MSK 3 Mod 2 Wrist and Hand Exam PDF

MSK 3: mod 2 wrist and hand Wrist/ hand exam 1.​ History 2.​ observation: swelling 3.​ palpation of bony and soft tissue 4.​ upper quarter screen 5.​ range of motion and MMT 6.​ End feels 7.​ accessory motion 8.​ special tests History -​ Precipitating incident or activity...

MSK 3: mod 2 wrist and hand Wrist/ hand exam 1.​ History 2.​ observation: swelling 3.​ palpation of bony and soft tissue 4.​ upper quarter screen 5.​ range of motion and MMT 6.​ End feels 7.​ accessory motion 8.​ special tests History -​ Precipitating incident or activity -​ date of onset -​ Position of wrist during loading and subsequent degree and direction of stress -​ Location of symptoms, intensity, and duration -​ activities/position that aggravate or relieve symptoms -​ Reports of dropping objects and shaking hands improve symptoms showed a minimal statistical shift -​ previous treatment and results -​ impact of conditions on work and other activities of daily living Observation: swelling -​ Search for swelling, nodules, and masses -​ Note erythema, abrasions, incisions -​ Measure AROM and PROM bilaterally -​ note pain: when and where it occurs, compare bilaterally -​ Muscle atrophy (thenar eminence wasting with prolonged carpal tunnel) Palpation of bony and soft tissue -​ Palpate all carpal bones especially scaphoid (most commonly injured), anatomical snuffbox, radius, ulnar, spasm, pain -​ When conducting palpation and provocative testing of the wrist and hand you will: 1.​ Define areas of tenderness by systemically palpating bony and soft tissue anatom 2.​ localized crepitus, clicks and clunks of instabilities 3.​ correlate mechanism of injury with physical findings -​ when conducting a topographical exam the wrist and hand, you will systematically work through the five zones as described by Lichtman: 1.​ radial dorsal Zone 2.​ Central dorsal Zone 3.​ Ulnar dorsal zone 1 4.​ Ulnar dorsal zone 2 5.​ Ulnar dorsal zone 3  6.​ Radial volar zone ​ Radial dorsal Zone -​ Scaphoid -​ Shows anatomic snuffbox -​ Present with focal tenderness in the anatomic snuff box -​ tenderness may be fracture or instability -​ Palpate snuff box between attendance of EPL and 1st extensor compartment (APL and EPB) with wrist in ulnar deviation -​ Fractures usually involve a history of a fall on an outstretched hand -​ x-rays maybe negative immediately after the fall CMC Arthritis -​ Common in older patients and presents as chronic pain -​ can have acute flairs -​ symptoms include diffuse pain at the base of the thumb metacarpal -​ aggravated by sustained grasping or pinching or forceful use of thumb ​ CMC grind test -​ Axial compression with thumb rotation -​ positive if painful over the first CMC along with palpation ​ DeQuervains Tenosynovitis aka finkelstein test -​ 1st Dorsal compartment consists of EPB and APL -​ pain and tenderness with active motion may indicate tenosynovitis  -​ usually causes radial sided wrist pain that increases with ulnar deviation, pinch grasping, thumb movement -​ entrapment of APL and EPB at radial styloid -​ Thumb flexion with UD, Positive if painful over compartment ​ Gamekeeper’s/Skier’s thumb -​ Injured ulnar collateral ligament of the thumb at the MCP joint caused by forced abduction and extension of the thumb (as in the fall onto a ski pole ​ Superficial radial nerve/wartenberg’s syndrome -​ Check for hypersensitivity and numbness and tingling -​ perform sensory exam -​ superficial radial nerve can become irritated with radial sided injuries ​ Central dorsal zone ​ Lister’s tubercle -​ Palpate this bony prominence over the dorsal surface of the distal end of the radius -​ use listers to recall as a landmark to locate other structures ​ Scapholunate interval -​ Learn more about examining scapholunate ligament instability using the scaphoid shift test (watson’s test).  -​ Place The Forum into pronation -​ place them over the Palmer prominence of the scaphoid -​ use the other hand to control the wrist position. start in ulnar deviation and slight extension -​ move the wrist radially with slight flexion with constant thumb pressure on the scaphoid -​ normally as the wrist radially deviates and flexes, the scaphoid moves polmarly. the examiner's thumb opposes this motion and causes a subluxation stress -​ with ligament laxity, the scaphoid shifts up onto the dorsal rim of the radius -​ when thumb pressure is withdrawn, the scaphoid returns to its normal position with a clunk -​ positive test: elicits a click or a clunk that is greater than the other side and reproduces the patient's symptoms ​ Lunate (dome) -​ Palpate just distal and ulnar to lister’s tubercle with the wrist flexed -​ The lunate forms a rounded prominence with the wrist flexed -​ Typical patient presentation is male 20 to 40 with activities that continually load the wrist -​ tenderness May indicate AVN (kienbock’s disease) -​ traumatic history may or may not be present -​ swelling is usually over the dorsal side of the wrist -​ remember mechanics: at 45 degrees the proximal carpal row becomes a fixed unit and load across the lunate will increase significantly ​ Capitate -​ Palpate proximal to the base of the third metacarpal and distal to the lunate -​ a mild depression can be felt representing the neck of the capitate -​ Tenderness may be associated with scapholunate instability, triquetral lunate instability, capito lunate DJD with scapholunate Advanced collapse (SLAC) wrist  -​ SLAC is usually associated with some type of previous injury: scaphoid fracture, AVN of the scaphoid (preiser’s disease), lunate fracture/AVN or wrist fracture ​ Ulnar dorsal zone 1 ​ Exam 1.