Week 13-14: Wrist & Hand

Carpal bones proximal row

scaphoid, lunate, triquetrum, pisiform

Carpal bones distal row

trapezium, trapezoid, capitate, hamate

wrist joints

-DRUJ

-----pro/sup

-Radiocarpal

------includes articular disc

-Midcarpal

------ med/Lat compartments

Extrinsic wrist ligaments

Connect the forearm to a carpal bone

More superficial layers

Intrinsic wrist ligaments

from carpal to carpal.

Deepest layer.

Tightly binds the carpal bones

TFCC (triangular fibrocartilage complex)

Occupies the ulnocarpal space.

Includes

Triangular fibrocartilage (TFC) aka articular disc

Capsular ligaments of DRUJ

Ulnar collateral ligament

TFCC main responsibility

Primary stabilizer of the DRUJ, which is responsible for pronation and supination

Max grip force occurs at about

30º of extension

nerves of the wrist/hand

-Median (motor and sensory)

-Ulnar (motor and sensory

-Radial (sensory only in wrist/hand)

wrist/hand specific patient history

-Age

-repetitive movements? (Occupation?, Sports?, Hobbies?)

-Onset (sudden, gradual, clear cause or insidious)

-MOI

-Numbness/tingling, Paresthesia's at night?

-Alleviating movements/positions

-pain/problems/injuries anywhere else in the upper quarter

Trauma to hand

Causes lots of hand injuries esp occupational health d/t workplace accidents and equipment malfunctions

Observation: Common Hand Deformities

Bouchard's nodes

Heberden's nodes

Mallet finger

Boutonniere

Claw Hand

Zigzag

Ulnar drift

Swan neck

Wrist drop

Functional hand assessment

Open and closed hand

Lumbrical

hook grip

Straight fist: DIPs are extended, PIP and MCP are flexed

Closed fist w/ thumb

Pulp to pulp

Tip to tip

Key pinch

straight fist

DIPs are extended, PIP and MCP are flexed

Intrinsic plus

MCP flexion, PIP and DIP extension

extrinsic plus

MCP hyperextension and IP flexion

Grip and grip strength

CMC of thumb and 5th CMC are contributors to make cylinder and spherical grip

Chuck or three finger pinch (digital prehension)

Thumb, index, and middle finger grasp and object

wrist/finger Tissue Length testing

- Finger extrinsics

- Finger intrinsics

lateral or key pinch

Thumb and index finger adduct and flex

resting position of the radiocarpal joint

neutral, slight ulnar deviation

Closed pack position of the radiocarpal joint

extension

capsular pattern of radiocarpal joint

flexion and extension equally limited

resting position of the intercarpal joint

neutral or slight flexion

close pack position of the intercarpal joint

extension

resting position of the midcarpal joint

neutral or slight flexion with ulnar deviation

closed pack position of the midcarpal joint

extension with ulnar deviation

capsular pattern of the midcarpal joint

equal limitation of flexion and extension

carpometacarpal joint resting position

thumb - midway between abduction and adduction, flex/ext

finger - mid flexion/extension

carpometacarpal joint closed pack position

thumb - full opposition

finger - full flexion

carpometacarpal joint capsular pattern

thumb - abduction, extension

fingers - equal in all directions

metacarpophalangeal joint resting position

slight flexion

metacarpophalangeal joint closed pack position

thumb: full opposition

fingers: full flexion

metacaropophangeal joint capsular pattern

flexion, then extension

interphalangeal joint resting position

slight flexion

interphalangeal joint closed pack position

full extension

interphalangeal joint capsular pattern

flexion and extension

when providing OP to the wrist, where should the pressure be placed, and why?

the 3rd MCP, it is the central pillar and most stable. 4th, 5th, and 1st MCP are very mobile.

wrist flexion end feel

tissue stretch

wrist extension end feel

firm/hard

wrist RD/UD end feel

firm/hard

end feels of the digits

-MCP flex - hard/firm

-MCP ext - firm

-Abd - firm

-IP flex - firm/hard, maybe soft tissue

-IP ext end feel - firm

-composite finger flex - soft tissue/ firm

end feels of the thumb

-CMC flex - firm/soft tissue

-CMC ext - firm

-CMC abd - firm

-CMC opposition - firm/soft tissue

Composite finger flexion

Measure from distal palmar crease to tip of finger

Tip should be able to touch palmar crease for norma

CMC opposition

Measures distance between thumb and 5th metacarpal

position for dynamometer grip testing

arm at side, elbow at 90 degrees. Handle in midposition, but depends on patient's hand size.

grip is most effective with the wrist in what position?

slight extension

when to question's a patients effort with grip dynamometry ?

if there is a >20% discrepancy in repeated trials

general trends of grip strength

peaks from early to mid-adulthood, then declines.

