Clinical Orthopedics 222 Exam 3 Common conditions of the wrist and hand

Nerve entrapment

Median nerve
-carpal tunnel syndrome
ulnar nerve

what does palsy mean

weakness

Nerve entrapment
-median and ulnar nerve are what

peripheral nerves and have no nerve roots

Nerve entrapment
-there is no what

radial nerve conditions because there is no tunnel so there is no place for the nerve to get trapped

Carpal Tunnel Syndrome
-what is it

Entrapment compression neuropathy of the median nerve
-Increase in synovial fluid

Carpal Tunnel Syndrome
-most common what

Most common compression neuropathy of the wrist

Carpal Tunnel Syndrome
-caused how

by repetitive motion
(overuse of the flexors)

Carpal Tunnel Syndrome
-the carpal tunnel is formed by what

the transverse carpal ligament and the carpal bones

Carpal Tunnel Syndrome
-what is it (laymen’s terms)

swollen and irritated which entraps the median nerve.

Carpal Tunnel Syndrome
Symptoms

Pain
Numbness
parasthesia(tingling)
^-these 3 happen in the first 3 digits
weakness of grip and pinch
edema in the hand and forearm
atrophy of the thenar muscles
Symptoms are usually worse at night

Carpal Tunnel Syndrome
Factors

(all systemic)
Pregnancy
-fluid retention
Renal Dysfunction
Infection
Gout
Trauma
Collagen Disorder

Carpal Tunnel Syndrome
-what is the thenar

the palmar aspect of the base of the thumb

Carpal Tunnel Syndrome
-symptoms will follow what

Symptoms will follow the median nerve dermatome including the 1st three fingers and the medial aspect of the 4th digit

Conservative treatment
-how

modified activity
NSAIDS as per MD recommendation
Splinting
Physical therapy

Conservative treatment
-modified activity

elimination of symptom producing movements

Conservative treatment
-splinting

“cock-up” splinting
-0-20 degrees of extension

Conservative treatment
-physical therapy

progressive ROM activities
joint mobilization
modalities as needed

Conservative treatment
-when are splints used

Cock up splints encouraged at night and PRN(as needed) throughout the day

Why do you think a splint in 20 degrees of extension will help carpal tunnel syndrome?

-puts the carpal tunnel in a position where its not stretched
-slight extension to keep the wrist functional

Conservative treatment
physical therapy
-when doing this for a person with carpal tunnel syndrome, what should you be asking

if they have any pain, numbness or tingling

what is this

median nerve glide

what does a nerve glide do

moves the tendon (doesn’t stretch)

Surgical consideration
-if what doesn’t happen, then what is the next step

If symptoms do not respond to conservative treatment, surgical release is an option

Surgical consideration
-what symptoms do the patient present

Patient with constant sensory loss, pain, and atrophy

Surgical consideration
-what happens in surgery

cutting of the transverse carpal ligament

Surgical consideration
-surgical treatment?

Treatment is similar to conservative care, in addition to scar mobilization

ulnar nerve entrapment
-where does this happen

guyon’s canal

ulnar nerve entrapment
-what is this

Claw hand deformity
-extensor digitorum communis

ulnar nerve entrapment
-what does this affect

affects how you grab

ulnar nerve entrapment
-you are unable to do what

Inability to extend second and distal phalanges of any of the fingers
Inability to adduct or abduct fingers
-Including the thumb

ulnar nerve entrapment
-patient loses wha t

Loss of sensation on ulnar side of hand
-ring finger, little finger

ulnar nerve entrapment
-treatment?

Same treatment as carpal tunnel syndrome (including splint)
except you are treating digits 4-5

Nerve entrapment deformities

Claw hand
hand of benediction
Wrist drop

Nerve entrapment deformities
wrist drop
-what does it affect

affects C1-C3 as well C4-C5
radial nerve (losing control of extensors )

Claw Hand
-what is it

Unopposed action of ED in the fourth & fifth digit

Claw Hand
-what causes this

due to ulnar nerve entrapment at the wrist

Claw Hand
-what do you lose

Inability to extend the second and distal phalanges of any digits
Inability to add/abduct the fingers or perform opposition
Loss of sensation on the ulnar side of the hand

hand of benediction
-what can’t you do

inability to make a fist fully

hand of benediction
-what can’t you do

Cannot flex the index and middle fingers at the MCP and IP
Loss of sensation of the median aspect of the hand

How can you differentiate between claw hand and hand of benediction

they look similar but what is impaired vs active is how you can tell the difference

Wrist drop
-what causes this

Entrapment via the radial head at the elbow

Wrist drop
-what can’t you do

Inability to extend the thumb, wrist and phalanges
-Possibly the elbow
Inability to pronate or adduct the thumb
this affects grip

Wrist drop
-what type of involvement

Sensory involvement of the radial aspect of the hand

Where else can the radial nerve be entrapped
what would the effects be

Elbow  / shoulder
Triceps muscle weakness, pronation weakness

Where else can the radial nerve be entrapped?

the elbow

TFCC sprain (triangular fibrocartilage complex)
-what does this refer to

referring to the disc inbetween ulna and metacarpal

TFCC sprain (triangular fibrocartilage complex)
-what does the TFCC do

functions to transmit the loads from the hand to the forearm

The distal radioulnar joint (DRUJ)
-what is it

is a double pivot joint that unites the distal radius and ulna and an articular disc

the triangular fibrocartilaginous complex (TFCC)
-what is it and what does it do

an articular disc
assists in binding the distal radius and is the main stabilizer of the distal radioulnar joint

the triangular fibrocartilaginous complex (TFCC)
-what does it enhance

It improves joint congruency and cushions against compressive forces

the triangular fibrocartilaginous complex sprain
-treatment

rest
gentle PROM
Modalities
PROM AAROM
AROM
Strength
Isometrics

Tendonitis and tenosynovitis are both what

tendinopathy

Tenosynovitis refers to what

sheath or fluid

Tenosynovitis
-what does this effect

Extensor Pollicis Longus
Extensor Indicis Proprius
Extensor Carpi Ulnaris
Flexor Carpi Ulnaris
Flexor Carpi Radialis
De Quervain’s Disease *