​ Ulnar head: -​ Palpate the surrounded prominence more evident in pronation 2.​ Ulna styloid -​ Palpate on the owner aspect of the wrist. most prominent in the neutral rotation 3.​ Distal radial ulnar joint -​ Palpate just radio to the owner head, identified best in supination -​ place one finger over the DRUJ as you rotate the forearm into maximum pronation or supination -​ no tenderness, abnormal volar or dorsal Mobility, change in the relationship between the distal radius and ulna -​ compared to the uninjured side ​ Distal radioulnar joint instability -​ Difficulty with pronation and supination -​ weakened grip strength -​ pain when using hands to push a heavy load Piano keys test -​ the piano keys test detects distal radial ulnar joint instability -​ stabilize the distal radius and attempt to passively translocate the ulna volarly and dorsally in various degrees of pronation and supination -​ pain, tenderness, and increased Mobility suggest DRUJ involvement -​ squeeze the owner head into the sigmoid Notch of the radius in pronation. pain may occur DRUJ arthrosis ​ Ulnar dorsal zone 2 ​ Triangular fibrocartilage complex -​ To identify the Triangular fibrocartilage complex, you will palpate immediately distal to the DRUJ and between the head of the ulna and the triquetrum. tenderness here may indicate a TFCC problem or a ulnocarpal abutment.  -​ palpate the TFCC in pronation and supination. Pronation shortens the radius relative to the ulna. It increases compression of the TFCC articular disc between the ulna and triquetrum. Ulnocarpal abutment is accentuated by pronation and ulnar deviation. ​ TFCC load test -​ To conduct this test you will 1.​ ulnarly deviate and axially load the wrist 2.​ move the wrist volarly and dorsally 3.​ look for crepitus and reproduction of symptoms which may indicate a TFCC tear or ulnocarpal abutment. ​ Radial volar zone -​ Scaphoid tuberosity -​ Carpal tunnel -​ Pisiform -​ Ulnar nerve -​ Hook of hamate ​ Radial volar Zone 1.​ Carpal tunnel -​ the carpal tunnel is where the flexor tendons and the median nerve travel from the forearm into the hand -​ is floor is the proximal row of carpools, and its roof is the transverse carpal ligament, which is a thickening of the retinaculum -​ the contents in the carpal tunnel include: all four tendons of flexor digitorum superficialis, all four tendons of flexor digitorum profundus, the tendon of flexor pollicis longus, the median nerve 2.​ Transverse carpal 3.​ Median nerve 4.​ Blood vessels 5.​ Tendons 6.​ Carpal bones 7.​ Guyon’s canal 8.​ Ulnar nerve  9.​ Ulnar artery Pisiform -​ Carpal sesamoid bone that lies within the fibers of the FCU -​ palpate this bony prominence at the base of the hypothenar eminence at the flexion crease of the wrist -​ the pisiform overlies the triquetrum -​ pain over the owner aspect of the wrist and over the hypothenar Eminence May indicate piso triquetrum arthritis Scaphoid: -​ Radially deviate the wrist -​ palpate this bony prominence at the base of the thenar crease -​ tenderness May indicate scaphoid disease ​ Hook of hamate -​ Move slightly radial and distal to the pisiform and ulnar to the thenar crease in the hypothenar eminence to palpate the hook of the hamate. As you palpate, you may find tenderness, which may indicate a fracture. you may also feel dorsal tenderness with hook fractures. there are also may have associated ulnar nerve symptoms. Upper quarter screen ( neurological screening/ exam) -​ dermatome/sensory testing -​ Deep tendon reflexes (biceps brachii: C5, brachioradialis: C6, triceps brachii: C7) -​ Myotome testing Additional neuro tests -​ Upper motor neuron signs (Hoffman’s reflex, babinksi test, hyperreflexia (tonic DTRs, clonus) -​ Upper Limb tension testing -​ cranial nerve tests -​ other neurological tests as appropriate -​ and neurological screen is relevant to a comprehensive upper quarter screen due to the possibility of the nerve root and or spinal cord compression. note that Dermot home testing should be done as one point and not sweeping as not to activate other sensory pathways. ROM, MMT, End feels, and accessory motions Capsular patterns -​ Pass with other major joints, capsular patterns exist for the hand, wrist, and elbow. -​ Elbow (humero-ulnar joint): limitation of flexion is significantly greater than extension -​ Wrist (radiocarpal/ulnar joints): limitation of flexion is approximately the same as limitation of extension -​ Finger (MCP/IP) joints: imitation Affliction is greater than extension -​ Look at wrist flexion, extension, ulnar/radial deviation, supination, pronation, thumb flx, ext, abduction, adduction, finger flx, ext, abduction -​ Look at grip strength (global way to assess for weakness), MMT for everything we did ROM on. Special tests 1.