Wrist.Hand Claire notes .docx

Wrist Joint Modalities II Anatomy Wrist joint is made up of two joints-radiocarpal and midcarpal. Anatomy review of joints. Radiocarpal- synovial joint Made of the distal radius and radioulnar disk (articular cartilage between radius and ulna) proximally. Made of scaphoid, lunate, triquetrum distall...

Wrist Joint Modalities II Anatomy Wrist joint is made up of two joints-radiocarpal and midcarpal. Anatomy review of joints. Radiocarpal- synovial joint Made of the distal radius and radioulnar disk (articular cartilage between radius and ulna) proximally. Made of scaphoid, lunate, triquetrum distally. Extension and flexion (Sagittal plane, frontal axis) Radial and Ulnar deviation (Frontal plane, sagittal axis) Classified as a Biaxial Condyloid Midcarpal (intercarpal) joint-Nonaxial Between two rows or carpal bones Ligaments Radial collateral-attaches to radial styloid and trapezium and scaphoid. Provides lateral support. Ulnar collateral-attached to ulnar styloid and pisiform and triquetrum. Provides medial support. Palmar radiocarpal-Limits wrist extension; attaches to the anterior ulna and radius and to the anterior surface of the proximal carpals. Dorsal radiocarpal-Limits wrist flexion; attaches from posterior surface of the distal radius to posterior scaphoid, lunate, and triquetrum. Palmar Fascia (palmar aponeurosis)- Superficial triangular fascia on palm of hand. Attachment for the palmaris longus and flexor retinaculum. Common Pathologies of the Wrist Carpal Tunnel Syndrome (CTS) -> affects 4% of the entire US workforce. Entrapment of the median nerve within the carpal tunnel. Median nerve innervated D1-D3 and half of D4 Caused by repetitive motion of the wrist (flexion, ulnar deviation, supination, gripping, and pinching) Common Symptoms Numbness and tingling in median nerve distribution Pain in wrist but can be muscular Clumsiness in hand activities Weak grip in pinch and thumb action Swelling in hand and forearm Atrophy in thenar muscles (can also be swollen) Symptoms worse at night because of how we tend to sleep Special Tests associated with CTS. Phalen’s-backs of hands pressed together resulting in tingling after a few seconds. Tinel’s-tapping ventral wrist to stimulate tingling response in median nerve. Digital Allen Test- tests radial and digital artery. Compress arteries and then evaluate circulatory recovery by seeing color return to both sides of palm evenly. Treatment Considerations Eliminate motions that create symptoms. Can’t eliminate some things like typing if person is a typist. Splinting the affected wrist in 0-20 degrees of extension Injection of corticosteroids Exercise of affected limb-primarily elbow and shoulder ROM and strengthening as tolerated by affected wrist If decompression surgery is indicated, transverse ligament will be cut to release. Not very effective because is results in scarring. Common to repeat surgery. (ASTYM may be better choice for carpal tunnel) Immobilization 2 to 14 days which encourages improper scar tissue development. Flex and extend fingers and use of hand is ok. Only wrist immobile. As wound heals, active writ motion initiated, massage to reduce scarring. Strengthening Encourage functional activities- gripping, pinching. DeQuervain’s Tenosynovitis a. Affects the tendons of the abductor pollicis longus and extensor pollicis brevis b. Results from repetitive ulnar deviation (stress of the thumb tendons from ulnar deviation) c. Common Clinical Symptoms include: a. Pain and swelling at the radial styloid b. Reduced motion of the thumb Special Tests a. Finklestein’s Test: Oppose and hold thumb under other digits. Then actively ulnar deviate and evaluate. Pain is positive test. Treatment Considerations a. Wrist and thumb immobilization, modalities, to decrease swelling and pain. b. If after few weeks pain and swelling are reduced then active motion of wrist and thumb can begin c. Resistance exercise of affected area must focus on contractions that do not produce symptoms d. Motions of wrist and forearm are also addressed looking for symptomology in other areas as well. e. Possible use of corticosteroids f. Chronic cases may require surgical decompression. Post-op care resembles that of CTS. Ligamentous injuries of the Wrist a. Wrist stability primarily provided by the ligaments. b. Most often occurs from a fall with the wrist hyperextended c. Wrist sprains are usually self-limiting, don’t usually treat these in therapy d. Once sprained, the ligaments are lax. Athletes often use tape to reinforce weak ligaments. e. If there is NO carpal instability: a. Wrist is immobilized. b. Ice for pain and swelling c. After removal of splint do gentle active pain free ROM d. Resistance exercise e. Functional motion exercise f. If there is carpal instability: a. Rigid cast b. Closed or open reduction of carpal bone