Wrist and Hand Sprains/Dislocations

what is the function ROM of the wrist for daily ADLs (flex/ext/UD/RD)

- 5-40 degrees flex - 30-40 degrees wrist extension - 10-20 RD - 15-20 UD

what positions/exercises/motions should you avoid to prevent excessive stress to the UCL of thumb MCP

- active tip pinch - thumb tip loading exercise - grasping

what is the MOI for volar plate injuries

- acute traumatic hyperextension injury - jammed finger - common athletic injury - closed pack position for IPs (ext) - dorsal dislocation or subluxation at the PIP joint (P2 moves dorsal on P1) - injury to volar plate and the collateral ligaments (mild to complete tear)

what are 4 common complications with sprains/dislocations

- chronic instability - joint degenerative changes due to instability - joint contracture - tendon adhesions, decreased tendon glide

what are 4 common complications with skiers/gamekeepers thumb

- instability - joint degeneration due to instability - MCP flexion or extension contractures - tendon adhesions and decreased tendon glide

what are 4 common complications of wrist sprains

- instability - persistent pain - joint degeneration due to chronic instability - requiring wrist fusion

what are 5 common complications of volar plate injuries

- instability if not treated - flexion contracture and loss of extension - tendon adhesions and decreased tendon glide (esp extensor lag) - may require static or dynamic extension splinting to restore full extension ROM - volar plate laxity at PIP joint

where do carpal bones gets stability from since they are intercalated

- ligamentous support - restraint and bony contact

what is the clinical presentation of carpal ligament strains/lunate dislocation

- localized pain - pain w/ ROM (esp end range) - pain w/ WB - snapping, clicking, or clucking w/ wrist movements or w/ gripping - resisted testing typically strong but painful - weak grip strength or giving way w/ forceful grip - swelling - accessory motion testing

what is the clinical presentation of UCL injury of thumb MCP

- pain - swelling - tender to palpation at ulnar MCP joint - possible palpabe superficial mass if UCL detached/displaced - positive ligament stress test - weakness or difficulty w/ pinch due to instability

what is the clinical presentation for a volar plate injury

- pain - swelling at PIP - tender to palpation - limited ROM - pain w/ movement - positive ligament stress testing - weak grip due to pain and dysfunction

what are two categories of wrist ligaments are most commonly injured

- radiocarpal palmar ligaments - proximal row carpal ligaments

what are the most commonly injured ligaments of the carpal bones (and with what forces)

- scapholunate (ulnar deviation) - lunotriquetral (radial deviation)

what is the mechanism of injury for carpal ligament strains

- traumatic event - FOOSH - often hear a "pop"

what is the MOI of skiers/gamekeepers thumb

- traumatic: FOOSH - abd/hyperextension force at thumb MCP joint

how are carpal ligaments strains/lunate dislocations diagnosed

- x-rays - MRI - arthrogram

when is the initial immobilization phase for wrist sprains if non-surgical, if surgical

0-4/6 weeks if non surgical 8-12 weeks if surgical

what is the reactive/inflammatory phase of ligament healing

0-5 days

when is there a decreased potential for wrist sprain (carpal ligament/lunate dislocation) healing

1-6 weeks

how long is the general timeframe for soft tissue/ligament healing

4-6 weeks

what is the remodeling phase of ligament healing

4-6 weeks to months/years

what is the repair phase of ligament healing

5 days to 4-6 weeks

after a wrist sprain, strenuous activities are discouraged for how long

6 months

when is there the best, max healing potential for wrist sprain (carpal ligaments/lunate dislocations) healing

<1 week

when is there poor potential, healing unlikely for wrist sprain (carpal ligament/lunate dislocation) healing

> 6 weeks

describe early wrist ROM w/ wrist sprains

AROM - mid range, controlled, pain free

T or F: wrist fusions result in a great loss of motion but ROM is functional and pain free

F: results in only some loss of motion

T or F: motion of the MCP joint is priority over stability in regard to rehab of UCL of MCP of thumb

