Wrist + Hand Pathology

distal radioulnar joint is a

distal radioulnar joint is a

uniaxial pivot type

radoiocarpal joint is a

biaxial ellipsoid (pivot)

the TFCC functions to

reinforce ulnar wrist - binds ulna + radius together

cushions wrist -radius bares 60-80 of load

CMC (fingers 2-5) joint is a

plane joint

name of the carpal bones proximal to distal

scaphoid, lunate, triquetrum, pisiform

trapezium, trapezoid, capitate, hamate

CMC joint thumb is

saddle joint

MP joints 1-5 are

condyloid joints

PIP and DIP are

uniaxial hinge joint

A1 versus A3 (pulley system)

trigger finger relief = A1

surgery in flexor can sacrifice = 3

A2 + A4 can cause

flexor loss

arches of hand

longitudinal arch - long ways/vertical through center of palm

proximal transverse arch - proximal to hand across thumb horizontally

distal transverse arch - distal (metacarpal arch) horizontally across MP

zone I and II are bad because

they create too much scar tissue

kienbocks disease MOI

trauma, repetitive stress, or short ulna

kienbocks disease s/s

stage 1: aching/stiffness, pain with motion, and mild swelling

stage 2: more severe symptoms including swelling and pain with motion

stage 3: decrease ROM, painful radial instability

stage 4: constant pain, chronic swelling, decrease ROM, decrease grip strength

stage 3 and beyond of kienbocks disease is

not salvageable

management of kienbocks disease

stage 1: immobilize

stage 2 and 3a: revascularization procedures

stage 3b: fusion of carpals or proximal row carpectomy

stage 4: proximal row carpeectomy or wrist fusion

PT management of kienbocks disease

pain control, maintain ROM, progressive ROM and strengthening

TFCC dysfunction MOI

trauma, overuse and chronic fraying, associated with DRUJ instability

TFCC dysfunction s/s

reduced grip, tenderness with palpation between FCU tendon and ulna styloid process, pain with axial loading

skier’s thumb MOI

repeated twisting and hyperabduction injury

skier’s thumb s/s

unstable pinch and grasp

positive valgus stress test

carpal instability MOI

trauma/fracture, RA

carpal instability s/s

wrist pain, stiffness - tenderness over lunate and scaphoid, clicking + snapping, decreased grip strength

dorsal intercalated segmental instability

scaphoid + lunate - lunate stays extended migrates dorsal and wedges between hamate and capitate

volar intercalated segmental

lunate stuck in flexed position

acute carpal instability

closed or open reduction

ligament repair

immobilizations

progressive ROM and strengthening

chronic carpal instability

athrodesis, arthroplasty

ganglion cyst MOI

young adults, trauma and defects occurring with capsular structures

ganglion cyst s/s

painless lump typically on dorsum of wrist

management of ganglion cyst

aspiration but more common to reoccurrence

duputyren’s contracture MOI

genetic, men > women, 50-70 yrs old, metabolic changes

duputryen’s contracture s/s

nodular thickening in the palm

PIP and MCP flexed (often bilaterally)

duputryen’s contracture management

cannot stop progression of disorder, BUT

stretching, friction massage, tendon glides, and modalities

trigger finger MOI

uncertain - can be associated with RA, DM, and gout

trigger finger s/s

discomfort at base of digit

locking of finger/thumb

worse in morning

osteoarthritis most common in

CMC

RA s/s

joint pain, stiffness, swelling

ulnar drift

nodules at MCP and PIP joints

complex regional pain syndrome s/s

loss of hair on hand

brittle fingernails + shiny skin

increase/decrease sweating of palm

temperature difference between hands

deQuervains disease MOi

unusual or unaccustomed use of hand

deQuervains disease s/s

pain, swelling at radial wrist

palpable thickening of tendon sheath

+finkelstein’s test

mallet finger s/s

distal phalanx rests in a flexed position

swan neck deformity MOI

tearing to volar plate

contracture of intrinsic muscles

RA, ehler’s danlos syndrome

swan neck deformity s/s

flexion of MCP + DIP joints

hyperextension of PIP joints

boutonniere deformity s/s

extension of MCP + DIP, flexion of PIP

flexor digitorum superficialis lesion s/s

inability to actively flex at PIP joints when adjacent fingers are held in extension

flexor digitorum profundus lesion s/s

inability to actively flex at DIP joint when PIP joint is in extension

flexor pollicis longus lesion s/s

inability to actively flex at IP joint when MCP joint is in extension

A2 and A4 injury to flexors s/s

bowstringing of flexor tendons and reduced motion

extensor tendon versus flexor tendon rehab

extensor less rigorous and intense than flexor rehab (extensors immobilize for month then PT straight forward, flexors mobilize immediately and PT is complicated)

extensor tendon lesion s/s

loss of hyperextension at MCP joint

extensor lag of finger

relative weakness and pain in one finger when compared to another

CTS MOi

anatomical/pathological

diseases and predisposing factors

chronic physical stress

individual and environmental factors

sleep postures

CTS s/s

worse at night

burning, tingling, needles and pins

numbness in median nerve sensory distribution (1-3)

hand weakness and incoordination

+tinel’s sign + phalen’s

hand elevation test + compression over carpal tunnel

CTS prediction rule

shaking hands for symptom relief

wrist-ratio index greater than 0.67

symptom severity scale greater than 1.9

reduced median sensory field of digit 11

age greater than 45 yrs

ulnar tunnel syndrome s/s

direct pressure over guyot canal

sensation loss little finger and half of ring finger

decreased strength for thumb add/finger abd + add/finger of little finger

drop wrist deformity s/s

paralysis of wrist and finger extensors

forearm pronation

drop wrist deformity MOI

trauma of shoulder, elbow, humerus fractures

compression

hand myelopathy s/s

inability to extend + adduct the ring and little finger

exaggerated triceps reflex

+pathological reflexes

colles fracture s/s

silver fork deformity

pain with wrist/hand movements

local tenderness

smith fracture s/s

local tenderness + pain with wrist/hand mvts

radial styloid fracture s/s

local tenderness + pain with wrist/hand mvts

scaphoid fracture s/s

pain with wrist extension

weak and painful grip

pain with compression through 1st MC

tenderness anatomical snuffbox