examining patients with wrist and hand pain
Common pathologies of the wrist and hand
-distal radioulnar joint fractures -carpal and metacarpal fractures -sprains -nerve entrapments -tendon injuries -other conditions
Associated with increased pressure in the carpal tunnel
-extreme finger and wrist postures -motions performed with MCP in 0 degrees record the highest pressure in tunnel followed by MCP in 90 deg
C6 level quadriplegia using tenodesis action to grasp a cup of water
-gravity induced wrist flexion causes the hand to open -active wrist extension by contraction of the innervated extensor carpi radialis brevis creates enough passive tension in the paralyzed digital flexors to hold the cup
Identifying wrist fracture
-localized tenderness -pain on AROM -pain on PROM -pain on grip -pain on supination
Carpal tunnel syndrome is
-medial neuropathy at or distal to the wrist -trapped under the transverse carpal ligament
Peripheral nerve injuries secondary to trauma can involve what nerves
-median -ulnar -radial -digital nerves
OA presentation
-pain -swelling -stiffness, particularly in the morning -muscle weakness (difficulty gripping and twisting objects) -presence of Heberden or Bouchard nodes or bony enlargements
DeQuervain's
-stenosing tenosynovitis, first dorsal compartment -primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extending of the thumb -aggravated by repetitive motions
Types of deformities in RA
-swan neck deformity -boutonnière deformity
RA characterized by
-swelling -redness -pain -warmth -joint enlargement -deformity
Signs of DeQuervain's
-swelling in the anatomical snug box -tenderness at the radial styloid process -decreased CMC abduction ROM in the 1st digit -palpable thickening of the extensor sheaths of the 1st dorsal compartment
Considerations for examining the wrist and hand
-trauma -repetitive stress injuries -neuropathies -OA -systemic disease (Ex. RA)
Main facts to remember about the wrist and hand
-tremendous amount of variability in the presentations of pathologies -extraordinary amount of dexterity and precision -involved in both motor and sensory tasks -tough, resilient
Functional flexion for the thumb at the MCP and IP
20 deg
How many extrinsic and intrinsic muscles in the hand?
24 extrinsic 18 intrinsic
How many bones in the distal radius and ulna joint
27
Diagnostic criteria for RA
4 out of the 7 -morning stiffness for an hour or greater -arthritis of 3 or more of the following joints: right or left PIP, MCP, wrist, elbow, knee, ankle and MTP joints -arthritis of wrist, MCP, PEP -symmetric involvement of a joint -rheumatoid nodules over bony prominences or extensor surfaces or in a juxta articular region -positive serum rheumatoid factor -radiographic changes including erosion or bony decalcifications localized in or adjacent to the joint
Functional flexion at DIP
40 deg
CTS occurs most commonly between
4th and 6th decades
Functional flexion at MCP and PIP
60 deg
The carpometacarpal joint is
A saddle biaxial joint between trapezium and 1st metacarpal
Traqezium concave sagittal plane abduction and adduction
Abduct: palmar roll and dorsal glide Adduct: dorsal roll and palmar glide
Types of dysfunctions
Articular Contractile Nerve
Tenodesis action of finger flexors
As the wrist is extended, the thumb and fingers auto flex Flexion occurs passively
Most common nerve entrapment in the body
Carpal tunnel syndrome
Swan neck deformity
Condition is a result of contracture of the intrinsic muscles or tearing of the velar plate and is often seen in patients with RA or following trauma
Functional wrist flexion and extension
Flexion: 10 deg Extension: 35 deg
Trapezium convex frontal plane extension and flexion
Flexion: ulnar roll and ulnar glide Extension: radial roll and radial glide
Focus during the wrist and hand objective exam
Gross movements and precision movements
Incidence in age and gender
Increases after 55 in women More common and more severe in women
The triangular fibrocartilage complex articulates with and provides
Lunate and triquetrum Stabilizes the wrist and cushions
Gross motor test
Minnesota rate manipulation test
Most common MSK disorder worldwide affecting the hands
OA
Heberden
On distal IP joints
Bouchard nodes
On proximal IP joints
Fine motor test
Perdue peg board test
Radius and ulnar load when in tact
Radius 60% Ulna 40%
Boutonnière deformity
Result of a rupture of the central tendinous slip of the extensor hood and is RA
Max grip strength when muscles are in a position of
Slight UD and wrist extension
Distal radioulnar joint is involved with
Supination and pronation
The radiocarpal joint articulates with and performs
The scaphoid and lunate Flexion/extension and ulnar/radial deviation
Focus during observation of the wrist and hand
Visual observation -swelling -joint deformity -circulation -nail and nail beds
CTS is more commonly seen in women or men?
Women
Neither flexors or extensors are long enough to allow for full
Wrist and finger movement