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