Wrist and Hand Conditions

general considerations

multiple articulations provide for wide range of movement
dexterity and precision-of-movement demands
integrity and balance of structures is key

work-related musculoskeletal disorders (WRMD)

injuries or disorders of the muscles, nerves, tendons, joints, cartilage associated with exposure to risk factors in the workplace
account for 1/3 of all lost work days
WRMD of wrist and hand are associated with greater lost productivity than any other body region

conditions

ligament injuries: wrist sprain, dislocation, UCL injury to thumb
tendon injuries: DeQuervain's disease, intersection syndrome
trigger finger
rheumatoid arthritis
Dupuytren's disease
TFCC tear
Kienbock's disease
fractures
tendon lacerations
CTS
nerve injuries
complex regional pain syndrome (CRPS)

wrist sprain

hx of trauma (FOOSH), negative ulnar variance
scapho-lunate dissociation most common and significant wrist sprain
pain well localized
active/passive physiologic movements may be normal, palpatory tenderness common (end range mvmt, particularly ext -> pain)

scapholunate dissociation

traumatic injury -> fall
disruption of scapholunate ligament
radiographic fractures: widened SL interval (>4 mm)
clinical signs and sx: minimal swelling/pain localized over dorsal scapholunate region, pain with active wrist extension

Terry Thomas sign

scapholunate dislocation/dissociation

MCP and IP joint dislocation

MOI: MCP - dorsally directed force
IP - axial loading during hyperextension
S&sx: pain, swelling, and stiffness (Grade I, II, III)
imaging may be indicated to r/o fx

Grade I - pain, swelling, no instability
Grade II - partial macro tear, increased joint play
Grade III - complete disruption, instability from basketball, volleyball

UCL of thumb

common hand injury in sports
can rupture from proximal phalange most common secondary to hyperabduction, hyperextension, or overuse
local pain and swelling in thenar web space, radial instability, dec pinch strength
radiograph should be requested

tenosynovitis

involves synovial-lined tendon
inflammation of tendon sleeves
stenosing - sheaths become thickened and fibroses (tendon doesn't slide like it normally should)

tendonitis

acute, inflammation

tendinosis

longer term, fibrotic, less inflammation

tendinopathy

chronic tendon pathology, weakening of the tendon

tendonitis/tendinosis/tenosynovitis

any extrinsic tendon can be involved
most common: (1) 1st, 2nd, and 6th extensor compartments
(2) digital flexor tendons beneath A1 pulley (volar side of MCP, usually see trigger finger)

flexor apparatus

5 annular and 3 cruciate pulleys
hold underlying tendons at fixed distance from joint (AOR)
allows for large ROM at fingers
*without pulleys, contraction of extrinsic finger flexors would pull tendons away from joint AOR*
paratenon - loose areolar connective tissue around tendon in areas of low mechanical stress

extensor compartments

1 - APL, EPB
2 - ECRL, ECRB
3 - EPL
4 - ED, EI
5 - EDM
6 - ECU

DeQuervain's Disease

tenosynovitis 1st dorsal compartment
EPB and APL tendons
mechanism: repetitive movement (gamers, factory workers, musicians)
clinical signs incl swelling, decreased ROM, weakness of grip and pinch (tip to tip/chuck)
primary sx: pain radiating to forearm (point tender)
+Finkelstein's test
cluster of signs and sx

intersection syndrome

involves tendons of EPB, APL "intersecting" with ECRB and ECRL
MOI: repetitive movements - esp raking, shoveling, canoeing, kayaking
signs and sx: local pain, radiating pain to thumb or radial forearm
swelling
redness
crepitus
palpatory tenderness

trigger finger

signs and sx: morning stiffness, pain with gripping, palpable nodule palmar aspect of digit, inability to extend digit or popping sensation followed by release during extension

rheumatoid arthritis

begins with synovitis of distal RU joint
hand joints most commonly affected: MCP, IP of thumb (interferes w hand function - painful, weak, dec grip strength)
signs and sx: joint pain and swelling, tenderness to palpation rheumatoid nodules, constitutional sx (fever, fatigue, weight loss)
surgical mgmt: synovectomy, arthrodesis, arthroplasty

ulnar drift

common with rheumatoid arthritis
formation of inflammatory pannus, vascular tissue laid down inside synovium - causes distruction/erosion under bone and hyaline cartilage
doesn't tolerate standard loading, susceptible to micro fractures
try to interrupt inflammation with meds but meds --> immunocompromised

RA v OA

RA: thickened synovium --> breakdown of cartilage and surrounding bone, eroded cartilage, bone loss, less white and more dark on radiograph

OA: modest synovial changes, bone spurs, degenerated cartilage

Dupuytren's disease/palmer fascial fibromatosis

affects palmar fascia between skin and flexor tendons - begins as inflammatory fibrosis
palmar aponeurosis becomes adaptively shortened
MCP joint most frequently involved, then PIP
can be insidious, occurs in people prone to CT problems
PT mgmt: US, extension splints, stretching, maintain hand function
surgical mgmt: fasciectomy with progressive MCP contracture >30 degrees

TFCC injury

has poor blood supply (central 1/3rd vascular), capability of healing not good
MOI: axial loading to extended, pronated wrist (sprain or fx), ulnar sided distraction and torsion (golfing) repetitive axial loading
associated with positive ulnar variance, can -> breakdown of this structure
classified based upon traumatic v degenerative (9 diff subtypes based upon structures involved)
signs and sx: deep, ulnar-sided pain with pronation, supination, + gripping, + supination lift test, + TFCC shear, + TFCC grind