if needed. Colles Fracture-known as the “Dinner Fork Deformity” a. Most common wrist fracture b. A radius fractur within 2.5 cm of the wrist with distal radius displaced in a dorsal direction “dinner fork deformity” c. Usually results from fall on an outstretched arm. d. Complications: a. Mal-union b. Non-union c. Tendon adhesions-usually flexor tendons d. Median nerve compression e. Instability f. Volkmann’s ischemic contracture- deformity of the hand, fingers, wrist, caused by injury to the muscles of the forearm g. Complex Regional Pain Syndrome (CRPS) Therapy Goals a. Reduce swelling b. When stable begin non-painful exercises, to maintain motion c. Distal cast must be proximal to the distal palmar crease to facilitate exercises. d. Exercises progress when cast removed Complex Regional Pain Syndrome-known as RSD (reflex sympathetic dystrophy) is a vasomotor response to chronic stimulus. a. Usually follows an injury; not just wrist and hand but other injuries as well (foot, ankle) b. Is sometimes a complication of Colles Fracture c. Don’t understand exact etiology but, is a vasomotor response to a chronic stimulus. d. Characterized by: a. Pain b. Hyperesthesia c. Edema d. Discoloration e. Loss of motion and function e. No direct relationship between severity of injury and severity of pain from RSD f. Some literature indicates a psych component citing low pain threshold and dependent personality. Smith’s Fracture a. Reverse Colles Fracture-the rigid fragment displaced in palmar direction instead of dorsal. b. Results from fall on dorsum of hand Scaphoid Fracture a. Distal and midportion of the scaphoid are vascular, proximal pole has a poor blood supply b. Fractures in the proximal pole (proximal 1/3 of scaphoid) are more likely to result in non-union and avascular necrosis and may require extended healing time up to 24 weeks. c. It is the most common fx within the carpal bones d. Mechanics of injury are wrist hyperextension with radial deviation. e. Pain localized in anatomical snuffbox Common Pathologies of the Hand 1. Dupuytren’s Contracture-also known as the “Pope Sign” a. Contracture of the longitudinal bands of the palmar aponeurosis (primarily 4th and 5th digits) b. Occurs more often in males than females. c. Occurs more often at age 40 and older. d. Some incidences note in diabetics and alcoholics e. Treatment is surgical intervention to excise palmar fascia or perform a fasciotomy (cut a Z in palm and leave open to allow decompression. Takes 4-6 weeks to heal. 2. Mallet Finger a. A tendon injury (rupture) or avulsion fracture of the extensor fracture of the extensor tendon b. Results in DIP joint flexion contracture c. Due to trauma in the distal end of the phalanx d. Treatment involves splinting of the DIP for 6 to 10 weeks in zero degrees extension (wire fragment if indicated) e. Excellent results if treated early 3. Boutonniere Deformity a. A rupture of stretch to the extensor tendon at the PIP joint (extensor hood splits in tow and tendon slips toward the palm to flex the PIP) b. Results in PIP flexion and DIP hyperextension c. May require suturing of the extensor hood followed by splinting the PIP in full extension for 6 to 8 weeks 4. Swan Neck Deformity a. Occurs with tightness of the intrinsic of the hand b. PIP Hyperextension and DIP Flexion 5. Tendon Lacerations a. Flexor tendons most commonly damaged b. Flexors superficial and easily injured c. Surgical Treatment 1. An area of palm called “no man’s land” -distal palmar crease to middle phalanx a. Area is characterized by tight flexor tunnels b. More negatively influenced by swelling 2. Microsurgery to treat 3. Splinting after surgery a. Start with a static splint where hand is usually flexed to slack flexor tendons b. Dynamic Splinting is a progression from static splint. This allows partial active extension and passive flexion. c. Active extension is okay because it does not apply tension to the flexor tendons d. Passive flexion is ok but not active flexion. General Joint Protection Considerations for an Orthopedic patient 1. Respect the pain a. In rehab pain is your guide. Listen to their pain. b. The expression “no pain-no gain” is for athletic training and not for rehabilitation. 2. Maintain motion and strength through the body a. Need to maintain their mobility 3. Reduce the amount of effort needed to do a job, plan ahead and pace yourself. a. Good advice for any rehab patient-modify your schedule to conserve energy 4. Avoid positions of deformity a. Positions of deformity are generally positions of comfort. Just change positions. 5. Use the strongest largest joints for a job a. Good body mechanics 6. Avoid staying in one position or holding an object for prolonged periods a. Same as #4 above worded differently. 7. Avoid activities that cannot be stopped immediately if they become too stressful or painful