5- 10% difference in dominant vs nondominant is normal

Pinch dynamometer

Average of 3 trials on each hand

Do each type of pinch

Chuck

Lateral

Tip to tip

Wrist reflex tests

Reflexes same as the UQ Screen

- Biceps

- Triceps

- Brachioradialis

static 2 point discrimination

uses a two point discriminator, determines where a patient can feel. Start at 15mm spacing, bring it down smaller and smaller

normal 2 point discrimination

<6mm spacing

fair 2 point discrimination

7-10 mm spacing

poor 2 point discrimination

11-15 mm spacing

2 point discrimination can help determine what?

can give idea about where a patients sensory function is.

what does a patient need for protective sensation?

perception of one point on 2 point discrimination

moving 2 point discrimination

More functionally correlated

Tests person's quickly adapting mechanoreceptors

Start with 8mm and move to 2-5mm

Easier to feel moving than static

Move along length of nerve longitudinally

normal moving 2 point discrimination

2-5 mm is normal, moving it along the length of the nerve longitudinally.

what to assess for circulation of the wrist/hand

-pulses

-skin color, trophic changes

-allen test

-capillary refill

-edema

-Volumetrics

-figure of 8 method

GIRTH OR CIRCUMFERENTIAL

Landmarks

MP heads, radial head, measured point from landmark

Volumetrics for edema

Fill with room temp water

Must be room temp

 Put arm in straight

 Spreader bar between 3rd & 4th

 Measure the water that comes out

Normal volumetrics

 ~10 ml >non-dom

MDC 10ml

Swelling volumetrics

30 - 50 ml

figure of 8 method

-Start at ulnar styloid.

-Across volar wrist crease

-Dorsal to 5th MCP

-Around to volar 2nd MCP.

-Dorsal back to ulnar styloid.

functional assessment for hand

-Jebsen-Taylor Hand Function test

-Box and Block Test

-Moberg's Pick up test.

-Purdue Peg board test

-9 hole peg test.

Dorsal glide of the wrist helps with what movement?

flexion

volar glide of the wrist helps with what movement?

extension

lateral glide of the wrist helps with what movement?

UD

medial glide of the wrist helps with what movement?

RD

Joint Play Digits

Fingers/Thumb MP, IP

- Volar glide

- Dorsal glide

- Lateral glide (MCP)

-Distraction

Joint Play Digits Intermetacarpal

- AP rocking

Joint Play Digits

Thumb CMC

- Volar/dorsal

- Medial/lateral

- Internal/external rotations

- Distraction/compression

palpation of wrist/hand

-skin/tissue mobility

-scars

-carpals

-metacarpals

-phalanges

-distal radius and ulna

-tendons

Wrist ligamentous special tests

Varus & Valgus Stress of Finger IP's

Thumb UCL Stress Test

Retinacular test (oblique retinacular lig)

Lunotriquetral Ballotment Test

Watson Scaphoid Shift Test (S-L Instab)

Dorsal Capitate Displacement Apprehension Test

Finger Extension "shuck" test (SL Path)

Piano Keys Test (DRUJ - TFCC tear, triq instab)

Lichtman Test (mid-carp instability)

Sitting Hands/Press Test (TFCC, wrist synovitis)*

Supination Lift Test

Wrist tendon and muscle special tests

Finkelstein's Test

Sweater sign

Central Slip Test ( test for extensor hood rupture)

Bunnel-Littler (joint contract v intrinsic v extrinsic)

wrist nerve special tests

Tinel's Sign (Carpal Tunnel Syndrome)

Flick sign/maneuver

Wrist ratio index

Phalen's (Flexion) test

Reverse Phalen's (extension) test

Carpal Compression Test

Froment's Sign (ulnar nerve)

2-pt discrimination

wrist intra-articular special etsts

Grind Tests (joint degeneration)

wrist outcome measures

DASH

**Not hand specific

CT Function Disability Form

Michigan Hand Outcomes

at minimum, what should an upper quarter screen consist of?

-Patient history outside of the wrist/hand

-AROM C-Spine, shoulder, wrist/hand

-neuroscreen C4-T1

Neuropraxia

Focal conduction block

Motor and proprioception defects

Transient problem

Good prognosis with quick recovery

Axonotmesis

Loss of conduction at injury site, and distal due to compression. Prognosis can be good or poor depending on severity.

Neurotmesis

Loss of conduction at site and distally due to severed nerve.

Requires surgical repair

Pathological nerve injury

-acute nerve ischemia

-segmental demyelination

-axonal disrupt/degeneration

Mononeuropathy

disease affecting a single nerve

Mononeuropathy Multiplex

Pathology of 2+ nerve in 1 extremity

Polyneuropathy

Pathological involvement of multiple nerves usually both motor and sensory involvement

Sensory re-education/hierarchy of return from nerve injury

-Pressure

-Heavy moving tough

-Moving 2 point discrimination

-Static 2 point discrimination

-Light touch

-Vibratory sensibility

-Tactile-gnosis.

general rehab guidelines for nerve injuries

-Repair of lacerated nerve requires 3-4 weeks immobilization

-correct and prevent contractures/deformity

-strengthen as muscle function returns

-adaptation

-pain control/desensitization

Guyon's Syndrome

Ulnar nerve entrapment in Guyon's canal (hand-piso-hamate canal)

Gyon's syndrome MOI

Ganglion > trauma, RA, direct compression

Guyons demographics

Bicyclists, racquet sports, wheelchair athletes

Less common than cubital tunnel entrapment

sensory deficit location with Guyon's syndrome

Palmar, NOT dorsal

motor loss with Guyon's

ulnar intrinsic weakness, deformity in advanced conditions.

Positive special tests with Guyon's

Phalen's/reverse Phalen's, Tinel's @ Guyon's, Froment's, Wartenberg's. Possible Allen's test

what to screen for with Guyon's

Cervical, cubital tunnel, double crush

how long to immobilize after repaired lacerated nerve in guyon's?

3-4 weeks.

interventions for Guyon's

-correct/repair contracture

-strengthen as muscle function returns

-adaptation

-pain control/desensitization

-scar management

-neural glides

Superficial radial nerve palsy

less frequent entrapment, can be from compression at the dorsal-radial wrist by tight wristwatch, or impact at that part of the wrist.

Superficial radial nerve palsy aka

Wartenburg's Syndrome/ Cheilalgia paresthetica