​ Allen’s test -​ Technique: -​ Clench fist several times while occluding radial and ulnar arteries. -​ open hand and release one artery. look for return of pink skin coloration within 10 seconds -​ repeat for the other artery 2.​ 1st metacarpal grind test -​ Technique -​ Axial compression with thumb rotation -​ positive if painful over the first CMC along with palpation 3.​ Froment’s sign -​ Purpose: To test distal ulnar nerve pathology -​ Technique -​ Have patient create a fist and have their thumb loose -​ Place their forearm in neutral pronation and supination -​ the patient will clasp a piece of paper between their thumb and lateral index finger and resist the paper being removed. -​ positive finding is when the patient cannot hold paper which is an adductor policies muscle weakness sign -​ the patient will try to compensate by over flexing the flexor pulises longest. the final position of the thumb is called froment’s sign 4.​ Phalen’s test -​ Purpose: To assess the distal median nerve -​ Technique: The therapist passively presses the dorsal sides of the patient's hands against each other at about chest height for 15 to 60 Seconds -​ positive test is the production of numbness and tingling in the distribution of the median nerve -​ this can also be performed as reverse phalen’s with the Palmar sides of the hands or passively pressed together for 15 to 60 Seconds 5.​ Pronator Teres syndrome test -​ Purpose: Tests for median nerve compression by the pronator teres -​ Positioning: The patient stands with the elbow in 90° of flexion, the therapist stands by the patient -​ Technique: -​ the therapist places one hand on the client's elbow for stabilization and the other hand grasps the patient's hand in a handshake position -​ The patient holds this position as the practitioner attempts to supinate the patient's forearm. ( forcing a patient to contract the pronator muscles) -​ while holding the resistance against pronation, the therapist extends the patient's elbow -​ patient should keep the elbow relaxed during the test, because holding the elbow firmly inflection will not allow elbow extension -​ positive sign is numbness and tingling or reproduction of the patient's pain along the median nerve distribution 6.​ Finklestein’s test -​ Dequervan’s test -​ Thumb flexion with UD, -​ positive is when it's painful over the compartment 7.​ Scaphoid shift test (aka watson test) -​ Purpose: Test for scapholunate ligament instability -​ Technique: -​ Place pt.’s the forearm into pronation. Place your thumb over their palmar prominence of the scaphoid. Use your other hand to control the wrist position. -​ Therapist’s action on to the patient’s wrist: Start in ulnar deviation and slight extension. Move the wrist radially with slight flexion with constant thumb pressure on the scaphoid. -​ Normally as the wrist radially deviates and flexes, the scaphoid moves palmarly. The examiner’s thumb opposes this motion and causes a subluxation stress.  -​ With ligament laxity, the scaphoid shifts up onto the dorsal rim of the radius -​ When thumb pressure is withdrawn, the scaphoid returns to its normal position with a “clunk”. -​ + test = elicits a click or a clunk that is greater than the other side and reproduces the patient’s symptoms. 8.​ Triangular fibrocartilage complex load test -​ ulnarly deviate and axially load the patient's wrist -​ then move the wrist volarly and dorsally -​ look for crepitus and reproduction of symptoms. May indicate TFCC tear or ulnocarpal abutment. 9.​ Tinel’s test -​ Tap four to six times over nerve, check for nerve impairment symptoms 10.​Piano keys test -​ Purpose: Detect DRUJ instability -​ Technique: -​ The therapist stabilizes the distal radius and attempts to passively translocate the patient's ulna volarly and dorsally in various degrees of pronation and supination -​ Pain, tenderness, and increased mobility suggests DRUJ involvement -​ If you are squeezing the ulnar head into the sigmoid notch of the radius in pronation, pain may occur due to DRUJ arthrosis. 11.​Tap test or tuning fork test -​ To check for a fracture, you can tap the bone for pain or using a tuning fork Knowledge check: 1.​ Phalen’s test provokes the median nerve Conditions: ​ Pathological conditions: 1.​ APL, EPB T1 - DeQuervian's Tenosynovitis 2.​ EPL (T3) - Rupture at Lister's Tubercle (after wrist fracture) 3.​ APL/EPB and ECRL/ECRB (T1 T2) – Intersection syndrome 4.​ ED, EI (T4)– Extensor tenosynovitis 5.​ EDM (T5) – Rupture (rheumatoid) 6.​ ECU (T6)– Snapping at ulnar styloid or tendinopathy 7.​ Dupuytren's contracture 8.