Wrist and Hand MSK with a few Case Studies

What is the progression of Dequervain's disease?

1. Thickening of extensor retinaculum 2.Stenosing of fibro-osseous canal 3.Entrapment and compression of tendons

What is the healing timeframe for a proximal pole fx of the scaphoid?

16-20 weeks

What joint in the hand is the most likely to develop OA?

1st CMC

What pathology would be indicated for this treatment pattern? -Splinting (support) -Thermal modalities -Pt. ed on joint protection (grasp modification) -Joint mobilizations (increase ROM/decrease pain) -STM (decrease ST dysfunction/decrease edema/increase ROM) -A/AROM to pt. tolerance -Progressive hand strengthening after pain/inflammatory symptoms start to resolve.

1st CMC OA

49 year old female presents w/ decreased pinch strength, very limited prehension and opposition during functional motor activities. She states that her pain is localized at the base of her thumb. What pathology might be indicated?

1st CMC OA (AKA Basal Joint Arthritis)

What is the most common zone injured with a flexor tendon rupture? Why is this zone bad?

2 Large number of structures and scarring

What percentage of proximal pole scaphoid fx will have non-union?

20-30%

How many zones are classified in flexor tendon ruptures?

5

How many zones are classified in extensor tendon ruptures?

8

How would you know you had a positive Watson Test?

A "clunk" is noted with pain symptoms on the radial side of the wrist

With Digital Flexor Tenosynovitis the pt. may have TTP at what structure?

A1 pulley

You administer Finkelstein's Test Positive = pain over the _______________ and_______________ tendons, should only be considered positive if it reproduces patient's symptoms

AP and EPB

What stage would these symptoms be present in CRPS? -Flushed -Dry -Edema -Dry -Diffuse/ Severe pain -Hair/nail growth increase

Acute inflammatory stage (10 days-3 months)

What stage would these symptoms be present in CRPS? -Irreversible damage to muscles and joints -Bone atrophy -Weakness or ankylosing of joints -Decrease in pain Pale/cyanotic skin (cool)

Atrophic stage (2-3 months after dystrophic)

What is the MOI for a metacarpal base fx? (2)

Axial load or other stresses on hand while wrist is flexed

MOI for metacarpal head fx? (2)

Axial loading or direct trauma

What is the MOI for a metacarpal shaft fx? (3)

Axial loading, direct trauma, or torsional forces on digits

Why would a grade 3 UCL sprain require surgery?

Bony avulsion

Jessica is a 24 year old female boxer who is coming into therapy today with severe pain on her metacarpal. You note she has a tender point on her 5th metacarpal and you become concerned of a possible fx. Based on her history what type of fx do yo believe Jessica has?

Boxers fx or metacarpal neck fx

Sally is a pregnant 36 year old accountant coming in to therapy today with c/o pain in her wrist. She states that her symptoms have progressively gotten worse over the last few months. She reveals to you that she has numbness and tingling that radiates down from her wrist into her thumb and index finger. She has had to discontinue going to knitting club and cut back at hours in the office due to her symptoms. What pathology might you suspect Sally has?

Carpal Tunnel Syndrome

Bobby is Billy's twin who is 19 and also came into therapy today because of a fall at the same soccer tournament. He states that he fell forward onto his hand after getting tripped. Objectively you note that there are tender points, swelling and edema. What type of distal radial fx might you suspect considering the MOI?

Colles fx

MOI for distal phalanx fracture?

Crush injury

What two locations could the ulnar n. become entrapped?

Cubital tunnel and Guyon's canal

What joint does a mallet finger deformity affect? What tendon is damaged?

DIP Terminal extensor tendon

The most common inter carpal instability that involves the disruption of the scapholunate ligament?

DISI

A progressive tenosynovitis that involves the 1st dorsal wrist compartment.

Dequervain's Disease

Doug is a 41 year old male with diabetes who came to physical therapy today because of severe wrist pain. He said that over the past month it has progressively become much worse and he stated that he is really having trouble responding to text messages to all of his hot tinder dates that he usually messages for a few hours a day. Objectively he has significant swelling and TTP to the radial aspect of the wrist. He also presented with a loss in CMC abduction and reports pain with radial deviation. What pathology might you suspect?

Dequervain's disease

________ involves instability in the same row. ________ involves instability across different rows.

Dissociative Non-dissociative

With a DISI the lunate will translate _________ with the __________.

