Week 13-14 - Wrist/Hand Conditions

Neuropraxia

Motor/proprioception effected, more of a transient problem with a good prognosis and 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.

Pathological nerve injury

-acute nerve ischemia

-segmental demyelination

-axonal disrupt/degeneration

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)

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?

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.

symptoms with superficial radial nerve palsy

pain at dorsoradial distal 1/3 forearm, hand, digits 1-3

positive special tests with superficial radial nerve

Tinel's over distal 1/3 of dorsal radius.

Are there motor losses with superficial radial nerve palsy?

NO. Only sensory.

Radial nerve injuries at the hand effect what muscles?

Extrinsics proximal to the wrist/hand

where is the only PURE region where radial nerve effects occur?

Dorsal Webspace.

common hand deformity with proximal radial nerve injuries?

Wrist Drop

Carpal Tunnel Syndrome

most common median nerve entrapment, as it runs through the carpal tunnel.

carpal tunnel structures

-FDS, FDP, FPL

-Radial/ulnar bursa

-Median NErve

interrupted median nerve function distal to the tunnel due to what?

-Carpal tunnel pressure

-Ischemic changes

-Compression

Personal risk factors for carpal tunnel syndrome

-Strong - Obesity, age, being female

-Weak - DM, OA, MSK disorders, estrogen replacement, hypothyroidism, CV disease, lack of activity, wrist ratio, hand shape, shorter stature

Occupation risk factors for carpal tunnel syndrome

forceful hand exertions, hand psych demand/low authority, vibration, prolonged off neutral position, repetitive work.

What is a red flag, that is NOT common for carpal tunnels syndrome

Bilateral symptoms

CTS differential diagnosis

cervical radiculopathy, thoracic outlet, systemic neuropathy, pronator teres syndrome.

symptoms of CTS

-Numbness/paresthesia digits 1-3 (half of 4)

-Burning pain

-Awakens at night

-radiation up to shoulder with hand use.

-dropping objects

-weakness/wasting APB, and thenar muscles

Tests for CTS

-Tinel's at wrist

-Phalen's/Reverse Phalen's

-Carpal compression

-ULTT1

Clinical prediction rule for CTS

Having more than three of the following:

1. Symptoms feel better when you shake hands?

2. Wrist/hand index >0.67

3. CTQ-SSS >1.9

4. reduced median sensory field of 1st digit

5. Age >45

poor prognosis for CTS

-Symptoms >1 year

-Night symptoms

-Positive phalen's

-Thenar muscle wasting

CTS conservative management

-Splinting/immobilization

-activity modification

-maintain strength

-nerve gliding

-tendon gliding

-address neck/shoulder

-postural stabilization

-corticosteroid injections

surgical management for CTS

releasing the transverse carpal ligament to stop compression of the median nerve

Post op PT for CTS

-Edema control

-scar management

-nerve and tendon gliding

-desensitization

-strengthening

-posture

Wrist tendinitis signs/symptoms

-tenderness, swelling, warmth

-Stiffness and pain, worse with activity.

-Reproduce pain with passive stretch and or active contraction of affected tendon

Wrist tendinitis interventions

-NSAIDs

-Physical agents

-Occasional splinting

-Activity modification

-Determine cause

Tendon disorders at the wrist

-DeQuervain's Syndrome

-ECU Tenosynovitis/subluxation

-Intersection syndrome

DeQuervain's Syndrome

Inflammation of the 1st dorsal compartment (APL < EPB), just proximal to the radial styloid.

DeQuervain's etiology

repetitive RD and UD, inflammatory process.

DeQuervain's symptoms

tenderness, swelling, warmth of 1st dorsal compartment. Squeaking, crepitus

DeQuervain's positive special test

Finkelstein's test (stretches APL, EPB)

differential diagnosis for DeQuervain's

-Thumb CMC OA

-FCR Tendinitis

-Scaphoid fracture

-Wrist OA

DeQuervain's interventions

-Thumb spica with wrist immobilized.

-IP is free of immobilized if bad.

-Interventions similar to tendinitis

-Determine cause (find trigger)

ECU Tenosynovitis and subluxation

From overuse. Subluxation may occur with wrist extension + UD + rotation.

Symptoms of ECU Tenosynovitis and subluxation

Pain distal to the ulnar head (6th compartment). Pain with MMT of ECU. Painful snap (subluxes) with provoking motions

ECU tenosynovitis and subluxation interventions

-Follow general treatment guidelines

-Subluxation - long term cast x 6 weeks (full supination + slight RD)

Intersection syndrome

Inflammation between APL and EPB, where is overlaps with ECRL/ECRB

intersection syndrome MOI

-Overuse

-repetitive flexion/extension

Intersection syndrome symptoms

Swelling and marked crepitus 6-8 cm proximal to the lister's tubercle. Pain with resisted wrist extension

Lister's tubercle

Dorsum of the radius proximal to the lunate.

Intersection syndrome interventions

-Conservative management

-Long thumb spica including the IP, 4 weeks.

-Corticosteroid injection (maybe)

-Maintain strength/ROM of other joints, safe ranges of wrist ROM.

Tendon Disorders of the Hand

-Flexor Tendon Ruptures

-Extensor Tendon Ruptures

-Trigger finger

-Dupuytren's Contracture

Isolated FDS rupture

no disability, no surgery required. Conservative management, compensation, adaptation

Isolated FDP rupture

No DIP flexion. Usually avoid surgery. DIP Arthrodesis (Slight flexion0

FDS + FDP rupture

-Repair within a week after acute injury.

