DPTD 853 - wrist pathology, wrist/hand lab

carpal tunnel syndrome pathology

compression of median n

carpal tunnel symptoms

• pain and parasthesias/numbness along n pathway

  • worsens w prolonged wrist flx/ ext, WB through hand/pal,, sustained repetitive activities (typing)

• weakness typically presents as decreased thumb opposition

• sympathetic n involvement can lead to hypohidrosis (advanced cases)

carpal tunnel objective findings

• SWMT w/ 2.83 or 3.22 monofilament for normal light touch

• + carpal tunnel compression test, phalen’s test, tinel’s test

• need to examine for other causes of nerve symptoms - there can be multiple sites of nerve compression

clinical prediction rule for CTS

1. shaking the hand relieves symptoms

2. wrist-ratio index > 0.67

3. BCTQ symptom severity scale score >1.9

4. decreased sensation in the top of the thumb compared to the base of thenar eminence

5. age >45

factors that decrease vs factors that increase carpal tunnel space

• decrease = arthritic spurs, synovitis from RA, space occupying lesion (ganglion cyst)

• increase = fluid retention (pregnancy, hypothyroidism), inflammation of tendon sheath

gold standard test for CTS

nerve conduction study

CTS PT management

• neutral positioned wrist orthosis

• pt ed on activity mod

• manual therapy

• stretching

colles fracture pathology and MOI

• fracture at distal end of radius - usually with fracture of ulnar styloid

• typically due to FOOSH - shoulder IR, elbow ext, forearm pronation, and wrist ext

colles fracture symptoms

• wrist/hand pain

  • esp w/ grip

• limited ROM due to pain or boney block

• dinner fork deformity

• if acute - edema and bruising

colles fracture imaging

• x-ray for acute fracture

• non-displaced fractures may require CT

colles fracture PT management

• restoring functional AROM

• wrist extensor strengthening

• radiocarpal & midcarpal joint mob

de quervain’s syndrome pathology

• chronic irritation of the EPB and APL tendons as they pass through first dorsal compartment

• typically occurs as result of repetitive wrist radial deviation

  • work related activities, new parents

• can be due to trauma (gradual onset)

de quervain’s syndrome symptoms

pain in radial wrist that may refer to thumb or forearm - worsens w repetitive radial deviation, resisting ulnar deviation

de quervain’s syndrome objective findings

• PTP over APL & EPB tendons

• resistive testing of APL & EPB painful

• may have edema at radial wrist

• + finklestein’s test

de quervain’s syndrome PT management

• pt ed and possible orthoses - reduce heavy grip while being pulled into ulnar deviation, avoid repetitive thumb use

• soft tissue and joint mobilization - radiocarpal joint

• stretching of EPB & APL

• progress into eccentric strengthening

CRPs type 1 vs type 2

• type 1 = no major n damage

• type 2 = major n damage

• but what is major n damage…..

CRPS s/sx

• widespread pain in affected region

• sensitivity to light touch

• changes in skin temp and/or color

CRPS diagnosis criteria

1. continuing pain, which is disproportionate to any inciting event

2. must report one symptom in three of the four categories

   • sensory - hyperalgesia, allodynia

   • vasomotor - temperature asymmetry, skin color changes or asymmetry

   • sudomotor/edema - edema, sweating changes/asymmetry

   • motor/trophic - decreased ROM, motor dysfunction (weakness, tremor, dystonia), trophic changes (hair, nail, skin)

3. must display at least one sign at the time of eval in two or more of the following categories

   • sensory

   • vasomotor

   • sudomotor/edema

   • motor/trophic

4. there is no other dx that explains s/sx

CRPS interventions

• retraining sensorimotor cortex

  • laterality training, graded motor imagery, mirror therapy

• desensitization

  • textures on skin

  • temp baths

• aquatic therapy

  • hydrostatic pressure can help with edema

  • buoyancy can help introduce LE WB

phalen’s test

pt seated and places dorsum of hands together, hold for 60 sec or until onset of symptoms in median n distribution

tinel’s at the wrist

PT taps area of median n, + if familiar symptoms occur

carpal compression

pt seated w hand palm up on table, apply compression to carpal tunnel for 30 sec, can add wrist flexion up to 60°

finkelstein’s test

pt forearm supported, PT grasps thumb and pulls down into ulnar deviation, + if familiar symptoms occur