Dorsally Triquetrum

What stage would these symptoms be present in CRPS? -Cool limb (constriction of BV) -Edema -Constant pain (burning/throbbing) -Brittle grooved nails -Limitation in ROM due to muscle wasting and joint stiffness

Dystrophic stage (3 months-6 months)

Intersection syndrome involves tenosynovitis of what two muscles?

ECRL and ECRB

What two tendons become entrapped in Dequervain's?

EPB and APL

Adults often sustain a _______-articular distal radius fx. Young children typically have a _______- articular distal radius fx.

Extra Intra

With a Jersey Finger you will see a loss in flexion at the distal phalanx. What tendon may need to be reattached?

FDP

T/F: Conservative treatment with a dupuytrens contracture is fairly successful.

False Only helps to maintain extension

T/F: With a non-displaced extra-articular proximal phalanx fx you should begin AROM in 4 weeks.

False (immediately begin AROM)

Patient places thumb inside their palm and closes their fingers. PT stabilizes the patient's distal forearm with one hand and the patient's hand with the other. PT will then gently ulnarly deviates patient's hand.

Finkelstein's Test

With intersection syndrome what movements might increase pain in the wrist? Passive: Active:

Flexion Extension

The therapist asks patient to grasp a piece of paper between the thumb and index finer in a key grip. The therapist then attempts to pull away piece of paper. Positive = if paper slips out or flexion of the IP of the thumb which is indicative of ulnar nerve pathology due to weakness of paralysis of the adductor pollicis

Froment's Sign

With the Swan-Neck Deformity the PIP is in _____________, and the DIP is in ________________ .

Hyperextension Flexion

A grade one and two UCL sprain in the hand would involve what treatment?

Immobilization and splinting

Tenosynovitis is commonly observed in people with what three conditions?

Inflammatory rheumatic disease Diabetes Hypothyroid conditions

A non-displaced middle phalanx fx will be splinted in this position to allow the soft tissue to optimally work into AROM and minimize adhesion formation and scarring.

Intrinsic plus postion

What four factors do the treatment of a metacarpal fx depend on?

Location of fx Degree of displacement Angulation Rotation

With a dupuytren's contracture it usually follows the _______ tension lines.

Longitudinal

A distal phalanx shaft fx is typically _________ or ___________.

Longitudinal Transverse

Dupuytren's contractures most to least common joint locations in hand. _____>_____>_____

MCP>PIP>DIP

Nick is a 19 year old football player that is coming in today with finger pain. He states that the ball hit the tip of his finger and he has not been able to move it much. What condition might you think he could have? (thumb was forced into flexion)

Mallet finger deformity

What type of nerve entrapment may occur at the wrist with these possible causes? -Distal radius fx -Repetitive trauma -FOOSH -Flexor tenosynovitis

Median n.

Boutonnièr's deformity involves damage to the central slip at the base line of the ___________ phalanx. The bands migrate___________ causing flexion at PIP and Hyperextension at DIP

Middle Volarly

CRPS (Type 1) involves pain triggered by a _________ event.

Noxious

Signs and symptoms of CRPS (4)

Pain Edema Limited ROM Trophic changes in skin including temperature and sweating

Patient sits with shoulders relaxed and backs of their hands facing each other. The patient then flexes wrist maximally by pushing wrists together and holds this position for one minute or until reproduction of symptoms occur.

Phalen's test

What portion of the scaphoid has the worst vascularization?

Proximal pole

Along with ulnar drift in RA, we also tend to see _________ ________.

Radial deviation

Sara is a 32 year old painter who is coming in to physical therapy today because she is no longer able to paint. Objectively she presents with decrease grip strength significantly in the affected hand, numbness, and weakness in extension. She states that she had previously been diagnosed with PINS, but her symptoms went away. What nerve do you suspect is playing a role?

Radial n.

What type of nerve entrapment may occur at the wrist with these possible causes and conditions? -Repetitive wrist extension -PINS -Dorsal Superficial Radial n. Palsy

Radial n.

What two movements should a pt. with digital flexor tenosynovitis avoid?

Repetitive movements Composite fist position

Attenuation of the _____________ band leads to subluxation of the EDC in RA.

Sagittal

What are the two primary activities that someone with CRPS should do in therapy?

Scrubbing and carrying

Billy is 19 and is coming into therapy today because of acute wrist pain. He states that he sustained a fall forward onto the back of his hand during a soccer game. What type of distal radial fx might you be concerned about considering his MOI?