-After 1 week, suture skin and delayed repair - may need to wait for skin healed; ROM restored before repair. Longer wait, poorer outcomes.

Flexor tendon Zone I rupture

Isolated FDP, not as serious

Flexor tendon Zone II rupture

FDP + FDS. "No man's land." serious very poor outcomes

Flexor tendon zone III rupture

flexors, common digital nerves and vessels, lumbricals. Good outcomes/prognosis.

Flexor tendon zone IV rupture

carpal tunnel area. Flexors, median nerve, ulnar nerve. Make sure no contraction of tendons prior to repair.

Flexor tendon zone V rupture

proximal to the carpal tunnel. Multi-tendon, neurovascular damage can occur.

wound healing with surgery in Zone II (No man's land)

inflammation, fibroplasia, maturation. Overabundance of scar tissue.

strength after surgery in zone II (no man's land)

falls for first 5 days. back to suture strength 9 days.

immobilization effects after surgery of zone II, no man's land

9 weeks immobilized can lead to 20% of normal tendon strength. with mobilization = 50% of normal tendon strength.

surgery with flexor tendon ruptures

tendon ends reattached, preserve pulley systems to preserve FDP/FDS relationship.

Healing rate after flexor tendon surgery depends on what?

Nutrition, part of the tendon affected, presence of viniculum.

Viniculum

small blood vessel that supplies the tendon.

Post op rehab for flexor tendon

-protocol driven

-promote healing

-preserve repair

-control edema

-reduce scar adhesion

-restore tendon gliding.

2 main flexor tendon protocol types

-Early Passive Mobilization (EPM)

-Early Active motion (EAM)

Early passive mobilization protocol

Passive flexion and active extension within a protective splint. Splinted so the flexor tendon is not put on stretch, but also not actively engaging them.

Early active motion protocol

active flexion and active extension within parameters of the protective splint.

benefits of an early active motion protocol

Better to increase excursion (gliding) of tendons and decrease adhesions. Added tension increases activity of teknocytes and collagen formation.

Extensor tendon rupture zones

Zone 1: Mallet finger

Zone 2: Splinting to surgical repair

Zone 3: central slip; boutonniere's

Zone 4: lateral band. Proximal phalanx

Zone 5: sagittal bands, at MCP

Zone 6: Hard to diagnose. Surgery

Zone 7: Risk for adhesion

Zone 8: Difficult to repair, graft possible

Mallet finger

Avulsion of the terminal tendon running down to the DIP extensors

Effects of a Mallet finger

Unable to extend the DIP

Intervention for mallet finger

Stack splint, DIP held in extension for 608 weeks. SHOULD NOT be allowed to flex, which could undue the healing process.

Central Slip Rupture

Weak PIP extension. >20 degrees loss of extension at the PIP with wrist and MCP full flexion. Able to extend DIP when PIP is fully flexed.

Central slip rupture may progress to what?

Boutonniere deformity

Intervention for central slip rupture

Splint PIP in extension x 6 weeks.

Swan Neck Deformity

Slipping of the lateral bands dorsally at the PIP. Causes PIP Hyperextension, DIP flexion.

Swan neck deformity is common in what condition?

RA.

Trigger finger (digital tenovaginitis stenosans)

Nodules on flexor tendons catch in a pulley, can thicken up to 3-4x its size. Usually A1 at MCP head.

Trigger finger may be assocaited with what?

RA, DM

With trigger finger, finger may lock in what position?

flexion

Symptoms of trigger finger

-Pain local to MCP or PIP associated with snapping

-Tender to palpation at MCP A1 pulley, where the nodule is.

-Possible palpable sheath thickening.

Interventions for trigger finger

-Local steroid injection, brief immobilization

-Splint in 0 degrees, MCP ext, allow IP to flex.

-Surgical release

Dupuytren's contracture

thickening of the palmar aponeurosis causing flexion contracture of 1 or more fingers. Formation of nodules

Dupuytren's contracture causes limitations with what?

MCP extension, PIP extension.

Dupuytren's contracture differential

flexor tendon contracture - bands will not move during flexion/extension

Interventions for Dupuytren's Contracture

-Surgery, indicated when MCP contracts to 30 degrees.

-Scar management, splinting, active assist and passive exercise.

-All initiated immediately.

Wrist instability classifications

-Scapholunate

-Lunotriquetral

-Mid-carpal

Static wrist instabiity

Usually a fracture or complete ligamentous disruption. Deformity is visible on radiograph, surgical intervention usually required.

Dynamic wrist instability

Sprains. Associated with laxity, partial disruption of supporting ligaments. No deformity/derangement.

Most frequent/common static wrist ligament injury

Scapholunate instability

Ligament associated with scapholunate instability

Scapholunate interosseous ligament

Carpal instability dissociative (within proximal carpal row)

DISI (Dorsal intercalated segment instability) - Complete ligament rupture

normal scapholunate angle

30-60 degrees

Scapholunate angle in a DISI

widening of the angle. Lunate tips backward dorsally, scaphoid goes into flexion

"Terry Thomas sign" on a radiograph with a DISI

darkness seen between the scaphoid and the lunate, indicates lack of connection between the bones

what is an intercalated segment?

proximal carpal row. Positioned between the radius and the distal carpal row.

What happens if the lunate connection to the scaphoid is disrupted?

ligamentous connection is disrupted and the lunate is only tied to the triquetrum. Lunate is pulled into dorsiflexion by the triquetrum, resulting in a DISI.