Week 5: Wrist and Hand Diagnoses

Distal Ulna Fractures

-Fractures of the distal ulna usually occur in conjunction with DRFs, and it is uncommon to see them in isolation -DUFs are important because if they are not treated correctly, persistant ulnar-sided wrist pain, DRUJ instability, and loss of forearm rotation can result -DUFs include injuries to the ulnar styloid, ulnar head, or ulnar metaphysis -Ulnar styloid fractures accompany DRFs in 50% of cases -Nonunion is the end result for 50% to 70% of ulnar styloid fractures- conservative treatment is the norm, and few remain symptomatic -Those DUFs at risk for affecting function of the DRUJ are stabilized using Kirschner-wires (also called "K-wires"), plates and screws, cannulated screws, and tension band wiring

Rehabilitation of Distal Radius and Carpal Fractures: *Subacute Phase (6 weeks and beyond)*

-*Cast/Orthotic Use* --During the subacute phase, the client may be fitted with a wrist orthosis; the primary goal of the orthosis is to support the soft tissue and encourage the wrist to remain in extension to facilitate finger motion --This orthosis is typically worn during the performance of heavier tasks, at night, and when out in public --Gradual decrease in orthosis utilization is progressed over time as pain decreases and motion and strength improve -*Edema Management* --Persistent edema past 6 weeks is generally fibrotic and will take weeks to resolve --Edema can be treated as it was outlined in the acute phase, but elevation will not be as beneficial for more fibrotic, high-protein edema --Manual edema mobilization can be beneficial for this type of chronic edema -*ROM* --In the case of ORIF, wrist ROM will have started as early as the first week post surgery --Clients with a cast, pin(s), or external fixator will usually be allowed to begin wrist ROM upon removal of these devices --More powerful wrist flexors will try to override extensors during grip. Focusing on isolated wrist extension and maintaining extension while gripping is important --PROM exercises can be added to the program when pain and swelling are controlled and X-ray comfirms adequate bone healing --Teach clients to stretch gently and to hold the stretch for 30 seconds --Preconditioning tissues with moist heat prior to ROM exercises can be bneficial, as this promotes tissue extensibility and helps make stretching more comfortable for the client. The use of heat can be initiated if edema is resolving -*Pain Management* --A mild increase in pain may occur as new exercises are introduced and as function increases, but this pain should be easily managed with activity modification and rest --More intense pain that persists into the subacute phase is concerning and may indicate CRPS --Therapeutic strategies used for pain management at this stage include ice, moist heat application, contrast baths, graded motor imagery, and electrical modalities such as transcutaneous electrical nerve stimulation (TENS) -*Scar Management and Desensitization* --Should continue as outlined in acute phase --Occasionally, painful neuromas can develop in this phase and will need to be addressed by the physician -*Use of Orthoses to Address Adherence and Tissue Shortening* --Following a wrist fracture, supination and wrist extension are often the most limited motions --When the traditional methods of stretching do not improve range to a functional level and progress has plateaued, dynamic and static progressive splinting should be considered --These mobilization orthoses use the concept of total end-range time (TERT) to elongate tissue. This concept is based on the principle that the longer a tissue is held at its maximum tolerable end-range ("low-load prolonged stretch"), the more the range will improve over time -*Functional Use* --Encourage clients to progress UE functional use as tolerated --Most clients require guidance to avoid overuse and the risk of persistent joint pain and tendonitis during this phase -*Strengthening* --Strengthening is usually started around 8 to 10 weeks dependent on pain, swelling, and progression of bony healing --Isometric exercises should be introduced first, followed by open kinetic chain exercises, and then closed chain exercises --Open chain exercises are those that allow the distal part to move (grip strengthening, wrist curls, and forearm rotation with a weight --Wrist curls are started using a 1-pound weight --Home programs for strengthening are usually carried out every other day using sets with enough repetition to fatigue muscles --Closed kinetic chain exercises where the distal extremity remains fixed (such as wall push-ups and pull-ups) can b e added as strength improves (however, these strengthening exercises may not be appropriate for all clients)

