MSK II Unit 4: Wrist and hand

what is complex regional pain syndrome

chronic neuropathic pain due to dysfunction of the PNS and/or CNS

what is the MOI of complex regional pain syndrome (5)

recent trauma

fracture and cast

surgery

stroke

heart attack

what makes up the carpal tunnel

Flexor retinaculum

carpal bones

what is complex regional pain syndrome also referred as (3)

sho hand syndrome

RSD

causalgia

why does complex regional pain syndrome occur

there is miscommunication between the ANS and brain which triggers a response with edema attempting to heal and heightened sensations to protect from more harm

how does the sympathetic system respond to injury in complex regional pain syndrome

it dilates blood vessels leading to onset of swelling, pain, and redness

what is reported in the subjective exam of complex regional pain syndrome (4)

severe pain disproportionate to injury

hypersensitivity

swelling and skin changes (hair, sweating, nails)

protective behaviors/fear avoidance

what is seen in the physical exam of complex regional pain syndrome (5)

swelling/pitting edema

redness, warmth

temperature changes (hot or cold)

hair and nail changes

decreased function

what interventions are done in PT for complex regional pain syndrome (5)

graded activity/exposure

sensory training

massage and muscle pump for edema

maintain mobility

pain science education

what goes through the carpal tunnel

4 FDP tendons

4 FDS tendons

flexor pollicis longus t

median n

what are the potential causes of carpal tunnel (6)

trauma

ergonomics

displaced or hypermobile lunate

edema/effusion

hormones

C5-T1 nerve roots

what gender is more likely to get carpal tunnel syndrom

female (1.5-4 x more likely)

what age is more prone to carpal tunnel

4th-6th decade of life

what health issues increase risk for carpal tunnel syndrome (3)

overweight or obese

diabetes

excessive alcohol

what are occupational risk factors for carpal tunnel syndrome (2)

repeated activity specifically grip

chronic wrist flexion or vibration

what are the s/s of carpal tunnel (4)

pain, numbness, tingling

paresthesia along median neve with palmar cutaneous sparing (more proximal)

improves with shaking of hands

nocturnal numbness

what is the clinical prediction rule for carpal tunnel syndrome (5)

hand shaking improves symptoms

wrist ratio index >.67

Brigham and women's hospital hand symptom severity scale >1.9

diminished sensation in median n sensory distribution

age >45

What special tests help diagnose carpal tunnel (3)

phalens

tinels

carpal compression test

what clinical findings are associated with carpal tunnel (3)

weakness and/or atrophy in thenar musculature

loss of two point discrimination, decreased sensation

EMG and NCV tests

how is carpal tunnel treated (6)

a-mod and pt edu (ergonomics, neutral wrist position)

splits and braces to prevent abnormal positions

release entrapment with joint mobility and soft tissue

neural glides

strengthen muscles to improve position and postures

RTF

what are finger tendon glides used for

promotes gliding of tendons in the carpal tunnel

what areas may benefit from manual therapy with carpal tunnel syndrome

cervical spine and UE

what makes up guyons tunnel

pisiform and hook of hamate

what runs through guyons tunnel

Ulnar nerve and ulnar artery

what is the most common cause of guyons tunnel entrapment

ganglion cyst

what are the causes of guyons tunnel entrapment (6)

ganglion cyst

repetitive trauam (cyclists handlebar, compression)

hook of hamate fracture/displacement

tumors

aberrant muscle or excess fat tissue in anal

ulnar artery thrombosis

what is the clinical presentation of guyons canal (5)

pain, numbness, and/or tingling in ulnar distribution

palmar and dorsal cutaneous sparing

weakness is grip

atrophy

hand deformity with progression

what may be seen when asking pt to make a fist with entrapment at guyons canal

can't fully extend fingers due to deep ulnar damage

what special tests are used for guyons tunnel entrapment (2)

