Unit 7 - Wrist & Hand

Medical Tx for CRPS

-All treatments should focus on functional restoration. Use of drugs, sympathetic blocks, and psychotherapy helps to achieve good pain control -For example, sympathetic or somatic blocks, if performed, should be integrated into a good rehabilitation program.

Associated Signs and Symptoms of CRPS

-Atrophy of hair, nails, and other soft tissue. -Alterations of hair growth. -Loss of joint mobility. -Impaired motor function (weakness, tremor) -Sympathetically maintained pain (may be present) -Pain described as burning, throbbing, shooting or aching -Hyperalgesia -Allodynia (perception of pain with normally innocuous stimuli - sympathetic mediated pain) -Abnormal sweating or anhydrosis -Redness or bluish discoloration -Heat or cold sensitivity

An axial force applied to a partially flexed thumb dislocates the metacarpal base and avulses a fragment of bone from the anterior aspect of the base of the metacarpal. With the dislocation that is also present, what is the tissue specific impairment that results? What is the Fx?

-Bennett's Fracture -Capsule laxity

Hallmarks of these (Heberden's & Bouchard's) nodes include:

-Decreased joint space. -sclerosis of sub-chondral bone -osteophytes at articular margins -joint deformities.

What are five possible causes of CRPS?

-Direct trauma to sympathetic nerves, -immobilization causing edema -direct trauma to peripheral nerve, -immobilization -having a psychological predisposition

Physical therapy treatment of DeQuervian's

-First the inflammation must be decreased. Then like any other tendonitis/tenovaginitis we must figure out why the tendon is irritated and treat that impairment -may involve treating any biomechanical abnormalities (hypo/hypermobilities), stretching tight muscles, strengthening weak ones and addressing work ergonomics. -A splint may also be used to decrease the stress and strain placed on the tendons.

What is the procedure and positive finding of a Finklesteins?

-First the patient will actively flex the thumb then actively make a fist over the thumb, the therapist will then passively ulnarly deviate the wrist. -Positive finding is pain with any of the movements, however, in order to say that there is a positive Finklesteins all components of the test must be performed

What are the six soft tissues that attach to the pisisform?

-Flexor and extensor retinaculum, -ulnar collateral ligament, -pisohamate ligament, -abductor digiti minimi, -flexor carpi ulnaris

Physical Therapy Treatment for CRPS inculdes

-Fluidotherapy or different types of materials to rub over the involved regions to help desensitize and increase sensation will be used. -increase ROM -massage & muscle pumping (desensitization & swelling)

How can you stretch the retinaculum?

-Move/manipulate the pisiform in the medial direction. -Manipulations are named in relationship to the anatomical man standing, so medial in the hand is the same as ulnar

Finger deformities are often seen as a consequence of:

-RA -inflammatory Arthritides -traumatic tendon avulsions -contractures -nerve injuries

What are three other names for CRPS?

-RSD (Reflex Sympathetic Disorder) -Sudeks atrophy -shoulder hand syndrome

What are complications of Colles' Fx

-Radioulnar or radiocarpal instability -Median and ulnar nerve injury -Deformity (malunion) The dinner fork deformity - the proximal portion of the fracture will be posteriorly displaced. -Post-traumatic arthritis -Soft tissue adhesions -RSD (see Lesson 3) -Shortening or lengthening of the radius

What other dysfunctions must be ruled out with DeQuervians Tenovaginitis?

-Superficial radial nerve entrapment, -1st CMC arthritis/hypomobility, -scaphoid fracture

Common symptoms of Compartment Syndrome include

-Swelling and c/o tightness -Diminished pulses and capillary refill -Most common acute involves the forearm and leg -Measurement of pressure remains controversial

Potential causes for Carpal Tunnel syndrome

-Trauma -Ergonomics -Displaced lunate -Edema -Effusion -Retinaculum tightness -Tight flexors -Pronator teres syndrome -C5-T1 nerve roots

The lunate dislocation results from a

-backwards fall on an outstretched hand -(FOOSH) - the wrist is forced into more extension

Clinical features of DeQuervian's Tenovaginitis

-complain of pain over the radial styloid process and over the area of the first extensor tunnel. -Pain will increase with active abduction and/or extension of the thumb. -There is typically a gradual onset of this tenovaginitis with females more often affected than males.