Smith fx

A pt. with digital flexor tenosynovitis may describe pain as... (2)

Snapping or locking

In regard to Intercarpal Instabilities, ______ is the most severe and will involve a complete tear of the supporting ligaments. _______ occurs when wrist is stressed.

Static Dynamic

Inflammation of a tendon or tendon-muscle attachment.

Tendonitis

Inflammation of a tendon sheath.

Tenosynovitis

With regard to RA we tend to see ulnar drift and subluxation of the MCP. Why?

The pull of ulnar intrinsics is stronger than radial intrinsics.

What test has the patient seated with wrist resting on a table or other hard surface while the therapist taps over carpal tunnel at wrist/hand

Tinnel's Sign at the wrist

Surgery for carpal tunnel syndrome involves the release of what ligament?

Transverse carpal ligament

For a CMC grind test the therapist will grasp and stabilize the _____________ proximal to the 1st Metacarpal. The therapist will then grasp with their other hand the 1st metacarpal. An _____________ force with combined rotation is applied to the metacarpal while it translates on the _____________.

Trapezium Axial or Compressive Trapezium

What are two common causes of a tendon rupture in the hand?

Traumatic injury Secondary to prolonged inflammatory tenosynovitis

What pathology are these treatment guidelines for? Acute -control inflammation with thermal and electrical modalities Joint protection -Increase functional use with energy conservation techniques -Adaptive equipment and splinting (decrease ulnar drift) -Balancing rest/activity through planning

Treatment for RA

T/F: AROM begins 2 weeks before PROM with scaphoid fx recovery.

True

T/F: Non-dissociative intercarpal instabilities can present asymptomatic?

True

T/F: Ganglion cysts can be treated conservatively.

True But it will not resolve the issue.

The therapist stabilizes the patient's hand with one hand then the clinician uses their other hand to position the thumb into extension. While the patient maintains their thumb in extension, the therapist applies a valgus stress to the MCP joint to stress the _________. What test is this?

UCL UCL stress test

42 year old male comes to physical therapy presenting with hand injury. He says that he has a Call of Duty tournament in three weeks that he would like to be able to play. Upon palpation you notice significant TTP on the ulnar aspect of the 1st CMC. What pathology might you suspect, and what testing would you perform?

UCL sprain Thumb UCL Stress Test

Patient is seated and elbow is on the table at 90ᵒ with wrist in slight ulnar deviation with digits in a gentle composite fist. Therapist will load the ulnar side of the wrist with direct pressure through the 4th and 5th metacarpals.

Ulnar Impaction test

"Excessive impaction of the ulnar head against the TFCC and carpal bones" What pathology?

Ulnar impaction syndrome

What nerve entrapment could lead to the "claw" position of the hand?

Ulnar n.

Intercarpal instability that involves disruption the lunotriquetral ligament?

VISI

Todd is a 29 year old professional football player who comes in suspecting a distal phalanx fx after a traumatic injury in practice. He stated that while attempting to tackle another player he grabbed his shirt and immediately felt pain as the player shifted in a different direction You note that the pt. cannot flex his distal phalanx. Immediately what type of distal phalanx fx might you suspect Todd has sustained?

Volar Lip Fx

Where do Ganglion cyst typically occur on the wrist?

Volar or dorsal aspect along radial side of wrist

With a VISI the lunate will translate ________ with the _________.

Volarly Scaphoid

Patient places elbow on tabletop at 90ᵒ of flexion. Forearm slightly pronated and wrist starts in ulnar deviation. Before the wrist starts in ulnar deviation, the Therapist needs to locate the Scaphoid Tubercle with their thumb. The therapist's other hand will stabilize the Metacarpals while moving the patient's wrist into radial deviation and slight flexion. The therapist's hand that was palpating the Scaphoid Tubercle needs to maintain pressure on the tubercle as the wrist is radially deviated and flexed.

Watson Test for Carpal Instability

Becky is a 32 year old female that comes in today with wrist pain. She states that she was giving a presentation in MSK when she tripped over a pile of cords landing forward onto her palms. She said she seemed fine initially, but when she got home that day she noted a lot of swelling and bruising. She received some x-rays and no fractures were noted. What pathology might Becky present with?

Wrist sprain

With a Ganglion cyst, the pathology involves a thin walled cyst that contains ____________ that develops quickly over joint capsule and/ or tendon sheath.

hyaluronic acid