Froments

wartenburg

what should the pt be educated on with guyons canal entrapment

limit prolonged compression

ergonoics

what manual therapy should be used for guyons canal entrapment (3)

releasing the entrapment site

nerve mobilization

joint mob as needed

what nerve is impacted in chieralgia paresthetica (wartenburg syndrome)

superficial radial nerve

where is the superficial radial nerve compressed (2)

at brachioradialis where nerve becomes superficial

at wrist due to external compression

what other diagnosis need to be differentiated with superficial radial nerve entrapment (4)

intersection syndrome

dequervains

CMC OA

C6 radiculopathy

what special tests are used for superficial radial nerve entrapment (4)

tinels

sensation

Finkelstein's

radian nerve tension

what are the synovial sheaths of the hand

specialized synovial sheaths for the long tendons in the wrist and hand that protect tendons

what is tenosynovitis

infection, trauma, and overuse causing excess friction

what is trigger finger

stenosing tenosynovitis/tendovaginitis

thickening of flexor tendon sheath causing finger to stuck in flexion and unable to extend

what is seen in trigger finger with active flexion

the tendon becomes stuck proximal to A1 pulley and the pt must passively extend finger to pass tendon

what are the predisposing factors of trigger finger (3)

swelling around the flexor tendons

nodule within flexor tendons

thickening of fibrous sheath of flexor tendons

what is done for activity modification in the acute phase of trigger finger

avoid potentially aggravating movements like pinching or grasping of the finger

what splint is used for trigger finger in the acute phase

oval 8 and blocking splint to prevent passing of flexors through A1 pulley

what activity modifications should be made for trigger finger

avoid potentially aggravating movement such as pinching or grasping of the fingers

what splinting can be done for trigger finger

oval 8 or blocking splint to prevent passing of finger flexors through A1 pulley

what can be done for pain in trigger finger (4)

NSAIDs

stretching

local glucocorticoid injection

surgery

what is dupuytrens contracture

contracture of the palmar fascia of the hand

cellular level formation of nodules on palmar fascia that thickens and shortens palmar fascia pulling MCP and PIP into flexion

what fingers are commonly impacted in dupuytrens contracture

digits 4 and 5

what are the predisposing factors for dupuytrens contracture

European Caucasian males

trauma

what treatments are used for dupuytrens contracture (3)

resting hand splint

excise tissue with Z incision

tenolysis

when is PT often used for dupuytrens contracture

after surgery for scar management and ROM

what is dequervains tenosynovitis

tenosynovitis of the first dorsal compartment impacting the abductor pollicis longus and extensor pollicis brevis

what population is impacted by de quervains tenosynovitis

females more than males

age>40

common in pregnant and new moms

how does de quervains tenosynovitis present

gradual onset but can be traumatic overload

pain and swelling on dorsolateral radial side of wrist and pain with grip

what activities are difficult with de quervains tenosynovitis

difficulty with repetitive gripping, lifting, and twisting

in the objective exam for Dequervains what is seen in AROM and PROM

pain with active and passive stress to APL and EPB

what special tests are likely positive with dequervains

finkelsteins test

where is palpation painful in de quervains

palpation to the radial styloid and/or tendons

what is seen upon structural exam and movement exam with de quervains

crepitus or thickening of tendons moving in the tendon sheath

what is seen in strength with de quervains

diminished grip strength

what is proximal intersection syndromew

inflammation due to friction at the intersection of the 1st and 2nd dorsal compartments (APL and EPB/ECRB and ECRL)

tenosynvitis of the ECRB/L, APL, and EPB

how does proximal intersection syndrome present (3)

history of repeated pronation/supination and wrist movements

crepitus

pain and/or swelling 4-8 cm proximal to Listers tubercle

what population has increased risk for proximal intersection syndrome (5)

weightlifters

rowers

racket sports

horseback riders

skiers

what movements are painful in the objective exam with proximal intersection syndrome (2)

