PT528 Hand and Wrist Differential Diagnosis

_________ are the most frequently fractured bones in the body

distal phalanges

hand fractures MOI

usually a crush injury

hand fracture treatment

drain hematoma, early protection with plastic or aluminum orthosis holding DIP in extension

PT not very common with these -> focus on ROM, desensitization

mallet finger is also known as what?

baseball finger

mallet finger MOI

striking the tip of the finger

mallet finger clinical presentation

DIP in flexed resting position, with loss of active extension; sometimes PIP is in hyperextension

Swelling.

Bruising.

Redness.

An inability to straighten your fingertip.

Tenderness.

A detached fingernail.

Redness under the fingernail bed.

what is mallet finger (baseball finger)?

extensor tendon rupture

mallet finger tests

do resisted testing -> probably weak and painless, may be pain due to swelling

mallet finger treatment

orthosis to maintain full extension of DIP

Patient's must maintain this position 24/7 to

what is jersey finger?

avulsion of the insertion of the FDP

Most commonly on the ring finger

jersey finger MOI

Active DIP flexion followed by a large force pulling the finger into extension

jersey finger clinical presentation

Inability to actively flex the DIP joint

jersey finger treatment

Tendon repair and bone pinning if necessary

splint finger (DIP and PIP) in slight flexion

orthopedic follow up for surgical repair

scaphoid fracture MOI

FOOSH

scaphoid fracture clinical presentation.

Complaints of dorsal wrist pain, especially with any type of wrist motion or activity, such as gripping.

Tenderness over the anatomic snuffbox.

Decreased active range of motion of the wrist.

Decreased grip strength.

Normal neurologic examination

scaphoid fracture differential diagnosis

Wrist sprain

De Quervain tenosynovitis.

Fracture of the distal radius.

Scapholunate dissociation.

Wrist osteoarthritis.

Intersection syndrome.

Intercarpal instabilities

Superficial radial neuritis

C6 cervical radiculitis/radiculopathy

scaphoid fracture treatment

Immobilization in a long-arm or short-arm thumb spica cast, with the wrist position and length of immobilization dependent on the location of the fracture for approximately 2 weeks at least

PROM to wrist and hand followed by AROM

Gentle strengthening exercises are begun with 1- to 2-lb weights or putty. Over a period of several weeks, the exercise program is progressed to include weight-bearing activities, plyometrics, open and closed chain exercises, and neuromuscular reeducation, before finally progressing to functional and sport-specific exercises and activities.

distal radius fracture MOI

FOOSH

distal radial fracture clinical presentation

Swelling, deformity, and discoloration around the wrist and distal radius.

May have associated skin injury and bleeding. -> complete fracture that penetrated the skin

May have decreased sensation in the median, radial, or ulnar nerve distribution.

May have decreased circulation to the hand.

common associated injuries with a distal radius fracture

Carpal and distal ulna fractures, intercarpal ligament sprain, TFCC injuries, median nerve injuries

Rupture of EPL can be a late complication of nonsurgical treatment of distal radius fracture

distal radius fracture treatment

Casting, surgery

Can mobilization joints distal and proximal while immobilized

what are wrist sprains?

Can range from minor injury to SL ligament to lunate dislocation into the carpal tunnel

Often involves the SL, LT and RSC ligaments

wrist sprains MOI

falling -> ice, stairs

sports

wrist sprains clinical presentation

Pain on the radial side of wrist either at rest or with activities

Complaints of decreased grip strength

Pain with WB

TTP over scaphoid tuberosity or SL joint line

Possible positive scaphoid shift

wrist sprain treatment

depends on the grade of the sprain!!

IF GRADE 1

-ice, compression, massage, e-stim, elevation, submit isometrics all to decrease swelling and pain

-AROM

-strengthen muscles around the ligament to increase stability

what is gamekeepers thumb also known as?

skiers thumb

what is gamekeepers thumb?

Injury to the ulnar collateral ligament of the thumb (the MCP joint)

Leads to instability of the MCP joint, and decreased functioning in both pinching and opposition involving the thumb

gamekeepers thumb MOI

Traumatic injury or repetitively injury

gamekeepers thumb clinical presentation

Pain, tenderness and swelling along the ulnar side of the MCP joint (in the acute phase).

Complaints of pain, weakness, or loss of stability (in the chronic phase).

Impaired MCP joint flexion and extension, especially when acute and swollen.

Decreased pinching strength resulting from instability or acute pain.

special tests for gamekeepers thumb

UCL stress test

gamekeepers thumb differential diagnosis

Fracture, extensor tendon injury

gamekeepers thumb treatment (grades I and II)

Grade I and II tears immobilization in a thumb spica cast for 3 weeks, with additional protective splinting for 2 weeks.

The splint is worn at all times except for removal for hygiene and exercise.

AROM of flexion and extension begins at 3 weeks, and progresses to strengthening exercises by 8 weeks, taking care not to apply any abduction stress to the MCP joint during the first 2 to 6 weeks.

gamekeepers thumb treatment (grade III)

Grade III tears and displaced bony avulsions are treated with surgery and immobilization.