De Quervain’s tenosynovitis
-what is it

cumulative trauma disorder

De Quervain’s tenosynovitis
-what does it affect

affects the tendon sheath of the abductor pollicis longus and extensor pollicis brevis

De Quervain’s tenosynovitis
-what kind of disorder

Disorder of the first dorsal compartment posteriorly

De Quervain’s tenosynovitis
-what is happening

Thickening of extensor retinaculum, narrowing of fibro-osseus canal
-Degneration

De Quervain’s tenosynovitis
-very common in who

Very common in new moms; lifting their babies with incorrect technique

Symptoms of De Quervain’s
which is

Pain at the radial styloid and decreased thumb ROM (snuff box)
Pain and weakness with radial deviation, thumb abduction and extension Possible inflammation
Difficulty gripping, grasping and lifting
Gradual onset

Symptoms of De Quervain’s
-what activites will be affected

Painting, hammering, golfing, fly fishing, typing, sewing, knitting, cutting, turning doorknobs

What is the difference between lateral epicondylitis and de quervain’s?

location, lateral epicondylitis is at the lateral epicondyle and de quervain’s is at the thumb

Treatment options for de quervain’s

Wrist/thumb immobilization x 2-4 weeks
Modification of activities
NSAIDS
Ice Iontophoresis/phonophoresis
Gentle ROM
Cortico-steroid injections
Surgical decompression

Treatment options for de quervain’s
-what demographic of people need to know what

New moms need to focus on using larger muscles and keeping thumb static when lifting their children

Treatment options for de quervain’s
-what does the surgical decompression entail

consists of the release of the sheath, post-op care/treatment parallels that of carpal tunnel release

Trigger finger
-what is it

Painful snapping of the finger
-Disproportion between flexor tendon and tendon sheath

Trigger finger
-sensitivity where

Tenderness over base of finger MCP

Trigger finger
-where is this found more

more common in the thumb, ring finger, and middle finger

Trigger finger
-cause?

idiopathic onset
-no real cause

Trigger finger
-treatment

immobilization in extension, steroid injections or surgical release (cutting the tendon), maybe modalities, STM

Dupuytren’s disease
-what is it

Palmar Fasciitis
-Disease that affects the palmar fascia with fibrodysplastic development in the connective tissue

Dupuytren’s disease
-what can this produce

Develops nodules that progress into cord-like contractures

Dupuytren’s disease
-what demopgrahic does this affect

usually affects men over 40 years of age

Dupuytren’s disease
-what percent involves how many sides

45% of all cases are bilateral

Dupuytren’s disease
-what can cause this (risk factors)

overuse of alcohol, diabetes, seizures

Dupuytren’s disease
-first stage

formation of the nodule

Dupuytren’s disease
-second stage

alignment of myofibroblast along lines of tension

Dupuytren’s disease
-third stage

thick bands of collagen to form contracture

dupuytren’s disease and contracture are what

the same thing

Dupuytren’s Contracture
-Dupuytren’s disease leads to what

Eventually will cause contractures of the fingers
-Usually the ulnar aspect of the hand
-Most common is the fifth digit

Dupuytren’s Contracture
-when this is greater than what value lead to what

Contractures greater than 20 degrees usually indicate surgical release

Dupuytren’s Contracture
-surgery where

Fasciotomy(cutting of the fascia to relieve pressure) or excision(cutting of the tissue to remove it) of the palmar fascia

Dupuytren’s Contracture
-what happens after surgery

Surgical incision is usually left open to prevent the development of scar tissue

Dupuytren’s Contracture
-what happens when incisions are closed

History shows that incisions that are closed developed scar tissue, tendon adhesions, tissue necrosis and infection

Dupuytren’s Contracture
-conservative treatment?
-what about after>

Conservative treatment hasn’t been shown to help prior to surgery Stretching, PROM and scar massage have been shown to be helpful after surgery

Tendon ruptures

Mallet finger
boutonnniere
deformity
swan neck
deformity

Mallet finger deform
-what is it

Traumatic disruption of terminal tendon of extension hood
(trauma- DIP flexion )

Mallet finger deform
-treatment?

6 weeks immobilization then AROM and PROM progressing flexion in 5-10 degree increments

Boutonniere deformity
-what is it

Disruption of the central extensor tendon at the PIP

Boutonniere deformity
-what is this grouped with and where

Typically associated with RA
In thumb = zigzag deformity

Swan Neck Deformity
-what is it

DIP joint is hyperflexed
PIP joint is hyperextended

Swan Neck Deformity
-what is this group with, what also ahppens

Typically associated with RA
Disruption of the extensor tendon across the PIP joint

Ulnar drift (MP ulnar deviation)
-what is it

palmar subluxation of the carpals
damage to collateral ligaments and the extensor mechanism

Ulnar drift (MP ulnar deviation)
-imbalance the is the result of wha t

imbalance that has the resultant effect of pulling the fingers into ulnar deviation, pronation, and palmar subluxation.
RA

Distal Radial Fractures
Colles’s fracture

A radial fracture within 2.5 cm of the wrist
Distal radius is displaced in a dorsal direction

Distal Radial Fractures
smith’s fracture

“Reverse Colles’ fracture”
Results from a fall on the dorsum aspect of the hand
Distal radius is displaced in a palmar direction

colles’s fraction results from what

a FOOSH injury