Wrist & Hand (no flexor/extensor zones)

What is the most common injury following FOOSH?

distal radius fracture (DRF)

What is conservative treatment for DRF?

- closed reduction with immobilization

- hard cast 6-8 weeks followed by possible use of OTC or custom cockup splint

What should be addressed with splinting?

comfort

ORIF for DRF

- more invasive, some patients don't like the idea of surgery

- benefit of decreased immobilization time

- increased infection risk

T or F: Carpal Tunnel Syndrome following DRF is relatively common acutely OR delayed?

True

T or F: More patients treated surgically developed carpal tunnel following DRF?

True

What is the second most common fracture of a FOOSH?

scaphoid fracture

T or F: Half of scaphoid fractures are missed on initital x-ray.

False - 20-30%

What is a possibility with scaphoid fracture?

- non-union and eventual AVN due to unique blood supply

How is blood supplied in scaphoid?

distal to proximal pole

lateral border of snuff box tenderness

abductor pollicis longus

extensor pollicis brevis

medial border of snuff box tenderness

extensor pollicis longus

T or F: incidence of metacarpal fractures increases from ulnar to radial.

False - more ulnar = more fracture risk

What is a boxer's fracture?

a break in the neck of the 5th metacarpal

What does a boxer's fracture result from?

striking a hard object with a clenched fist

What is treatment for non-displaced boxer's fracture?

immboliziation

What is treatment for displaced boxer's fracture?

internally fixed with screw of k-wire

What is a Bennett fracture?

break occuring at the base of the thumb resulting from forced ABDUCTION of 1st metacarpal

T or F: Bennett fracture is easily identified on an x-ray

True

T or F: Bennett fracture has the same mechanism as Skier's Thumb/Gamekeeper Thumb (UCL) injury

True

What is the most common site of OA in the hand?

1st CMC

What is the amount of force the 1st CMC joint takes when pinching?

8x

What is treatment for 1st CMC OA?

- joint distraction/mobilizations

- light strengthening

- functional gripping/gathering

What modifications should be made for 1st CMC OA?

reduce pinching force by increasing the diameter of commonly held objects

T or F: bracing is used to treat 1st CMC OA

True

T or F: Arthroplasty is a good option when conservative measures fail for treating 1st CMC OA.

True

What happens to palmaris longus with 1st CMC arthorplasty?

trapezium bone is removed and the first metacarpal is suspended or supported using a graft from the palmaris longus, FCR, or APL tendons​

Post-op for 1st CMC arthroplasty

immobilized and light motion and strength to begin around 4-6 week​

What are tendinous injuries?

- mallet finger

- jersey finger

- Bountonneire deformity

- swan neck deformity

- trigger finger

- tendon lacerations

mallet finger

injury to a finger's EXTENSOR tendon (which attaches to the bone at the distal phalanx)

causes: finger to fall into flexion and unable to straighten

T or F: mallet finger can be a tendon rupture of avulsion fracture

True

What is the most common cause of mallet finger?

direct blow to the tup of the finger - attempting to catch a ball

How is the splinting performed for mallet finger?

DIP into EXTENSION

fill extension maintained at all times for usually 6-8 weeks

What do patients generally present with after mallet finger splinting?

severe joint stiffness

When is surgery an option for mallet finger?

severe cases with displaced P3 fragments

jersey finger

FDP tendon tears at its insertion on the distal phalanx of the finger

What is the most common finger for jersey finger?

ring finger

T or F: Jersey finger requires surgical intervention

True - Button repair

Boutonniere deformity

affects PIP joint

occurs when the central slip of the extensor tendon (which extends the finger) tears or ruptures

What happens to the lateral bands of the extensor mechanism with Boutonniere deformity?

slides down over the middle phalanx

PIP joint flexes, DIP joint hyperextends

T or F: Bountonniere may be the result of trauma or chronic inflammatory conditions like RA

True

Swan neck deformity

hyperextension of PIP with flexion of DIP

Why do most people develop a swan neck deformity?

from an inflammatory conditiono

What also may cause swan neck deformity?

connective tissue disorder or imbalance due to neurologic disorders

What splint can be used for swan neck deformity?

oval 8

trigger fingger

a catching or clicking sensation when moving the finger

What may be felt at the base of the affected digit with trigger finger?

a nodule

What may happen in a severe case of trigger finger?

finger may lock in a bent position

What is the "triggering" caused by with trigger finger?

inability of the flexor tendons to glide through the annular ligaments

What is the most common site of triggering?

