Wrist Conditions

Anatomical Snuffbox

Tendons of EPB & APL

Tendon of EPL

Scaphoid

Carpal Tunnel Syndrome

compression of the median nerve within the wrist between the carpal bone and the transverse carpal ligament

symptoms: pain, numbness, and leads to weakness

complaints of numbness in the thumb, index, & middle fingers

Causes: Repetition/prolonged bending at wrist, sprains or fractures, arthritis, diabetes, pregnancy

Phalen’s test

test for carpal tunnel

Patient: Standing or sitting. Elbow flexion to 90, wrists placed into maximum flexion and pressed together, hold for 30-60 seconds.

Positive test: symptoms are reproduced as seen with carpal tunnel syndrome (numbness, burning, tingling) in median nerve distribution.

Tinel’s Sign Wrist

◦Useful for testing for carpal tunnel syndrome

◦Patient: Seated with hand on table (palms up).

◦Examiner: Lightly taps/percusses over the median nerve

◦Positive test: reproduces symptoms noted by tingling, “pins and needles” in the median nerve distribution.

Durkan’s Carpal Compression Test

◦Patient: Standing or sitting.  Forearm is supinated.

◦Examiner applies direct pressure over the carpal tunnel (median nerve) between the thenar and hypothenar eminence for 30 seconds.

◦Positive test indicates any numbness, pain, or paresthesia in the distribution of the median nerve.

Carpal Tunnel Syndrome - Conservative Treatment

◦Splinting

◦Patient education and activity modification –

◦Exercises

•Tendon Gliding - 15 reps, 2-3 x per day

•Median Nerve gliding

◦Decrease pain/Edema

◦Increase/maintain muscle strength

◦Modalities

Carpal Tunnel Syndrome - Conservative Treatment

Splinting

Wrist cockup splint, wrist 0-15 degrees extension

Worn @ all times if possible & at night for 6 weeks

Carpal Tunnel Syndrome - Conservative Treatment

Pt edu & activity modification

Wrist in neutral with daily activities, avoid sustained grip and pinch (especially with wrist flexion), repetitive use of wrist, sleeping with wrist in flexed position, workstation, ergonomic handles, avoid vibration or anti-vibration gloves

Carpal Tunnel Syndrome - Conservative Treatment

Exercises

•Tendon Gliding - 15 reps, 2-3 x per day

•Median Nerve gliding

Carpal Tunnel Post-Surgical Treatment

10-14 days post op

scar management 3-4 x/day for 3 min

scar pad while sleeping

desensitization 4-6 x/day

AROM & PROM to wrist and digits

Composite flexion and extension of digits

Tendon gliding exercises

Blocking exercises

Intrinsic stretches

Median nerve gliding exercises

Typically released with HEP until 4 weeks post op. 

Carpal Tunnel Post-Surgical Treatment

4-6 weeks

•Light hand strengthening (extrinsic and intrinsic)with soft putty

•Patient education and activity modification (repetition, vibration, flexibility exercises for rest breaks at work)

Carpal Tunnel Post-Surgical Treatment

6+ weeks

return to norm actives

Pillar Pain

common post op condition

typically occurs 3-6 months post surgery

deep pain in palm, near hook of hamate (usally resovles 8-12 weeks post)

pressure on palm, aggravated by activity or by hard objects in hand can cause pain

Padded gloves can be effective in diminishing pain

Modalities such as ultrasound and Iontophoresis have been helpful in dampening pillar pain

Clinical experience has found TENS to alleviate chronic nerve-related pain

Clinical experience has found ____ to alleviate chronic nerve-related pain

TENS

What is the most common fracture of the arm? That occurs with the fall of an outstretched hand.

It’s a distal radius fracture (DRF)

Colles Fracture

  - Results from falling onto an outstretched hand (wrist extension)

  - “Dinner fork” deformity: displacement is dorsal

-flexion harder to get back

Smiths fracture

Fracture of distal radius

“graden spade” deformity- displacment is volar/plamar

extension is harder to get back

Casting/closed reduction of Distal Radius Fracture (DRF)

-fracture may or may not require reduction (placed back into anatomical alignment)

-closed reduction, often performed in the ER, with nerve block, may use traction to help reduce the fracture

Often will place a fiberglass cast while pt is in traction

If unsuccessful → ORIF

Type 1 Extra/Intra-articular fractures – plaster cast is applied for 4-8 weeks.​

Type 2 Extra/Intra-articular fractures – plaster cast for 4-8 weeks after alignment of the fracture with manipulation.

Casting/Closed Reduction of DRF

Type 1

Extra/Intra-articular fractures – plaster cast is applied for 4-8 weeks.​

Casting/Closed Reduction of DRF

Type 2

Extra/Intra-articular fractures – plaster cast for 4-8 weeks after alignment of the fracture with manipulation.

ORIF - Distal Raidus fracture (DRF)

Type 3

Extra/Intra-articular fractures – either manipulation of the fracture with traction and stabilization with stainless steel wires or fracture is aligned and stabilized by plate and screws (Internal fixation) .

External Fixation of DRF

require surgery for alignment and stabilization of the fracture by external fixation, or internal plate and screws or both together.  Bone grafting is required when after stabilization there is more than 2mm gap between main fracture fragments.

-bullet wounds, MVA, trauma

Therapy for Distal Radius Fractures

Reduce pain

Reduce edema

Increase ROM

FMC    

Splinting

Strengthening 

Desensitization 

Function

Complications following wrist fractures

Stiffness: Extensor tightness of digits. Make sure patient’s flex at MP’s as well as IP joints.  Also encourage patient to move shoulder, elbow and forearm 3-4 times a day.

Complex Regional Pain Syndrome (CRPS)
Carpal tunnel syndrome

Tendon Rupture

Non-union or failure of the fracture to unite- fracture losses blood flow

Paresthesia in the hand during casting (increased edema)

Non-surgical Management of ​
Distal Radius Fractures (closed reduction)

1-5 weeks post-reduction

Therapy is minimal, education important for digit ROM and edema management

Non-surgical Management of ​
Distal Radius Fractures (closed reduction)

5-6 weeks post-reduction

•Cast removed and wrist cock-up splint fabricated

•Edema management (stockinette, edema glove, kinesiotape)

•AROM to wrist and forearm

•Complete supination with elbow flexed and pronation with elbow extended (maximizes stretch)

Non-surgical Management of ​
Distal Radius Fractures (closed reduction)

7 weeks post-reduction

•AAROM (focus on wrist and forearm ROM)

•Modalities as needed

•Splint removed for ADLs and when at home

•Hand strengthening