F: stability is priority over motion

T or F: severe thumb MCP UCL sprains don't require surgical repair

F: they do

what causes flexion at the PIP joint w/ swan neck deformities

FDP puts tension on the DIP due to extension at the PIP

what type of stabilization is used for severe wrist sprains/tears

ORIF and repair, reconstruction w/ bone-ligament-bone graft or tendon graft

what mob is done to test the integrity of the volar plate

PA accessory motion

what is the most commonly injured joint in the hand

PIP

describe the dart throwing motion

RD/slight extension to UD/slight flexion

T or F: 6 months after a wrist sprain, you should continue wearing your wrist brace for sports, work, and/or heavy tasks

T

T or F: for volar plate injuries, most often the dislocation is reduced immediately

T

T or F: you still have a firm end feel with a moderate sprain

T

describe a severe sprain of the UCL of thumb MCP

UCL detaches from P1

what type of stabilization is used for mild wrist sprains

cast or splint, typically able to remove for exercise

what is the hand positioning for carpal ligament strain/lunate dislocation x rays

clenched fist

wrist sprains/dislocations tend to be injured when in the (open/closed) pack position

closed

what type of splint is used with a volar plate injury/swan neck deformity (what position are the joints in)

dorsal blocking finger splint - PIP at 20-30 degrees flex

what treatments should you avoid during the mobilization phase of wrist sprains

end ranges, aggressive PROM, aggravating motion, or aggressive joint mobs

what is the closed pack position of the wrist

extension

what is the mechanism of injury (force direction) for lunate dislocations that cause dorsal intercalated segment instability

extension

what is the mechanism of injury (force direction) for lunate dislocations that cause volar intercalated segment instability

flexion

when wrist sprains are casted/splinted, it is (hand/forearm) based and the wrist is at _____ degrees (flex/ext)

forearm based, wrist 20-30 deg extended

a wrist carpal ligament strain/lunate dislocation often mimics what type of injury

fx

what does it mean to be an intercalated segment

having no muscles attach onto those bones

what position does the silver ring figure 8 splint prevent

hyperextension

when would surgery be required to repair the volar plate

if it's a complete tear or if associated w/ a fx

during the late phase of volar plate injury management, at what rate would you adjust the dorsal blocking splint

increase ext ~10 degrees per week

what causes hyperextension at the PIP joint w/ swan neck deformities

lateral bands become dorsal to PIP joint, extensors activiate

in what conditions may someone require a wrist fusion

longstanding instability and pain that severely limits function

a grade I sprain is what classification

mild sprain

a grade II sprain is what classification

moderate sprain

in the late phase of skier thumb management, what does progression depend on

painless MCP ROM

what type of stabilization is used for moderate wrist sprains

percutaneous pinning, arthroscopic debridement/repair w/ pinning

what is the function of the volar plate

prevent hyperextension

the wrist is predisposed to sprains in the (proximal/distal) row of carpal bones

proximal

ligaments attached to which carpal bone are the most commonly injured ones

scaphoid

what bone is the bridge between the two rows of carpals

scaphoid

a grade III sprain is what classification

severe sprain/ complete tear

during the mobilization phase of wrist sprains, there is an emphasis on (mobilization/stabilization) exercises

stabilization

grade III/complete tear of UCL of thumb MCP requires what treatment/splinting

surgical repair, pinning w/ K-wires, and cast/splint ~4-6 weeks

volar plate injury of the PIP joint leads to what deformity

swan neck deformity

what is sprained in "skier's" / "gamekeeper's" thumb

thumb MCP ulnar collateral ligament

what is the position for immobilization for skiers/gamekeepers thumb. describe the splint

thumb spica cast w/ IP joint free, thumb slight abd and flex

in what population do we often see carpal ligament strains

younger people

when is the early phase of management for volar plate injuries

~0-4 weeks

when is the initial phase of management for UCL injury of thumb MCP

~0-4 weeks

with skier's thumb, there is a full return to functional activities at what point

~12 weeks

grade I and II skier's/gamekeepers thumb sprains are immobilized for how long

~2-4 weeks

w/ volar plate injuries/swan neck deformities, how long do you limit full ext at the PIP

~4 weeks

when does the late phase of skiers thumb begin

~4 weeks

when does the late phase of volar plate injury management start

~4 weeks

in the late phase of volar plate injury management, you can achieve full ROM when

~6 weeks

strengthening and lateral/key pinch exercises for skier's thumb can begin when

~6 weeks

when can you start progressive strengthening after volar plate injuries

~6 weeks

active tip pinch, thumb tip loading exercise, or grasping is avoided until medically approved, about how long is that

~8+ weeks