Postsurgical rehabilitation involves wearing a thumb spica cast or splint for 3 weeks with an additional 2 weeks of splinting, except during the exercises of active flexion and extension

special tests for OA of the thumb CMC

grind test

1st CMC OA clinical presentation

Joint pain at the base of the thumb, which is increased with usage, restricted ROM in a capsular pattern, and joint crepitus.

The patient may also report difficulty performing tip to tip pinching, lateral pinching, and twisting motion (starting a car) and heavy gripping.

Tenderness over the palmar and radial aspects of the thumb in the region of the base of the thumb.

Positive grind test at the CMC joint.

1st CMC OA differential diagnosis

Fracture of the scaphoid.

De Quervain tenosynovitis.

Arthritis of the wrist.

Carpal tunnel syndrome.

Flexor carpi radialis tendonitis.

1st CMC OA treatment

Conservative intervention includes splinting, thermal modalities (moist heat or paraffin), exercise, and patient education.

Joint mobilization

The thumb spica splint should position the CMC joint in palmar abduction, to maximize the stability and anatomic alignment of the joint, with the IP joint free. The splint is typically worn for 3 weeks

patient education

what should you educate your patient on with 1st CMC OA?

minimize or avoid mechanical stresses including sustained pinching.

avoid sleeping on the hands as this forces the thumb into adduction.

use self-help devices such as jar lid openers and ergonomic scissors.

what is the capsular pattern of the thumb CMC?

abduction more than extension

what is trigger finger?

Trigger finger is an inflammation of the two flexor tendons of the finger, which become thickened and narrowed as they cross the MCP head in the palm causing a painful snapping phenomenon. The thumb, long and ring fingers are most commonly affected.

trigger finger MOI

Idiopathic (often observed in middle-aged women) or associated with rheumatoid arthritis or diabetes mellitus.

trigger finger clinical presentation

Complaints of a painful finger or loss of smooth motion (catching) of the finger when gripping or pinching.

There may be complaints of a painful nodule in the distal palm usually at the level of the distal flexion crease.

Local tenderness is elicited with palpation at the base of the finger, directly over the tendon as it courses over the metacarpal head.

Crepitus or a moving nodular mass in the vicinity of, or slightly proximal to, the A1 pulley.

Pain select tissue tension tests

Full flexion of the finger may not be possible.

trigger finger differential diagnosis

Diabetes mellitus

Dupuytren disease.

Ganglion of the tendon sheath.

Rheumatoid arthritis

trigger finger treatment

Reduce swelling and inflammation in the flexor tendon sheath, and to promote smooth movement of the tendon under the A1 pulley.

Corticosteroid injection into the flexor sheet is now considered the treatment of choice.

promote smooth movement of the tendons -> tendon glides

what is Boutonnière deformity?

caused by a rupture of the extensor tendon over the middle phalanx. Trauma occurs to the tip of the finger, which forces the DIP joint into extension and the PIP joint into flexion

Boutonnière deformity clinical presentation

complains of severe pain and inability to extend the PIP joint. There is swelling, point tenderness, and an obvious deformity

Boutonnière deformity treatment

cold application followed by splinting of the PIP joint in extension. Splinting is continued for 5 to 8 weeks. While splinted, encouraged to flex the distal phalanx.

what is De Quervain tenosynovitis?

An inflammation of the extensor and abductor tendons of the thumb (extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus)

De Quervain tenosynovitis MOI

repetitive or unaccustomed use of the thumb

De Quervain tenosynovitis clinical presentation

Wrist pain on the radial side

Difficulty with grasping and gripping

Possible swelling at the radial styloid process.

Palpation elicits pain at the site of the retinaculum at the radial styloid.

Positive Finkelstein's and Eichoff

De Quervain tenosynovitis differential diagnosis

Scaphoid fracture

Tendon rupture

Radial nerve neuritis

Basal joint arthritis (CMC joint of the thumb)

Rheumatoid arthritis

what is the goal of treatment De Quervain tenosynovitis?

The goals of the intervention are to reduce the inflammation, to prevent adhesions from forming, and to prevent recurrent tendonitis

De Quervain tenosynovitis treatment

Symptomatic relief through splinting—thumb spica splint.

Steroid injections made directly into the fibrous sheath of the first dorsal compartment.

Gentle active range of motion exercises for short periods. These are progress to isometric exercises and then concentric exercises.

Grasping and releasing of small objects emphasizing a wide variety of prehensile patterns

what is dupuytren disease?

Fibroproliferative disease of the digital and palmar fascia

Begins as a palpable nodule in the palm at palmar crease (in flexor tendon sheath)

Progression sees cords forming that extend distally and proximally

Resulting in joint flexion contractures at the MP, PIP joints

flexor tendons very prominent

dupuytren disease MOI

Genetic and environmental factors

Typically males of Northern European descent

dupuytren disease treatment

Conservative -> steroid injections, splinting

Surgical -> fasciotomy, post-op physical therapy

what is intersection syndrome?

friction at the junction between the first and second tunnels of the dorsal wrist -> tenosynovitis

Affects the first and second compartments of the dorsal wrist extensors.

