853: wrist pathos

PT diagnosis for carpal tunnel syndrome

May be a pattern of wrist flexion or wrist extension

Pathophysiology of carpal tunnel syndrome

• compression of the median nerve in the wrist as it passes through

  • Bordered by carpal bones and the transverse carpal ligament

• Increased pressure within the tunnel occurs when either the volume of the tunnel decreases or the volume of the contents increases

  • Increased pressure leads to ischemia or axonal compression of median nerve

  • Presents as pain, paresthesias, and/or numbness in the volar aspect of the three radial digits

  • Advanced cases may include weakness and atrophy in the thenar muscles and lumbricals

Anatomy of the carpal tunnel

• bordered by the carpal rows and the transverse carpal ligament

• Contains 9 flexor tendons - 4 tendons from the FDS, 4 from the FDP, and 1 from the FPL

• Contains 2 bursae: radial bursa encasing the FPL, and ulnar bursa surrounding the FDS and FDP tendons

• Median nerve is most superficial structure within the tunnel, sits bw the transverse carpal ligament and the ulnar bursa

Number of risk factors associated with CTS

• diabetes, obesity, hypothyroidism

• Work or sport that requires repetitive wrist motions

  • Typing or vibration

• Often results from sleeping with the wrists positioned in full flexion

S+S of carpal tunnel syndrome

• pain and paresthesias are felt in the volar aspect of the index and middle fingers and in the radial aspect of the ring fingers and the thumb, as well as the dorsum of these digits distal to the DIP joint

• If there is weakness, typically seen as decreased strength for thumb opposition

• Sympathetic nerve involvement may manifest as decreased sweating in the involved area

• May report difficulty manipulating small objects

Nature of symptoms of carpal tunnel syndrome

Dull, aching pain and paresthesias in median nerve pattern

Aggs for carpal tunnel syndrome

Prolonged positioning in flexion or extension, WB through the hand/palm, sustained repetitive activities

Eases for carpal tunnel syndrome

Avoiding Aggs, orthoses to maintain a wrist neutral position, taking breaks from repetitive activities, shaking out the hand

24 hr pattern for carpal tunnel syndrome

Can occur anytime throughout the day, often can be worse at night causing the pt to wake up

Objective examination for carpal tunnel syndrome

• + compression test

• + Phalen’s test

• + tinel’s test

• Advanced cases may demo atrophy of the thenar eminence and weakness of thumb opposition

• Somme’s Weinstein monofilament testing

Clinical prediction rule for carpal tunnel syndrome

1. Shaking the hand relieves symptoms

2. Wrist ratio index > 0.67 Using a caliper

3. BCTQ symptom severity scale score > 1.9

4. Decreased sensation in the top of the thumb compared to the base of the thenar eminence

5. Age >45

Potential pertinent hx for carpal tunnel syndrome

May not be any significant relavent history

Could report a hx of wrist injury that might predispose to CTS

Potential predisposing factors for carpal tunnel syndrome

• work or sport requiring repetitive hand activities

• Diabetes, obesity, hypothyroidism

• Higher wrist ratio: more square wrist

• Factors that decrease carpal tunnel space

• Factors that increase the volume of the carpal tunnel contents

Imaging/tests for carpal tunnel syndrome

Nerve conduction studies are gold standard

PT management for carpal tunnel syndrome

• studies found manual therapy was effective in improving

  • Pain, physical function, and nerve conduction studies

Medical management for carpal tunnel syndrome

Surgical release of the transverse carpal ligament

• indicated for pts with measurable sensory loss and/or weakness/atrophy of the thenar eminence muscles

• Also for those that haven’t improved with conservative management

Definition of colles fracture

• fracture of the distal end of the radius, often accompanied by fracture of the ulnar styloid

• Usually occurs about an inch or two proximal to the radiocarpal joint

• Distal portion of the wrist and hand are displaced posterior and laterally resulting in “dinner fork” deformity

Pathophys of colles fracture

• typically occurs from a FOOSH

  • Posterior and lateral displacement of the fractured area is usually the result of landing in a position of shoulder IR, elbow ext, forearm pronation, and wrist extension

• More common in 6-10 and 60-69 year olds

S+S of colles fracture

• wrist pain, may refer into the forearm or into the hand

• Movement may be limited by pain or bony block

• Deformity in the wrist may be noted

• Nerve symptoms are not common and may indicate severe complications

Symptom nature for colles fracture

Acute fracture may present with sharp pain and may be a deep ache

Aggs for colles fracture

All movements likely to be painful in acute phase, gripping activities, lifting activities, and functional activities

Eases for colles fracture

Casting or orthoses, elevation, ice, compression, minimizing use of hand

24 hr pattern for colles fracture

Pain likely more constant with acute, then as healing continues may be more stiff/achy first thing in the morning

Objective examination for colles fracture

• pain and tenderness in the distal 2 inches of the radius/ulna

• Dinner fork deformity

• Acutely: will see edema and bruising, after casting → forearm atrophy

Potential pertinent history for colles fracture

Likely will report history of a FOOSH

• younger pts at risk with sports

• Older pts at risk with balance deficits

Potential predisposing factors for colles fracture

With older pts: hx of osteoporosis or osteopenia

Imaging/tests for colles fracture

• xray is the most appropriate in the setting of acute

• Non displaced fractures may require CT

PT management for colles fracture

• focus on restoring functional AROM in all planes of wrist motion

  • Pts that had ORIF can begin AROM sooner than those that were only casted

• Wrist extensor strengthening to improve grip and avoid maladaptive grip patterns