​ MCP (Gatekeeper's) Thumb APL, EPB T1 - DeQuervian's Tenosynovitis -​ Most common tendinopathy of the wrist in athletes -​ inflammation of the tenosynovium of the first dorsal compartment tendons, the APL and EPB  -​ repetitive wrist motion causes shear stress on the tendons in their small compartment -​ common and racquet sports, fishing, and golf -​ Finklestein’s test used to diagnose it -​ Commonly occurs in mother;s who pick up their children EPL (T3) - Rupture at Lister's Tubercle (after wrist fracture) -​ What is it? EPL tears most commonly occur at Lister’s tubercle -​ When does it most occur? Tears typically occur as a delayed complication of a non-displaced distal radial fracture, but may also occur spontaneously. Much less commonly, EPL tears may occur at the distal phalangeal insertion or at a site of laceration. APL/EPB and ECRL/ECRB (T1 T2) – Intersection syndrome. -​ What is it? Inflammation at crossing of muscles of the 1st & 2nd dorsal compartment- EPB, APL and ECRL, ECRB (6 to 8 cm proximal to radial-carpal joint). Site is tender, swollen, often crepitus during wrist flexion/extension “squeakers syndrome.” -​ When does it most occur? Seen in sports requiring forceful repetition of flex/ext (rowing, weight lifting, gymnastics, and racquet sports). -​ ED, EI (T4)– Extensor tenosynovitis -​ What is it? Extensor tenosynovitis is a condition that commonly affects rowing athletes. -​ When does it most occur? Tenosynovitis is an issue that affects tendons and their protective synovium sheathing with severe inflammation. This inflammation is usually caused by an injury, irritation, or degeneration causing the tendon’s sheath to reduce its production of synovial fluid. -​ EDM (T5) – Rupture (rheumatoid) -​ What is it? A spontaneous tendon rupture is a direct consequence of rheumatoid inflammation and can appear without any noticeable impact, often during sleep. -​ ECU (T6)– Snapping at ulnar styloid or tendinopathy -​ What is it? Snapping ECU syndrome is a condition due to the ECU tendon sliding in and out of its groove on the side of the wrist. -​ Dupuytren's contracture -​ Dupuytren’s contracture is a disease in which the palmar aponeurosis becomes more fibrous and begins to cause a flexion contracture of the fingers, particularly the 4th and 5th digits, possible in 2nd and 3rd, too. -​ Nodules develop near the distal palmar crease. -​ Most common in ages 50-60 and more common in people with diabetes -​ Conservative treatment: AROM, PROM, stretches, maybe a splint too -​ Surgical treatment:  -​ Indicated one's joint has a flexion contracture of 30° -​ open fasciotomy, followed by splinting with fingers in full extension for 3 weeks -​ upon splint removal: AROM and PROM of all joints, intrinsic stretching -​ after wound is healed, begin PREs ( around 4 to 6 weeks post-operatively) -​ watch for infection MCP (Gatekeeper's) Thumb -​ The most common clinical problem at the MCP of the thumb is an injury to the ulnar collateral ligament of the thumb causing pain and instability of the MCP joint. This is sometimes also called gamekeeper’s thumb. -​ This is typically caused by falling with compression force onto your outstretched thumb: ​ Wrist and hand osteoarthritis ​ Conservative care 1.​ Lifestyle modifications 2.​ physical therapy -​ Modalities -​ Joint mobilization -​ range of motion -​ Splinting -​ strengthening 3.​ intra-articular injections ( typically corticosteroids) 4.​ medication -​ NSAIDS -​ Aspirin  -​ acetaminophen ​ Surgical intervention -​ Surgery reserved for only the worst cases and where the wrist is unstable and non-functional -​ even those patients with significant pain are usually canceled to wait as long as possible -​ ROM, depending on procedure, is restricted to between 40-75% normal -​ Fusion seeks to stabilize the joint and decrease pain and is the treatment of choice for those patients who have significant carpal degeneration -​ Arthroplasty seeks to replace the surfaces and preserve function Hand osteoarthritis -​ Osteoarthritis of the hand is extremely common and it affects the DIP joints a bit more commonly than the PIP joints -​ the prevalence increases with age and is generally higher among women -​ Heberden’s nodes or hard bony lumps in the joints of your fingers -​ Anatomy of the hand most impacted by osteoarthritis: 1.​ CMC: more common site of osteo arthritis 2.​ digits: less common and MCP involvement May extend to the carpals EULAR OA hand recs -​ In the absence of high quality trials, expert opinion was sought. after 3 Delphi rounds 1.​ combination of non pharmacologic and pharmacological modalities 2.​ Individualized treatments that address risk factors (age, sex, adverse mechanical factors) and type of OA, presence of inflammation, level of pain, level of disability and severity of structural change  3.​ Joint protection techniques and an individualized exercise regimen 4.​ Modalities including heat, ultrasound and paraffin 5.​ Splinting for thumb base to correct position and relieve pain 6.​ Local use of topical NSAIDS and capsaicin 7.​ Paracetemol is preferred long term analgesic 8.​ Oral NSAID’s in lowest acting dose 9.​ SYSDOA (glucosamine, chondroitin sulphate, avocado soybean unsaponifiables, diacerhein, intraarticular hyaluronan) 10.​Intra-articular injections 11.​Surgery as a last resort when all conservative treatments have failed. May involve arthroplasty, osteotomy, fusion or any combination of these 12.​ ​ Conservative care -​ Lifestyle modifications -​ physical therapy -​ introarticular injections -​ medication ​ 1st CMC joint OA -​ May use a thumb spica splint to reduce motion at the joint -​ Patient education – teach compensatory strategies -​ AROM, PROM, joint mobilizations -​ PREs as tolerated -​ NSAIDs -​ Surgical treatment: 1st CMC arthroplasty Nerve entrapments 1.