The condition is thought to occur as a result of repetitive friction at the junction in which the tendons of the first dorsal compartment cross over the second, creating a tenosynovitis

intersection syndrome MOI

typically the result of repetitive extension and flexion exercises or activities

rowing or canoeing, skiing, racquet sports, and horseback riding

intersection syndrome clinical presentation

Swelling over the distal forearm as there can be some cases that present with a palpable finding on exam 4 cm - 6 cm proximal to Lister's tubercle.

Crepitus is a very common finding on the exam over the site of irritation (a finding that is specific to intersection syndrome).

The two dorsal compartments cross the movements of pronation and supination, create friction resulting in the exam finding of crepitus.

Pronation is typically found more uncomfortable than supination.[1]

The Finkelstein's test resulted in uneasiness.

intersection syndrome differential diagnosis?

De Quervain tenosynovitis (first extensor compartment involvement only, located more distal at the radial styloid)[2]

Muscle strain

Entrapment of the dorsal radial sensory nerve as it emerges beneath the brachioradialis (Wartenberg'ssyndrome)

Thumb CMC arthritis

Extensor pollicis longus (EPL) tendinitis

intersection syndrome treatment

Splinting

Taping

Anti-inflammatories

how to tell if pain is due to muscle tendon or tendon sheath (tendinitis vs tenosynovitis)?

with tendinopathies, there will be pain with isometrics

with tenosynovitis, there won't be the same pain with isometric contraction bc the tendon is not moving in the sheath

what is carpal tunnel syndrome?

compression of the median nerve is the carpal tunnel

carpal tunnel syndrome MOI

idiopathic but may be associated with pregnancy, hypothyroidism, diabetes, overuse phenomena, trauma, and tumors in the carpal tunnel.

carpal tunnel syndrome clinical presentation

Complaints of numbness in the median nerve distribution, primarily in the tips of the first three fingers.

Complaints of pain in the forearm and wrist.

Symptoms may awaken patient from sleep.

Thenar atrophy may be present (sign of advanced disease).

special tests for carpal tunnel syndrome

Phalen.

Tinel.

Carpal compression test.

ULTT 1 (median nerve bias).

carpal tunnel syndrome differential diagnosis

Cervical radiculopathy

Peripheral neuropathy

Proximal median nerve compression syndromes—pronator syndrome, anterior interosseus syndrome

what is ulnar nerve entrapment?

Entrapment of the ulnar nerve at the wrist can occur at the Guyon canal

ulnar nerve entrapment MOI

Typically caused by repetitive trauma or a space occupying lesion such as a lipoma, ganglion, ulnar artery aneurysm, or muscle anomaly

ulnar nerve entrapment clinical presentation

May or may not have pain.

Claw hand (in advanced cases) resulting from unopposed action of the extensor digitorum communis in the fourth and fifth digits.

An inability to extend the second and distal phalanges of any of the fingers.

An inability to adduct or abduct the fingers, or to oppose all the fingertips, as in making a cone with the fingers and thumb.

An inability to adduct the thumb.

Positive Froment sign.

Atrophy of the interosseous spaces (especially the first) and of the hypothenar eminence.

A loss of sensation on the ulnar side of the hand, the ring finger, and most markedly over the entire little finger. The dorsal ulnar aspect of the hand should be normal as that is innervated by the dorsal cutaneous branch.

ulnar nerve entrapment differential diagnosis

Peripheral neuropathy—diabetes, with its associated neuropathies or cheiroarthropathy, may be an underlying cause of chronic wrist pain.

Carpal tunnel syndrome.

Thoracic outlet syndrome.

Arthritis of the wrist.

Ulnar neuropathy at the elbow.

Cervical radiculopathy (C 7-8).

ulnar nerve entrapment treatment

Conservative intervention for mild compression involves the application of a protective splint and patient education to avoid positions and postures that could compromise the nerve.

Surgery

what is Wartenberg Syndrome/cheiralgia paresthesia?

Radial nerve compression at the wrist

Wartenberg Syndrome/cheiralgia paresthesia MOI

Trauma, diabetes, repeated exposure to the cold, hand exertion, tightly worn wristwatch or handcuffs, lipoma, surgeries, or compression between the brachioradials and ECRL muscles

Wartenberg Syndrome/cheiralgia paresthesia clinical presentation

Pain, numbness, tingling or hypersensitivity in the distribution of the radial nerve

Positive Tinel's at distal radius or radial styloid process

MMT of brachioradialis and or wrist extensors may elicit symptoms

Wartenberg Syndrome/cheiralgia paresthesia differential diagnosis

Cervical radiculopathy (C6), De Quervain, first CMC OA, intersection syndrome

Wartenberg Syndrome/cheiralgia paresthesia treatment

Avoiding wrist compression, gentle nerve gliding

Possible surgeries