motion before strength 1 month post op hand strengthening with putty might be approved **Not all agree that 2 weeks is the best time to begin therapy subsequent to volar locking plate **Referral up to 6 weeks post-surgery does not significantly impact results Scaphoid Fracture MOI FOOSH Presentation pain on palpation to anatomical snuffbox Orthosis Forearm based thumb spica-radial or volar based, sometimes clamshell Ask physician which part of the scaphoid was fractured Proximal pole has poor blood supply and is at risk for avascular necrosis Finger Fracture MOI Fall onto hand, crush injury, hitting a hard object Presentation deformity, tenderness, edema, possible loss of ROM Orthosis Variable depending on location of injury Metacarpal fractures are splinted with MP in flexion and one joint above and below fracture site immobilized PIP joint fractures are splinted in extension Boxer’s Fracture MOI Metacarpal neck fractures, usually resulting from striking a solid object with a clenched fist Presentation fracture usually occurs at the neck of the 5th metacarpal Orthosis Ulnar gutter orthosis immobilizing 4th and 5th digits Can be hand or forearm based Common Hand Conditions Part 2 9/21/2023 Mallet finger Often caused by a rupture or avulsion of the terminal tendon, such as a baseball hitting the tip of the distal phalanx while in full extension Can also be forcefully tucking in a bedsheet or a laceration Presentation Pain at the dorsal DIP joint Instability to actively extend the joint Flexion deformity Treatment No ROM of the DIP joint is permitted Orthosis DIP/stack orthosis in slight hyperextension worn at all times for 6 weeks PIP is not immobilized At 6 weeks, AROM DIP is initiated Nighttime wear is continued for 2-4 more weeks Dupuytren’s Disease Progressive fibroplasia affecting the palmar fascia Leads to flexion contracture of the MP and PIP joints causing functional disability Etiology is unknown Begins with a nodule at the level of the distal palmar crease enlarges forms pathologic thick cords that extend both distally and proximally Cords thicken and shorten can cause contractures The 4th and 5th digits are commonly involved, but all digits can be involved Surgery indicated when functional status is affected Open fasciectomy cords are cut and removed Closed fasciotomy cords cut but not removed Needle fasciotomy needle used to pierce the skin and cut the cord with repeated needle insertions into the cord at multiple levels Enzymatic fasciotomy uses clostridial collagenase to weaken the cords Following day, the joint is passively extended, rupturing the cord **Surgery does not cure the disease; it usually reoccurs years later** Postoperative care Wound care drain removal (if present), wound cleansing with sterile water, wound compression to reduce edema abd sterile dressing changes Edema control hand elevation, gently compression with Coban Extension orthosis Hand exercises are avoided for the first few days (about 48 hours) AROM PROM progress to strengthening when wounds are healed Scar management Functional tasks that emphasize flexion (gripping) and extension (release) Also need to exercise the shoulder Orthoses No tension applied protocol wrist neutral, MPs 35-45 degrees flexion, IPs in relaxed extension; exercises initially performed in orthosis Digital orthoses can be applied to the volar aspect of the digits and secured with one inch transport tape once wound healing progresses (20-30min 4-5x/day) Wear schedule initially at all times except to remove for ROM and bathing Complications Dehiscence separation of the edges of the wound Infection Hematoma Skin loss Injury to digital artery and nerve CRPS Collagenase for Dupuytren’s Affective and safe treatment due to recurrence rates Skier’s Thumb Rupture of the ulnar collateral ligament of the MP of the thumb Most commonly due to acute injury from a fall in which ski pole is forcibly moved from the hand Conservative Treatment Short opponens orthosis for 4-6 weeks AROM of MP and pinch strengthening at 6 weeks Functional tasks requiring opposition and pinching Surgical Treatment AN ORIF to reduce fracture fragments UCL re-attached to insertion Pinning to MP joint Post-op treatment Casted for 4 weeks, pin removed After removed, AROM of thumb CMC and MP Scar management Edema control Short opponens for 6-8 weeks post repair TFCC Comprised of cartilage and ligaments Central portion is disc with no blood supply which does not heal when torn Peripheral portion is comprised of ligaments with good vascularity Extrinsic stabilizers of the distal radioulnar joint Tendon end sheath of ECU, interosseous membrane, and pronator quadratus, which compresses the ulnar head in the ulnar notch of the radius Intrinsic stabilizer of distal radioulnar joint TFCC, which transmits forces form ulnar sided carpal bones to the ulna Can get injured when patient fractures radius, they will complain of ular sided wrist pain Can also be the result of trauma from rotational forces at the wrist as well as chronic, degenerative damage Signs of TFCC injury Swelling over ulnar aspect of wrist Inflammation of ECU Point tenderness over TFCC and distal ulna Ulnar deviation