​ Median nerve -​ Muscles: -​ Muscles supplied by the median nerve exclusively: pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis -​ AIN exclusively: lateral 2 slips of flexor digitorum profundus, flexor pollicis longus, pronator quadratus -​ Hands -​ Intrinsics of the hand are supplied by the median nerve after it passes through the carpal tunnel: Lumbricals (1,2), opponens pollicis, abductor pollicis brevis, flexor pollicis brevis -​ sites of entrapment: a.​ High nerve lesions: -​ Usually the result of some sort of trauma -​ will result in total loss of musculature innervated by the median nerve (AIN and motor branch as well)  -​ weak wrist flexion via the FCR - ulnar deviation because of the imbalance -​ flexion of digits 1 to 3 is lost at the PIP and dip and 4-5 is weakened. (FDS) 4 and 5 or only we can because of the ulnar nerve supply to the FDP -​ hand of benediction -​ with a high lesion, thenar function will be lost as well b.​pronator teres syndrome -​ Entrapment as the nerve passes between the two heads of the pronator teres -​ symptoms increase with activity and there is a feeling of heaviness -​ few symptoms at night as compared to carpal tunnel -​ pain reproduced with forearm pronation and elbow extension, palpation of the pronator teres -​ possible weakness along the median nerve distribution but pronator teres is usually spared because it is innervated before the site of compression c.​ anterior interosseous nerve syndrome -​ Sometimes impinged right below the heads of the pronator teres -​ associated with fractures -​ there is no sensory components to the AIN- motor to the FPL, pronator quadratus, and FDP to the second and third finger -​ symptoms include: vague pain in the proximal forearm, weakness of theFPL and FDP to the index finger, affected persons cannot form a circle by pinching their thumb and index finger ( hyperextension of index distal interphalangeal joint and thumb interphalangeal joint) -​ Special tests for nerve entrapment -​ Pronator Teres syndrome test: 1.​ The patient stands with the elbow in 90 degrees of flexion 2.​ Clinician then places one hand on the client's elbow for stabilization and the other hand grasps the patient's hand in a handshake position 3.​ Patient holds this position as the practitioner attempts to supinate the patient's forearm (forcing the patient to contract the pronator muscles) 4.​ While holding the resistance against pronation, the clinician extends the patient's elbow  5.​ If the patient's pain or discomfort is reproduced, + test for median nerve compression by the pronator teres 6.​ The patient should keep the elbow relaxed during the test, because holding the elbow firmly in flexion will not allow elbow extension. 7.​ Positive sign is numbness and tingling & pain along the median nerve distribution 8.​ -​ pinch grip test: 2.​ carpal tunnel syndrome -​ Median nerve entrapment at the carpal tunnel -​ most common in those aged greater than 45 -​ three times more likely in women than men causes are multifactorial: -​ Idiopathic or traumatic onset -​ Overactive pituitary gland, underactive thyroid gland, rheumatoid arthritis, diabetes -​ Pregnancy, menopause -​ Cyst or tumor in the wrist joint -​ Use of vibrating tools -​ Anatomy: -​ The tunnels formed by: carpal bones, transverse carpal ligament, scaphoid and trapezium, pisiform and hook of hamate -​ contents of the tunnel: FDs tendons, 4 FDP tendons, FPL, median nerve -​ Symptoms: -​ Decreased sensation -​ paresthesia and tangling in the distribution of the median nerve in the hand -​ weakness of thenar compartment mm, lumbricals 1-2 -​ Pain around the volar wrist and hand -​ Severity -​ Mild: the patient may complain of numbness, paresthesia, or dysesthesias radiating to the first, second, third, and lateral 4th digits. symptoms may be exacerbated during sleep and relieved with wrist shaking -​ Moderate: the patient may complain of continuous sensory deficits in the median nerve distribution, involving the entire palm and radiating proximally. the ability to handle fine objects is impaired -​ severe: the patient may complain of severe sensory loss and muscular atrophy of the thenar eminence -​ Symptoms increase with repetitive use -​ Symptoms increase at night with Awakening with tingling or numbness -​ occasionally painful radiate up the forearm -​ possible dinar muscle wasting with advanced cases -​ Carpal tunnel clinical prediction rule 1.