• Mobilize radiocarpal and midcarpal joints to improve motion

• If still casted can work on finger flexion to prevent contractures

Medical management for colles fracture

Surgery

• percutaneous pinnin or ORIF for unstable fractures

  • Surgery may also be warranted if there is loss of bone length, malalignment, fracture into the joint

• Simple, stable fractures that can be reduced manually do not require surgery, just casting

PT diagnosis for De Quervain’s Syndrome

Typically a pattern of wrist ulnar or radial deviation

Pathophys of De Quervain’s Syndrome

• refers to chronic irritation of the EPB and APL tendons as they pass deep to the extensor retinaculum in the first dorsal compartment

  • Acute: may have inflammatory component but thickening of tendon sheath is more likely → leads to decreased tendon gliding

  • Chronically: degenerative changes develop, leading to tendinosis

• Typically occurs d/t overuse or misuse, leads to inflammation

• Could be the result of a direct trauma, but symptom onset is still usually gradual

S+S of De Quervain’s Syndrome

Pain in the radial wrist that may refer down into the thumb or up into the forearm

Symptom nature for De Quervain’s Syndrome

Dull ache over radial wrist

Aggs for De Quervain’s Syndrome

Activites involving repetitive radial deviation, activities resisting ulnar deviation

Eases for De Quervain’s Syndrome

Rest, ice, orthoses, avoiding Aggs, heat for chronic phase

24 hr pattern for De Quervain’s Syndrome

Worse with activities

Objective examination for De Quervain’s Syndrome

• pain to palpation over the APL and EPB tendons

• Restrictive testing of the APL and EPB will be painful

• May have visible or palpable edema at the radial wrist

• + finkelstein’s test

Potential pertinent hx for De Quervain’s Syndrome

• may report hx of similar episode - recurrent episodes are common

• May report work related Aggs

• Can be common in new parents dt frequent lifting of infant

Potential predisposing factors for De Quervain’s Syndrome

• work requiring repetitive wrist motion

• Change in activities: new movement pattern or increase in wrist use

• Wearing constricting watches or bracelets may increase irritation of the tendon

PT management for de quervain’s syndrome

• edu and maybe orthoses initially to reduce loading on the tendons

  • Reduce heavy grip when being pulled into ulnar deviation, avoid repetitive thumb use

• Soft tissue and joint mobs: radiocarpal joint

• Gentle stretching of EPB and APL

• Progress into eccentric strengthening

Medical management for de quervain’s syndrome

• imaging: n/a

• Surgery: release of 1st dorsal compartment, may be considered if conservative treatment is not improving symptoms

• Conservative: corticosteroid injection is an option, but consider what we know about them long term

PT diagnosis for CRPS

May be diagnosis of hypersensitivity, hyperalgesia, or allodynia

Pathophys of CRPS

• Syndrome characterized by a continuing regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion

• The pain is regional and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or tropic findings

• Typically occurs after surgery

• Persistent stimulation of peripheral nociceptors leading to central sensitization is one of the hypothesized mechanisms

• Also evidence of altered CNS processing

Ways that were used to categorize CRPS pts

• type 1 vs type 2: those with no nerve damage vs those with major nerve damage

• Three progressive stages: primarily vasomotor, primarily neuropathic pain/sensory, and combined presentation

• Warm vs cold

  • Warm, red, dry, edematous vs cold, blue, sweaty, less edematoud presentation

S+S of CRPS

• widespread pain in the affected region

• Sensitivity to light touch

• Changes in skin temp and/or color

CRPS diagnostic criteria

1. Continuing pain, disproportionate to an inciting event

2. One symptom in 3 of 4 categories - sensory: reports of hyperalgesia and/or Allodynia, vasomotor: reports of temp asymmetry and/or skin color changes, sudomotor/edema: reports of edema and/or sweating changes, motor/trophic: reports of decreased ROM/motor dysfunction/trophic changes

3. At least one sign at time of eval in two or more categories - sensory: evidence of hyperalgesia/allodynia/light touch/deep pressure, vasomotor, sudomotor/edema, motor/trophic

4. No other diagnosis that explains the symptoms

Nature of symptoms for CRPS

Burning, throbbing, aching, sensitive

Aggs for CRPS

Will vary for pts, but even light touch or gentle movement can be an agg

Eases for CRPS

Not many eases besides avoiding Aggs

Objective examination for CRPS

Examine

• sensory: pinprick and light touch

• Vasomotor: temp and/or skin color differences

• Sudomotor/edema (sweating and/or edema)

• Motor/trophic: ROM, MMT, skin and nail observation

Potential pertinent hx for CRPS

• may report hx of fracture or surgery that predisposed symptom onset

• May report previous bout of it in same region

Intervention examples for CRPS

• retrain sensorimotor cortex

  • Progress through laterality training, graded motor imagery, mirror therapy

• Desensitization training

  • Start with soft/gentle fabrics and progress to rougher textures

  • Contrast baths

• Aquatic therapy

Medical management for CRPS

• sympathetic blocks

• Psychotherapy

• Pharmacological intervention