The medical interventions for Avascular Necrosis (Scaphoid Fx):

-immobilization, pharmacology and a bone stimulator

Main symptoms for Carpal Tunnel

-paresthesias in the median nerve distribution, -muscle weakness in the hand (the muscles innervated by the median nerve) and night pain.

Surgical Interventions for CRPS includes

-spinal cord stimulator (SCS) -intrathecal infusion -baclofen pump -morphine pump -sympathectomy -radiofrequency

How fast will nerve heal (Tinel)

1 inch per month

How long can a muscle last without a blood supply before it starts to demonstrate changes?

6 hours

Name a potential over counter remedy for Carpal Tunnel that might help

A common one is the use of a night splint - especially to assist with the night pain.

What muscles run in the first extensor tunnel?

Abductor Pollicis Longus and Extensor Pollicis Brevis

What functional activities will be affected with a displaced lunate?

Activities that involve wrist extension pushing up from a chair, pushing a door open, weight bearing activities.

Why No Man's Land is so crucial

Any injury to the tendons in this area will require surgery. Surgeons are concerned with this region since there are many muscles and tendons' sheaths are located here. Following the surgery, the tendons are susceptible to adhesion formation and poor healing due to decreased blood supply. Additionally, 'no man's land' is a small anatomical area.

Scaphoid Fracture. There is a high incidence of complications with this fracture because of limited vasularity. _____ as well as delayed and non unions are potential complications.

Avascular necrosis

Injury damages the axons but not the body of the nerve -----o axons, myelin, and internal structures are disrupted ----o overlaps with 2, 3, and 4th degree injuries --The axons are disrupted and must regenerate while the epineurium is intact. --Typically occurs with traction type injuries. corresponds to which injury

Axontemesis

Dupuytren Contracture shares a similar presentation with.....

Benediction sign & bishops deformity

This is a fracture/dislocation injury at the first carpometacarpal (CMC) joint.

Bennett's Fracture

What are three factors that contribute to the limited vacularity of the scaphoid and therefore poor healing?

Blood supply enters from the distal pole, no muscle attachments and it is covered with articular cartilage

_______ appear on the dorsal surface of the PIP and are associated with RA.

Bouchard's nodes

_____ deformity is extenstion of the MCP and DIP joints with flexion of the PIP joint.

Boutonniere

This is a fracture of the neck of the fifth metacarpal (distal) that results from an unskillful blow with a clenched fist. This may also be called a Street Fighter's Fracture.

Boxer's Fracture

The patient may present with signs and symptoms into the wrist and hand due to the innerveation of the nerve roots, but the median nerve itself is not compressed at the carpal tunnel, thus it is not CTS. Which Nerve Roots?

C5 - T1

is a form of hypersensitivity typically in the upper extremities, but it can also be found in the lower extremities. It is characterized by pain and hypersensitivity that is not proportional to the inciting event.

CRPS (Complex Regional Pain Syndrome)

Diagnostic Labels for Carpal Tunnel Syndrome. Defining Acronyms CTS - RMI - OOS - RSI - RSS - MNI -

CTS - Carpal tunnel syndrome RMI - Repetitive motion injury OOS - Occupational overuse syndrome RSI - Repetitive spring injury; where spring means non-contractile RSS - Repetitive stress syndrome MNI - Median nerve injury

How will you check the blood supply?

Capillary refill

_____ is compression of the median nerve within the carpal tunnel. It is a common dysfunction

Carpal Tunnel Syndrome

This is a transverse fracture through the distal radius that occurs as a result of an extension injury. There is a dorsal angulation of the distal fragment which is often called a "dinner fork deformity".

Colles' Fracture

Stats for which syndrome -Increased tissue pressure results in decreased blood flow that results in ischemia. -Compartment pressures of 50mm Hg are associated with a 70% decrease in blood flow. -Compartment pressures may return to normal after a fasciotomy. -The most serious consequence of increased compartment pressures is Volkmann's ischemia of nerves and muscles.

Compartment Syndrome

_________ is thickening and inflammation of the tendon sheath of the first extensor tunnel. Something has caused increased friction in this area resulting in fluid accumulation within the tendon sheath.

DeQuervian's tenovaginitis

This is a contracture of the palmar fascia where there is a flexion deformity of the MCP and PIP.

Dupuytren's Contracture

What is the treatment for a hypermobility that is causing the lunate displacement?