​ Shaking hands to relieve symptoms -​ wrist ratio > 0.67: -​ Measured by using a pair of sliding calipers to measure the anteroposterior (AP) wrist width and the mediolateral (ML) wrist width at the distal wrist crease -​ Index is then calculated by dividing the AP wrist width by the ML wrist width in centimeters. Ratios greater than.70 were found to be a predisposing factor for carpal tunnel syndrome -​ symptoms severity scale >1.9 -​ 11 item questionnaire that examines the six critical domains for the evaluation of CTS: pain, paresthesia, numbness, weakness, nocturnal symptoms and overall functional status. Each question is scored from 1 (mildest symptoms) to 5 (most severe symptoms); therefore, a higher score indicates a more severe case of CTS. -​ diminish sensation and median sensory field 1( thumb) -​ measured on the pad of thumb with end of a straightened paper clip, and compared to sensation at the proximal thenar eminence. Sensory tests were grades as absent, reduced, normal or hyperesthestic -​ age greater than 45 years old -​ Special tests -​ Tinel’s sign:Percussion of the median nerve at the wrist -​ Phalen’s test: hold the wrist at 90° of flexion for approximately 1 minute -​ tourniquet test: inflated blood pressure cuff reproduction of symptoms at 1 minute -​ carpal compression test: hold them compression over the tunnel for 30 seconds -​ Reverse phalen test: hold the wrist at 90° of extension for approximately 1 minute -​ Treatment -​ conservative treatment: -​ Stretch volar forearm muscles -​ avoid positions that may compress the median nerve -​ teach compensatory strategies -​ median nerve Glides -​ anti-inflammatory medications or injections -​ night splint is very important -​ Surgical treatment -​ If conservative treatments exhausted and not effective -​ open release 2-in incision, cut across the transverse carpal ligament to enlarge tunnel -​ endoscopic surgery also possible -​ less than 50% report full recovery after surgery, most have some residual weakness and or numbness 3.​ ulnar nerve -​ Ulnar nerve (C8-T1) -​ from the medial cord of the plexus -​ the most medial terminal motor branch and the largest of the terminal branches of the medial cord -​ Descends along medial surface of the medial head of the triceps. It runs within a deep groove of thick fascia, the Arcade of Struthers. -​ It continues posteriorly in the retrocondylar groove between the medial epicondyle and olecranon -​ Palpable here, your “funny bone” -​ Susceptible to trauma at this point -​ Passes through the cubital tunnel. tunnel roof in the posterior medial elbow: -​ Fascia of the FCU and the cubital tunnel retinaculum (CTR) -​ The CTR is a fibrous band that passes from the medial epicondyle to the tip of the olecranon -​ Tunnel floor:Elbow capsule and the posterior and transverse portions of the MCL -​ Tunnel walls: medial epicondyle and olecranon -​ Tinel’s sign at the elbow: positive findings are reproduction of symptoms -​ As the nerve passes by the hamate and through the canal it divides again -​ superficial Branch supplies sensation and innervates the palmaris brevis -​ deep branch is primarily motor and innervates everything else -​ Ulnar nerve: From the medial Cord of the plexus -​ Dorsal posterior cutaneous, palmar cutaneous branch -​ wrist/finger flexors -​ Originates from the common flexor origin on the medial epicondyle -​ FCU -​ only muscle of the anterior compartment fully supplied by the ulnar nerve -​ has a second head of origin on the olecranon and the posterior border of the ulna -​ to the pisiform, hamate, and the 5th MC (will flex with UD) -​ FDP -​ supplies digits 4 and 5 -​ Signs, symptoms, and tests -​ Entrapment signs and symptoms: -​ possible atrophy specifically in the web space because of the adductor innervation -​ distal lesions result in what is termed claw hand: -​ The MCP of the ring and little finger are hyperextended and the IP’s are flexed2 -​ FDP remains intact -​ Loss of abduction and adduction of the fingers and thumb. -​ Sensory loss over the medial side of the hand and little finger + medial border of the ring finger. -​ Special test is Froment's Sign test -​ proximal lesions result in many of the same symptoms -​ FDPs are denervated in addition to the ulnar side of FDS -​ DIPs are not flexed and the clawing is less obvious. -​ Referred to as an “ulnar paradox” -​ The first photo shows the MCP of the ring and little finger are hyperextended and the IP’s are flexed and the second photo shows the possible atrophy specifically in the webspace and the second photo: -​ Froment’s sign -​ Patient is seated in front of examiner -​ Examiner gives patient a piece of paper which patient grasps between thumb and index finger -​ Examiner attempts to pull paper away -​ Test is positive if patient flexes terminal phalanx of thumb instead of pinch -​ jeanne’s Sign occurs if thumb hyperextends -​ 4.​ Radial nerve  -​ C5, 6, 7, 8, and T1 -​ Terminal branch of the posterior cord -​ runs posteriorly, inferiorly, and laterally -​ between medial and long head of the triceps -​ runs around the radial Groove with the profunda brachia artery -​ in the upper arm and interface the triceps, anconeus, and the supinator. -​ At the elbow it interview brachioradialis, ECRB and ECRL -​ Branching nerves -​ At the elbow the nerve bifurcates and separates into the superficial and the deep branches: -​ High nerve lesions -​ High nerve lesions are usually the result of compression or mid-shaft humeral fractures -​ Result is a Radial Drop wrist -​ Saturday Night Palsy (inability to extend wrist or fingers, absent radial and dorsal side sensation) -​ Honeymooners Palsy (same as above) -​ PIN syndrome -​ Edge of the ECRB, arcade of Frohse or as the PIN passes through the supinator -​ Pain with passive elbow