A1 ligament/pulley

What type of resting/splinting is used for trigger finger?

night splinting

Why should steroid injections be used for tendinous injuries?

decrease inflammation

What is the surgery for trigger finger?

release of A1 pulley

How many flexor zones are digits 2-5?

5

How many flexor zones are there for digit 1?

3

What happens in zone 2?

FDS/FDP/bone adhesions

What is often required following healing of tendon repair in zone 2?

tenolysis

What follows surgical repair for tendinous injuries?

splinting

How is a splint placed following surgical repair of tendinous injuries?

maintain slack in flexor tendon to protect repair

What will rehab protocols vary based on with tendon repairs?

- zone of injury

- strength of repair

What are strands?

number of lengths of sutures used to repair tendons?

What does a higher number of strands mean?

stronger the repair

tendon gliding exercise 1

open hand

tendon gliding exercise 2

hook fist

tendon gliding exercise 3

full fist

tendon gliding exercise 4

table top

tendon gliding exercise 5

flat fist

T or F: patient needs to return to open hand position between each rep of tendon gliding exercises

True

What are the positions of tendon gliding exercises designed to encourage?

FDS and FDP excursion between each other and underlying bone

Dupuytren Contracture

condition that causes the fingers to curl and thicken due to the formation of thickened cords of tissue of the palmar aponeurosis

T or F: Dupuytren contracture is more common in women.

False - men

T or F: Dupuytren contracture is most often seen in people of Northern European descent

True

T or F: Dupuytren contracture is associated with other health conditions.

True - ex. diabetes and liver disease

What are the most effected fingers with Dupuytren Contracture?

ring and small finger

What are the 3 stages of Dupuytren Contracture?

proliferative

involution

residual

Dupuytren Contracture:

proliferative stage

small, firm nodules (bumps) in the palm of the hand

Dupuytren Contracture:

involution stage

nodules mature and become cords

Dupuytren Contracture:

residual stage

cords become dense and permanent

Injections for Dupuytren Contracture

- corticosteroids

- collagenase (breaks down the collagen in the cords)

What leads to increased risk of flexor tendon rupture during manipulation?

collagenase injection

What is the most common surgery for Dupuytren Contracture?

fasciectomy - removal of thickened tissue that caused the contracture

minimally invasive procedure where needs are used to break up the fascia (for Dupuytren Contracture)

needle fasciotomy

When should PT interventions begin after Dupuytren contracture surgery?

early - promote motion and limit re-formation of scar tissue

What is the minimum contracture for Dupuytren Contracture?

30

TFCC

triangular fibrocartilage complex

located on ulnar side of the wrist - between ulna and triquetrum

What is the TFCC made up of?

- triangular fibrocartilage disc (TFC)

- ulnocarpal collateral ligament

- dorsal and volar radioulnar ligaments

- extensor carpi ulnaris tendon sheath

What does the TFCC provide?

- stability to the wrist joint

- cushions during impact

- helps transmit forces between forearm and hand

What can cause TFCC injury?

- trauma

- repetitive stress

- ulnar variance (ulna is too long)

TFCC splinting

ulnar gutter splint:

provides protection and rest

**Limits pronation (ulna longer in relation of radius)

TFCC surgery

debridement of TFCC tear

osteotomy to shorten ulna

SLAC Wrist

scapholunate advanced collapse

progressive degeneration and collapse of the wrist joint - specifically between the scaphoid and lunate bones

SLAC Wrist - traumatic injury or repetitive stress

ticked ya both

What does the capitate act as?

a wedge separating the scaphoid and the lunate especially during heavy gripping activities

T or F: SLAC wrist early stages may not show on x-rays

True - unless wrist is "loaded"

Treatment for stages 1-2 of SLAC Wrist

conservatively

Treatment for stages 3-4 of SLAC Wrist

surgical candidate