External support, it is hard to support/stabilize the carpal bones

-Displaced fractures of the distal third of the radial shaft are not common but when they occur, they are associated with complete disruption and dislocation of the distal radioulnar joint -In this injury the distal fragment of radius is tilted posteriorly

Galeazzi Fracture

Is a positive Tinel sign good or bad?

Good

______ appear on the dorsal surface of the DIP and are associated with OA

Heberden's nodes

Which of the 18 steps would tell me that I have osteochondoris of the lunate?

Imaging

How will a Colles Fracture be treated?

Internal fixator (ORIF), external fixation, or a cast for immobilization after setting the fragments.

What are two reasons why a night splint may not decrease the night pain for patients with Carpal Tunnel?

It does not fit correctly and patient compliance, i.e. they do not wear it!

Biomechanically, what happens to the lunate with wrist extension?

It moves in the volar direction with the rest of the proximal row.

-Osteochondrosis of the lunate -Lunate is involved with the process of avascular necrosis -May be secondary to trauma -Precarious blood supply relates to which disease

Kienbock's Disease

This is an injury of the extensor mechanism that occurs as the result of hyperflexion of the distal phalanx.

Mallet Finger (dropped finger)

What is the treatment for a hypomobility that is causing the lunate displacement?

Manipulation

-A Fracture of the shaft of the Ulna combined with dislocation of the radiohumeral joint. -Often the dislocation is overlooked

Monteggia Fracture

The internal structural framework and the enclosed axons are destroyed ----o corresponds to 5th degree injury -An injury that results from disruption in the continuity of both axons and all supporting structures, including epineurium corresponds to

Neurontomesis

Slight damage to the nerve with transient loss of conductivity. ---o corresponds to 1st Degree ----o demyelination with restoration in weeks corresponds to which injury

Neuropraxia

3 Types of Nerve Injuries

Neuropraxia Axontomesis Neurontomesis

Signs + Symptoms of Neurontemsis

No pain Muscle wasting Complete motor, sensory and sympathetic function loss

-Anesthesia is seen in hysteria, leprosy, and diabetes, and CRPS. -It is a condition in which there is numbness from the elbow to the fingers in the form of a glove.

Opera Glove

What are the characteristic features of CRPS?

Osteopenia, -hyperalgesia, -edema, -atrophy -glassy skin

Signs + Symptoms of Axontemesis

Pain Evident muscular atrophy Diminished motor, sensory and sympathetic function Recovery sensations return before motor function

Signs + Symptoms of Neuropraxia

Pain None or minimal muscle wasting Some muscle weakness Numbness Loss of proprioception

Positive Exam Findings for DeQuervian's Tenovaginitis Palpation for Condition - AROM - PROM - MSTT - MLT - Special tests -

Palpation for Condition - warmth, swelling and thickening over the APL EPB AROM - pain with active abduction and extension of the thumb PROM - pain with classical flexion and adduction MSTT - strong and painful for abduction and extension of the thumb MLT - pain with lengthening of the abductors and extensors Special tests - positive Finklestein's

________ can also cause symptoms similar to CTS. __________ syndrome is NOT the same thing as CTS. Both involve compression on the median nerve but the compression is at different locations

Pronator Teres Syndrome

Regeneration timeframe for Axontemesis

Regeneration occurs along the intact neural tubes, but slowly (1mm/day)

What special test would pick up tight flexors as a cause of CTS?

Reverse Phalens

This fracture results from a fall on the open hand with the wrist in extension and radially deviated. It is the most common carpal fracture.

Scaphoid Fracture

This is a reverse Colles' fracture that is caused by a fall or a blow to the back of the flexed wrist.

Smith's Fracture

_____ Deformity is flexion of MCP and DIP joints with extension of the PIP joint.

Swan Neck

If the lunate is displaced in a volar direction what will be the end-feel with passive wrist extension? Why?

The end-feel will be a bony block due to the lunate being in the way of the other carpal bones

How is a compartment syndrome treated?

The pressure needs to be relieved, this can be done through a fasciotomy or removal of the cast

Once the external fixator or cast has been removed from the Colles' Fx, how are we going to treat this patient?

The treatment can include passive ROM, manipulations for pain and mechanical, e-stim to help muscle guarding and muscle wasting, and massage and muscle pumps for swelling as well as RIC

Once the external fixator or cast has been removed from the Colles' Fx, what will the patient present with?