Distal Radius Fractures

-Fractures of the distal radius usually result from a fall on outstretched hand (*FOOSH*) injury -The fracture tends to occur in two main groups: *1. Individuals less than 18 years of age* (usually a result of high-energy forces *2. Individuals older than 50 years of age* (usually a result of lower-energy forces) -The fracture is seen on the distal 2cm of the radius where the bone is more porous, making it easier for fractures to occur in this area (fortunately though, this area of the radius also houses a good blood supply, making these fractures fairly easy to heal) -The most common form of distal radius fracture (DRF) is the *Colles' Fracture*, which is an extraarticular fracture of the distal metaphysis. It results from the scaphoid and lunate placing a dorsal force through the distal radius with subsequent dorsal displacement. Colles' fracture is often used as a blanket term to refer to all fractures of the distal radius. *NONOPERATIVE TREATMENT OF DISTAL RADIUS FRACTURES*: -Closed reduction with casting is the most common treatment for DRFs -Extraarticular and stable fractures, as well as nondisplaced intraarticular fractures, are casted for about *2 to 8 weeks* -Casting may also be considered for more unstable intraarticular fractures in individuals with low functional demands and high surgical risk given their medical history (in these situations, the client needs to be informed that there will likely be a resultant deformity with reduced available wrist motion -The wrist is usually cast in slight flexion and ulnar deviation based on the theory that this position uses the supporting soft tissues surrounding the joint to stabilize the fracture *SURGICAL TREATMENT OF DISTAL RADIUS FRACTURES*: -Unstable DRFs will require surgery to ensure proper alignment and healing -Surgical options include percutaneous pinning, open reduction and internal fixation (ORIF), open reduction with volar or dorsal plates, and external fixation -*Percutaneous Pinning* involves driving pins/wire into the reduced fracture to secure the fragments. This can often be seen in the treatment of radial styloid fractures. Following the pinning, the individual is placed in a cast or custom wrist orthosis to prevent wrist motion. The pin site provides a direct path to the bone, which increases the risk for *osteomyelitis* (bone infection). Therefore, pin sites need to be kept clean. -*ORIF*: complex intraarticular fractures, comminuted extraarticular fractures, andn fractures with open soft tissues will usually be treated with an ORIF using volar or dorsal plate and screws to rigidly fix the fracture pieces -Complications of plating include digital tendon rupture, tendon adherence, and median nerve compression. One of the benefits of this surgery is that it allows early wrist movement, usually within a few days after surgery -*External Fixation*: is becoming less common but remains a viable option for DRFs. It relies on ligamentotaxis, in which longitudinal traction is placed across the radiocarpal joint to optimize the length of the radius and alignment of the fracture. The pins that are attached to the metcarpals and the shaft of the radius are attached to the external fixator. -Risks of this include pin site infection, dorsal sensory branch irritation, and median nerve neuropathy. -Early finger motion is encouraged immediately following surgery, but the wrist cannot move while the external fixation device is in place. Supination and pronation are allowed but will be very limited -The device is usually worn for 4 to 6 weeks and the wrist is then placed in a supportive orthosis upon removal of the fixator *POTENTIAL COMPLICATIONS FOLLOWING DISTAL RADIUS FRACTURE*: -Residual pain, loss of motion, ongoing sensory loss or paresthesia, and changes in the cosmetic appearance of the wrist can leave some clients disappointed *COMPLEX REGIONAL PAIN SYNDROME (CRPS)*: -The cause of CRPS remains unclear. The pain is neuropathic in nature and is extreme during attempted movement of the affected limb -There is fluctuation in vasomotor function including skin color, temperature, and sweating -The exact incidence of CRPS following DRFs is not known, but recent studies have reported rates as high as 8.3% and 32.2% -Evidence suggests that a pain level of 5 or greater on the pain numerical rating scale during the first 3 postoperative days is linked with increased incidence of CRPS -Individuals presenting with CRPS are best managed with a multidisciplinary approach including hand therapy, psychiatry, and pain management -Various medications may be prescribed, and clients are often referred to a pain clinic for sympathetic blocks *MALUNION* -this happens when a fracture loses reduction, resulting in malalignment upon healing -This can lead to significant pain at the radiocarpal joint, distal ulna, and DRUJ, and post-traumatic arthritis can develop in these areas -The primary complaints are pain with movement and loss of motion -Resolving these problems will usually require corrective surgery to restore the height and angles of the distal radius anatomy -Several procedures exist to correct pain and dysfunction related to malunion: corrective osteotomy of the radius and/or ulna, distal ulna resection, and radiocarpal fusion -Wrist fusion is always a last option and considered a salvage procedure; but an immobile, pain free and stable wrist is more functional than a painful wrist with limited strength -When malunion results in ulnar-sided wrist pain, it can be attributed to increased load on the ulna following loss of radial height from the fracture (change in radial height, even by a few millimeters, can result in an increase in the relative height of the ulna as compared to the radius. This is known as *ulnar positive variance*. This change may alter force distribution through the distal radius, distal ulna, and interposed TFCC. For example, the typical force distribution of 80/20 might become 70/30) -Ulnar positive changes can further progress to *ulnar abutment* (also known as "ulnar impaction syndrome"). Ulnar abutment presents as a continuum of changes including decreased grip strength, limited ulnar deviation, degeneration and impingement of the TFCC, and osteoarthritis of the ulnar wrist. Ulnar positive variance can be resolved surgically by correcting the distal radius anatomy or by shortening the ulna *SOFT-TISSUE INJURY* -While fractures are often easily identifiable on X-ray and heal in a relatively short period of time, STIs can be more challenging to manage -Radiographic review will reveal a greater than normal separation between the scaphoid and lunate in the presence of a SL ligament disruption *TENDON IRRITATION OR RUPTURE* -Tendons can rupture from repeated movement and friction over volar and dorsal plates -If hardware must be removed due to these complications, it is generally not performed until *at least 6 months postsurgery* to ensure bone has matured and plate removal won't compromise bone integrity -Tendon ruptures must be repaired, but the timing of the repair depends on when the tendon ruptures. Some tendons rupture shortly after the fracture occurs, while other ruptures happen months or years after the fracture has healed -Tendons can be repaired directly, grafted, or addressed with tendon transfer *NERVE COMPRESSION OR IRRITATION* -The median nerve, dorsal radial sensory nerve (DRSN) and ulnar nerve can be affected by DRF -The median nerve is the most commonly involved -Nerve compression can result from edema, the development of flexor tenosynovitis, trauma to the carpal tunnel during a FOOSH injury, repeat reductions, or fracture fragments compressing the nerve -Acute carpal tunnel syndrome (CTS) presents in 5.4% of DRF treated surgically, and can be treated with a carpal tunnel release at the time of ORIF. -The DRSN provides sensation over the dorsal radial hand. It can become damaged or irritated from pin placement or from compression in a cast. This can be aggravating to the client but usually resolves over time -Less frequently, ulnar nerve symptoms may be reported due to swelling in the area of Guyon's canal at the wrist or from irritation at the elbow due to the propensity to hold the elbow in flexion during immobilization. Edema control efforts and alteration in positioning often assist in managing these symptoms