extension, forearm pronation, and wrist flexion (ECRB), active supination -​ Differentials are going to include lateral epicondyilitis and radial tunnel syndrome -​ Radial Tunnel Syndrome is pain only, sites of entrapment are same as PIN -​ Functional drop wrist -​ Special tests: Middle and index finger extension test, compression over the radial tunnel -​ Signs and symptoms: -​ Involves all the radial nerve innervated distal extensors: EDC, EIP, ECU, EPB, EPL, APL -​ May complain of weakness or a functional drop wrist may develop -​ Pseudo claw hand presentation because of the finger extensor weakness -​ Radial deviation during wrist extension because of the imbalance created by the loss of the ECU -​ supinator, brachioradialis, triceps, ECR-L, ECR-B, anconeus are spared (proximal to entrapment) -​ Purely a motor syndrome -​ If there are sensory symptoms entrapment is occurring proximally Tendon impairments and fractures  1.​ Tendon repairs Management of Post-Op Flexor Tendon Repair -​ Patient education is paramount a.​ Failure to glide tendons during the first month post-op will result in permanent ROM losses b.​ Repair will be weakest between weeks 1-3 -​ Splint is usually a dorsal extension block to restrict extension and stress on the flexors c.​ Do not overstress the flexor tendon(s) into extension -​ 4-5 Weeks after repair you can begin active tendon glides -​ 2.​ Mallet finger -​ terminal band avulsed -​ loss of active DIP extension -​ Gutter splint for 8 weeks -​ Gentle AROM to start -​ PREs can begin around 12 weeks -​ 3.​ Swan neck deformity -​ Oblique retinacular ligament destroyed -​ Leads to Dorsal displacement of the lateral band, causes hyperextension at the PIP and flexion at the DIP -​ 4.​ Boutonniere -​ loss of the central tendon and transverse retinacular ligament -​ lateral band slide volarly and result in PIP flexion with DIP hyperextension -​ 5.​ Dequiervain’s tenosynovitis -​ Wrist thumb spica splint for 1-2 weeks -​ NSAIDs, rest, possible cortisone injection -​ A/PROM may begin after splint removal -​ Gentle return to activity 6.​ laceration/repair -​ Fractures 1.​ Considerations for rehab -​ Treating impairments: -​ Limitations in joint motion and muscular strength -​ immobilization can also reduce ligament strength and function -​ Certain types of fractures and metal implants may limit the return of full motion–Know the goals so you don’t injure the patient. -​ Progressive weight bearing -​ follow Progressive loading schedule and guidelines 2.​ issues to monitor -​ Skin Discoloration -​ Reduced pulses -​ Reduced temperature  -​ Severe pain on passive stretch of muscles may indicate vascular injury -​ Numbness of the extremity -​ Persistent weakness of extremity muscles may indicate neurological injury -​ Fever may be a sign of infection -​ Persistent signs of inflammation around joint or fracture site may indicate infection -​ Redness -​ Swelling -​ Pain -​ Increased skin temperature -​ ​ Types of fractures 1.​ Humeral shaft 2.​ Mallet fracture: distal phalange caused by forced flexion on an extending digit 3.​ Metacarpal fractures: boxer -​ a boxer fracture is a fracture of the fifth metacarpal bone in the hand. typically occurs when you punch an object at a high speed -​ symptoms include: pain and swelling of the hand, limited range of motion of the pinky finger, misalignment of the finger 4.​ Metacarpal fractures Bennett -​ is an intra-articular fracture of the first metacarpal combined with dislocation and subluxation. Typically, occurs from an axial load to a flexed thumb and is the most frequent thumb fracture. 5.​ scaphoid fracture -​ Typically result from fall on outstretched hand (FOOSH). Most frequently fractured carpal bone (2nd to only radius in wrist). They may be missed with standard imaging. -​ Patients present with pain in the anatomical snuffbox & base of thumb. -​ They are prone to non-union because of compromised blood supply. 6.​ Hamate fracture -​ Occurs with athletic activities, especially golf and batting. -​ The hook of Hamate is the lateral border of Guyon’s canal and transmits ulnar nerve and artery. -​ If fractured, needs immediate immobilization. 7.​ Colle’s fracture -​ fracture of the distal radius with dorsal displacement. Most common FOOSH injury where the distal radius displaces dorsally. Ulnar styloid is also fractured > 60% of time. More common in older adults, especially women. It can result in DRUJ instability, radial shortening, carpal tunnel syndrome as a longer-term complication. -​ 8.​ Chauffer fracture -​ is a fracture usually occurs through the articular surface. It can become complicated secondary to location of growth plate. It is a type of oblique fracture of the radial styloid process in the forearm. -​ 9.​ Distal ulnar styloid fracture -​ As long as DRUJ is not affected, does not pose long term negative prognosis. 10.​Galeazzi fracture  -​ fracture of the middle to distal third of the radius associated with dislocation or subluxation of the DRUJ. Necessitates surgical treatment (ORIF). -​ 11.