and axil loading of wrist elicits painful response Click frequently present with forearm rotation Loss of grip strength Treatment Conservative methods can be tried for up to 6 weeks Anti-inflammatory Cortisone injection Modalities Progress to pain free isometrics then to PREs (progressive resistance exercises) Surgical Instability arthroscopic evaluation with TFCC and ligament repair They will be immobilized for 4 weeks by Munster orthosis and 2-3 weeks in short arm orthosis AROM will start at 6 weeks post op CMC Arthritis Trapezium and base of 1st metacarpal Orthosis, gently AROM, activity modification, modalities for pain deQuervain’s Tenosynovitis Inflammation of APL and EPB tendon sheaths Thickening of the overlying fibrous sheaths occurs and stenosis develops as inflammation persists 1st dorsal compartment Gradual onset Repetitive thumb motion combined with radial/ulnar wrist deviation Usually 30-50 years of age, more often in males Commonly see with new moms as well due to wrist positioning when lifting a baby Less frequent causes direct trauma, ganglion cyst in the 1st dorsal compartment, etc. Treatment Activity modification what causes or exacerbates symptoms? Modalities for pain Iontophoresis to first dorsal compartment Orthosis forearm-based thumb spica to immobilize the area Swan Neck Deformity Lateral bands move in excessive dorsal position in relation to the PIP joint axis, resulting in hyperextension of the PIP joint and flexion of the DIP joint Seen in individuals with RA, burns to the hands, and Lyme disease Conservative management Orthosis that positions PIP in slight flexion to promote function Options Dorsal blocking, silver ring, oval 8 Boutonniere Deformity Lateral bands fall volar to the PIP joint axis, resulting in excessive flexion of the PIP joint and hyperextension of the DIP joint Conservative management PIP immobilized in extension Isolated AROM DIP flexion Done in case the oblique retinaculum ligament becomes tight Trigger Finger Nodule or scarring of the tendon at the level of the A1 pulley Nodule prevents tendon for extending the finger Cardinal Signs Locking in flexion Pain with gripping Conservative management Orthosis finger based, MCP joint in 0-15 degrees for minimum 6-8 weeks Activity modification avoid excessive MCP flexion and activities that cause pain/triggering Block MCP flexion Lab Notes 9/30/2023 Dynamometer Dominant hand should be stronger by 15-20%. Do it 3x in each of the three grip positions and take the average of each position. Pinch Meter Used to test the different pinch grips. Tip to tip to test the median nerve. Lateral pinch to test the ulnar nerve. Three jaw chuck pinch tests the median nerve. Three times for each position and average them out. Differential Tissue Diagnosis Intrinsic Tightness Extrinsic Flexor Tightness Extrinsic Extensor Tightness Finkelstein’s test (For tenosynovitis of first dorsal compartment (EPB and APL) /deQuervain’s) Stabilize the arm, forearm on table, thumb attached to hand. Part 1, ask them to ulnarly deviate. Part 2 is therapist overpressure. Part 3 is thumb flexion, have patient make a fist, and apply overpressure. A positive test is reproduction of symptoms along the first dorsal compartment. Carpal Tunnel Tests Carpal compression test/ Durkan’s Come between thenar and hypothenar eminence and apply pressure Phalen’s (carpal tunnel) Dorsum of hands together, ask them to hold for 30s, ask if their symptoms are reproduced Modified Phalen’s/ Reverse Phalen’s Palms of the hands together if they cannot tolerate the first position. Tinel’s Sign Tapping between thenar and hypothenar eminence, asking the patient to report if they have symptom provocation Berger’s Test Make a fist, thumb outside. Hold for 60 seconds. A positive test is carpal tunnel symptom provocation. Varus/Valgus of the wrist Stabilize the DRUJ, ulnar deviation, and apply force at end range. Stabilize DRUJ, radial deviation, a (testing UCL,TFCC, FCU, ECU), apply force at end range. Assess with FOOSH, radial or ulnar sided pain, or if they report feeling unstable. Froment’s Sign (deep ulnar nerve or C8) Have patient use key grip to hold onto a piece of paper while the therapist pulls. IP thumb flexion as a compensation is a positive sign Jean’s Sign IP thumb flexion and MP hyperextension would be a positive sign TFCC Grind Test (CMC) Rest arm on table. Apply axial load and go into ulnar deviation. A positive sign would be reproduction of symptoms, pain, popping, clicking Piano Key Test For distal radioulnar instability. Find radial and ulnar styloid processes (or just distal ulna and radius) and apply counteractive posterior anterior forces. A positive test is a lot of movement. Watson’s test – scapholunate instability Patient seated and arm in neutral position. Palpate the scaphoid. Bring patient into wrist extension and ulnar deviation. Then apply pressure to the scaphoid and move the patient into wrist flexion and radial deviation. In a positive test, you would feel a shift Scaphoid Shift Test (modification of the Watson’s test) Joint Play – Wrist Distraction Dorsal/ Ventral Glides Radial/ Ulnar Glides Joint Play – Metacarpophalangeal Distraction