TFCC contents

triangular fibrocartilaginous disc and meniscus homolog
-TFC attaches to hyaline cartilage radially making it vulnerable to injury
extensor carpi ulnaris subsheath
ulnotriquetral and ulnolunate ligaments
dorsal and volar distal radioulnar ligaments
ulnocarpal collateral ligament
*do not need to know exactly what's causing the issue in the TFCC

Kienbock's disease

necrotic changes in lunate d/t loss of blood supply
associated with negative ulnar variance
most common in men 20-40 y/o
signs and sx: wrist pain and swelling, palpatory tenderness of lunate, impaired wrist ROM and strength
surgical management common (bone graft)

fractures

Galeazzi
Colles
Smith's
Scaphoid
Bennett's
Boxer's
Barton's
Kienbock's

distal radial fx

most common fx
75-80% minimally displaced: 6-8 weeks of immobilization
25% are complex and unstable - high impact and require surgical mgmt and rigid fixation (ORIF), longer immobilization, prolonged rehab

Galeazzi fx

distal radius fx with dislocation of the distal RU joint
requires ORIF
potential for compartment syndrome involving anterior interosseous nerve
-symptoms: no sensory innervation, motor n - FPL, PQ, flexor compartment

colle's fx

involves distal radius with dorsal displacement of distal fragment and radial shift of carpus and hand
extra-articular
external or internal fixation
5-8 weeks healing time
may lead to complex regional pain syndrome (CRPS)
"silver fork deformity"
dorsal angulation about 30 degrees

smith's fx

involves distal radius with volar displacement of distal fragment (reverse Colle's fx)
MOI fall onto flexed wrist or direct blow
5-9 weeks healing time
usually an extraarticular transverse fx
internal fixation likely

scaphoid fx

represents 60% of all carpal fx; 2-7% of all fxs
FOOSH injury
avascular necrosis is a common complication (~30%) due to poor blood supply (in fx proximal to waist)
-70-80% occur through scaphoid waist (moderate AVN risk)
-20% occur through proximal pole (high incidence of AVN)
-10% occur through distal pole (low incidence of AVN)
capitate and lunate dislocations are commonly associated

scaphoid blood supply

X-ray every week or two
looking for evidence of healing
if not - bone graft

avascular necrosis of scaphoid

Bennet's fx

fracture and displacement of 1st MC from the proximal end
oblique intra-articular fx
tension of AbPL sublimes fragment in dorsal, radial, and proximal direction -> tension from AdP displaces fragment into palm
MOI: trauma (ie football), high impact sports

Boxer's fx

fx of the neck of the 5th MC
results in acute angulation of the head of the MC into palm
mechanism of injury - typically punching a wall, not a seasoned boxer

flexor tendon injuries

second most common injury to hand
tendon disruption: varies from clean cut/tear to untidy injury with blood vessel and nerve damage
delayed repairs involve artificial tendons or graft (palmaris longus)
early mobilization is advantageous to facilitate collagen remodeling (if don't get them moving, risk fibrotic hand tissue)

flexor tendon injury zones

1 - flexor digitorum profundus distal to insertion of flexor digitorum superficialis
2 - insertion of flexor digitorum superficialis to proximal edge of A1 pulley ("no man's land")
3 - proximal edge of A1 pulley to distal edge of carpal tunnel
4 - within the carpal tunnel
5 - proximal to the carpal tunnel

extensor tendon repairs

surgical repairs are much more common for extensor injuries
tx is less complex and healing response is greater as compared to flexor injuries
7 zones identified to classify injury
easier to manage d/t less complex nature of anatomy

carpal tunnel syndrome

causes include radioulnar, radoiocarpal, and carpal fx; swelling of nerve, swelling of flexor tendon sheaths and anatomic variants
sx include numbness and tingling, pain (night), and weakness
signs incl dec sensation (median n. distribution), atrophy of thenar mms (1/2 FBP, OP, 1st and 2nd lumbricals), + phalen's and tinel's test
NCV testing results (look for latency - takes longer for impulse to travel down axon)

CPR for CTS

shaking hands relieves sx
wrist-ratio index >.67 (AP/ML width)
symptom severity scale (SSS) >1.9
age >45
reduced sensory field of 1st digit (in median n. distribution)

>/= 3 positive: +LR = 2.1
>/= 4 positive: +LR = 4.6
all 5 positive: +LR = 18.3

ulnar n. compression

occurs at guyon's canal - formed by pisiform, volar carpal ligament and transverse carpal ligament
-extends ~4cm to hook of hamate
commonly caused by direct pressure on handlebar with biking
clinical signs: loss of sensation (ulnar distribution) and weakness of the ulnar 2 lumbricals, hupothenar mms, interossei, dep head FPB, AddP

complex regional pain syndrome (CRPS)

AKA: reflex sympathetic dystrophy (RSD) or causalgia
hallmark is vasomotor dysfunction
pain is the primary sx
involves an abnormal sympathetic reflex
three characteristic phases

CRPS phase I

acute phase of injury
pain and edema primary sx
discoloration of the hand develops
hyperhydrosis also develops
approximately 3 months duration

CRPS phase II

subacute
pain and edema remain primary sx
pale cyanosis reduces redness (more straightforward vasoconstriction)
dry skin
skin and subcutaneous tissue atrophy
3-12 months

CRPS phase III

marked joint stiffness
thickening of palmar fascia
osteoporosis
skin and subcutaneous atrophy more severe - hand deformity
skin is dry, pale and shiny
pain may continue or begin to subside
(lacks hair growth)