​Smith fracture -​ break to the end of the radius. Often, this injury occurs by a fall to the back of a flexed wrist but can occur in any fall to an outstretched hand. It can result in DRUJ instability, radial shortening, carpal tunnel syndrome as a longer-term complication. 12.​Carpal bone fractures -​ Scaphoid is the most common. Thumb spica splint typically applied with A/PROM upon splint removal. Patient can continue to work uninvolved joints in the meantime. -​ The triquetrum is the second most common carpal fracture after the scaphoid and then lunate fractures. These fractures are typically splinted for 3-6 weeks in “intrinsic plus” position. A/PROM after splint removal. PREs at 8-12 weeks. Treatments for fractures -​ Non-displaced fractures: cast 6 weeks -​ displaced fracture, non-surgical: closed reduction, then cast 6 weeks -​ displaced fracture with significant ambulation: ORIF ( or external fixation), immobilize for 6 weeks -​ physical therapy: AROM, PROM as soon as permitted, joint mobs as soon as permitted, light PREs to start, full PREs at 12 weeks Knowledge check 1.​ Select all of the muscle tendons that can be compressed in the carpal tunnel which could lead to weakness of the finger flexors. -​ Flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus 2.​ What extensor expansion deformities occur when the lateral bands are injured? -​ Boutonniere, swan neck deformity 3.​ A colle’s fracture At the wrist involves dorsal displacement of which bone? -​ radius Treatment -​ Interventions: NSAIDS, wrist hand brace, stretches, massage, PREs, equipment modification ​ manual therapy 1.​ Intercarpal dorsal and volar Glide assessment and treatment -​ purpose is to assess carpal Mobility -​ positioning: patient is relaxed and seated with hand in full supination and stabilized on a table and therapist is standing or seated -​ Technique: -​ patient is asked to relax -​ using fingers and thumbs, stabilize one carpal bone and sheer volarly and dorsally to assess mobility -​ Compare sides -​ There is a positive test if there is more or less accessory glide when compared to the uninvolved side. -​ If there is a hypomobile direction, treat by mobilizing into this direction. 2.​ Proximal radioulnar joint posterior glide assessment and treatment -​ Purpose: to assess mobility of the proximal radioulnar joint and increase pronation -​ Positioning: patient is supine, and therapist is standing or seated -​ Technique: -​ Place elbow in 70 degrees of flexion and 35 degrees of supination (the open-packed position of the proximal radioulnar joint). -​ Stabilize the forearm on your thigh and use your proximal hand to stabilize the proximal ulna. -​ Use the thenar eminence of your proximal hand to apply a posterior directed force to the radial head. -​ Perform multiple bouts of 30-45 seconds. 3.​ Distal radioulnar dorsal glide -​ Purpose: to assess radioulnar range of motion and increase supination -​ Positioning: patient is supine with their forearm supinated, and therapist is on the same side of the table of the targeted joint. -​ Technique: -​ Patient is asked to relax with their forearm supinated. -​ Place your hand on the table grasping and stabilizing the ulna. -​ Grasp the distal radius with your other hand, placing your thenar eminence on the anterior portion of the distal radius. -​ Keeping your elbows locked, with one hand stabilizing the ulna, and gently glide the radius toward the table with your other hand. 4.​ 1st carpometacarpal dorsal glide -​ Purpose: to assess and treat limited thumb abduction range of motion -​ Positioning: patient is seated with their elbow flexed to 90 degrees on the table and therapist is seated across from the patient  -​ Technique: 1.​ Stabilize the trapezium. 2.​ Grasp the 1st metacarpal with the mobilization hand. 3.​ Apply a dorsal force with a grade 1 traction. 4.​ Assess for hyper or hypomobility or symptom reproduction. 5.​ 1st carpometacarpal radial glide -​ Purpose: to assess and treat limited thumb extension range of motion -​ Positioning: patient is seated with their elbow flexed to 90 degrees on the table and therapist is seated across from the patient -​ Technique: 1.​ Stabilize the trapezium. 2.​ Grasp the first metacarpal with the mobilization hand. 3.​ Apply a grade 1 traction followed by a radial force. 4.​ Assess for hyper or hypomobility or symptom reproduction. 5.​ 6.​ Metacarpophalangeal joint, proximal interphalangeal joint, distal interphalangeal joint glides -​ Stablilize the proximal bone and mobilize the distal bone. -​ Follow the convex/concave rule. 7.​ Radiocarpal ulnar glide -​ Purpose: to increase wrist radial deviation range of motion, joint mobility, and reduce pain -​ Positioning: patient supine or seated with the forearm supported on the table and wrist in neutral with the thumb facing up and the therapist is standing -​ Technique: 1.​ Stabilize the patient’s distal radius and ulna with one hand. 2.​ The other hand stabilizes the proximal carpal row making sure to take up skin slack for patient comfort. 3.​ A downward force in an ulnar direction is given to the first carpal row with a grade 1 traction. Knowledge check 1.​ Wrist flexion Can be increased by using a mid carpal dorsal Glide 2.​ First carpal metacarpal dorsal glide is used to increase thumb abduction