pain with passive wrist flexion

pain with resisted extension

where is palpation painful with proximal intersection syndrome

pain at the intersection point 4-8 cm proximal to lister's tubercle

what special tests are positive with proximal intersection syndrome

Finkelstein's is positive at intersection site

what is distal intersection syndrome

pain at the crossing of EPL and ECRL/B more distal

where is there pain and swelling with distal intersection syndrome

over listers tubercle

what is ECU tendosynovitis associated with (3)

rowing

racquet sports

golf

what occurs with supination in ECU tenosynovitis

the tendon bends in the sub sheath and if the sheath is injured it can sublux

how is tensosynovitis treated

a-mod and pt education of excessive wrist movements

wrist splint

gentle stretch

manual therapy

tendinopathy frameowkr for loading

contributing factors

what non PT interventions can be used for tenosynovitis (3)

cortisone injection

NSAIDs

surgical debridement

what is boutonniere deformity

central slip tear from middle phalanx as the lateral bands slip anterior

hyperextend DIP, flex PIP

what is swan neck deformity

injury to extensor mechanism where lateral bands slip posterior

hyperextend PIP flexed DIP

what is mallet finger

rupture or avulsion fracture of the terminal tendon

unable to extend DIP

what is the most common sprained wrist ligament (3)

palmar radiocarpal ligament

TFCC

scapholunate ligament complex

what is the MOI of scapholunate ligament injury

FOOSH/FOOSA or other hyperextension

what is reported with scapholunate ligament injury

pain deep in centra or dorsolateral wrist

pain with wt bearing and EOR movements

what is the MOI of lunate dislocation

FOOSH with UD

MVA or high speed impact

what is a common complication of lunate disloction

median nerve entrapment

what is seen in the objective exam of lunate dislocation (3)

limited ROM

limited joint mobility posteriorly, potential laxity with sublux

muscular guarding

what is gamekeepers thumb

Thumb UCL injury due to hyperabduction of the thumb MCP

what is the MOI of gamekeepers thumb (3)

hunting

FOOSH

football or ski poles

what is seen in the structural exam of gamekeepers thumb

swelling and ecchymosis

what is seen in PROM with gamekeepers thumb

excess radial abduction >35 deg or >15 deg opposite side

what is seen in joint mobility for gamekeepers thumb

increased radial translation

what special test is used for gamekeepers thumb

valgus stress test

what is the TFCC

articular disc at the distal ulna with ligaments stabilizing it to the distal radioulnar joint

what occurs to weight bearing if the TFCC is removed

the radius bears about 95% of load opposed to 60%

what is the function of the TFCC

stabilizes and cusions

what is the MOI of TFCC injury (4)

FOOSH with pronation and UD

forceful twist

repeated axial load from UD wrist

associated with radial head fracture dislocation

what is reported in a TFCC injury

deep ulnar sided wrist pain with pron/sup, grip, EOR wrist ext

tender to touch

local swelling

possible click

instability

weak wrist or forearm

where is palpation painful with TFCC injury

at ulna fovea sign

what is seen in joint mobility with TFCC injury

painful and laxity in UMTV and DRUJ

what special tests are positive with TFCC injury (2)

supination lift test

TFCC compression test

what is the general treatment approach to TFCC injury (3)

activity mod

immobilization

general strength and stabilization

what is the MOI of scaphoid fractures

FOOSH with wrist in extension and slight RD

where is pain reported in the subjective of a scaphoid fracture

pain in anatomical snuffbox

what is a complication with imaging for scaphoid fractures

it is commonly missed on radiographs acutely

can get imaging done weeks later

what is a common complication with scaphoid fractures (3)

avascular necrosis if the scaphoid is split in two there is no blood flow to the proximal carpal due to blood flow from the distal pole

delayed healing

non-unions

what should PT focus on post immobilization post scaphoid fracture (3)

hyper/hypomobilities

swelling

tight extrinsics