They will present with swelling with scar tissue formation, joint hypomobility, muscle atrophy and guarding, and decreased grip strength

_____ syndrome is also a potential source of wrist/hand symptoms

Thoracic outlet

This is digital tenovaginits of flexor tendons. The thickening of the fibrous sheath results in constriction and the patient is unable to extend the finger.

Trigger Fingers

________ is a form of a compartment syndrome that occurs because of increased pressure within the compartment of the forearm.

Volkman's ischemic contracture

If we were treating someone who had surgery in No Man's Land and they started developing adhesions, what would be some treatments to help decrease the adhesions? They are well healed and settled.

We want to be tissue specific in our treatment. Treatment may include fluidotherapy which will provide heat and plyability to the region, but a more specific treatment would be scar massage and transverse friction massage, tendon gliding exercises

What is physical therapy treatment for a Bennett's fracture/dislocation?

We will treat the impairments that result from the fracture and dislocation; however, we cannot fix the laxity. Once a laxity always a laxity. We may be treating the impairments that result from the medical treatment of surgery or immobilization.

How do you differentiate Dupuytrens contracture from a nerve injury?

With a nerve injury there should be motor or sensory changes in the correct distribution of the nerve, but with Dupuytens there are no motor or sensory changes.

If a scaphoid fracture is present, what motions of the wrist will be painful? (PT Tx for impairments)

Wrist extension and radial deviation. The same position that causes the fracture.

This is often associated with RA or OA where the thumb is flexed at the MCP and hyperextended at the IP.

Z-deformity

The diagnosis of CRPS is frequently used when there is

a difficult or no explanation for the various signs and symptoms that present.

Colles' Fracture. It is the most common fracture in

adults over 50 years old and occurs in women more than men.

Scaphoid Fracture. The patient will complain of pain over the _____ ; however this fracture is often overlooked and dismissed as a sprain as it is not often visible on a radiograph.

anatomical snuffbox

complete recovery from neuropraxia in approx

approx 12 weeks

The primary focus of either CTS surgery is to _______. Space occupying lesions may also be removed to decrease pressure on the nerve.

cut the flexor retinaculum to increase the amount of space available to the median nerve

Volkman's ischemic contracture can arise from

direct trauma to the area that causes edema or from a cast being too tight.

For Carpal Tunnel Trauma, this may include: any Fracture or ____process, or ______

disease process or lesion

There are two main types of surgery that are performed for CTS -

endoscopic or open.

Volkman's Contracture. Casting in this area (the forearm) is done for treatment of an elbow fracture or a fracture of the forearm. The resulting "contracture" is the shortening of a muscle or soft tissue, including nerve, that derives from decreased blood flow. The necrotic damage that occurs due to the ischemia leads to a ______ of the muscle and soft tissues. The _______ leads to contracture of the muscle and possible impingement of the nerve.

fibrosis

Why do you think that this type of fracture occurs more often in women than in men?

higher prevalence of osteoporosis in women which can result in increased fractures

Neurontomesis. The potential for regeneration is negated by the

loss of the neural tubes

The ______ makes up the floor of the carpal tunnel.

lunate

Galeazzi Fx. An _______, ______ displaced, and _______, with an associated abnormality, resulting in the dislocation of the ulnocarpal joint.

overriding, laterally displaced, and angulated

Dupuytren's Contracture. The _______ becomes thickened and adheres to the overlying skin.

palmar fascia

The flexor retinaculum attaches to the ______ .

pisiform

The dinner fork deformity - the proximal portion of the colles' fracture will be ______ displaced

posteriorly

The _____ makes up the roof of the carpal tunnel.

retinaculum

Dupuytren's Contracture. The patient will end up with flexion of

the MCP and PIP flexion of the fourth and fifth digits.

No Man's Land is located from

the distal transverse crease to the PIPs where profundus and sublimis tendons pass through fibrous tunnels.

During Neurontomesis, neurofibrils can grow out from

the divided ends to produce a neuroma

Prognosis of CRPS

~80% have complete spontaneous relief of signs + symptoms within 18 months No criteria have been established to predict outcome 50-80% have disability secondary to pain and or limited ROM Long duration of symptoms, presence of tropic changes, presence of cold RSD are associated with higher chances of poor outcomes