Carpal Fractures

-The 8 uniquely shaped carpal bones of the wrist are bound by ligaments that provide a fine balance between stability and mobility -These carpal bones are susceptible to fracture following a FOOSH injury, a direct blow to the wrist, or with repeated trauma *SCAPHOID FRACTURES* -The scaphoid is the most frequently fractured carpal bone in adults, accounting for 80% of all carpal fractures -The scaphoid is the second largest carpal bone and is shaped like a kidney bean. It has a proximal pole (20% of fractures), waist (70%), and distal tubercle (10%) -As part of the proximal carpal row and radiocarpal joint, the scaphoid also spans the midcarpal joint. As a result, it plays an integral role in overall wrist kinematics- these fractures can greatly impact function if managed improperly *DIAGNOSES AND PATHOLOGY OF SCAPHOID FRACTURES* -Scaphoid fractures typically result from a fall on a hyperextended and radially deviated wrist -Clients will present with radial-sided wrist pain, swelling, and reduced wrist extension and grip strength -Axial compression of the thumb (known as the *scaphoid compression test*) and tenderness within the anatomical snuff-box and over the distal pole help diagnose a scaphoid fracture -As many as 30% of scaphoid fractures go undiagnosed upon initial radiograph -Untreated scaphoid fractures have a high rate of nonunion and progression to disabling arthritis. Therefore, if primary X-rays are negative but a scaphoid fracture is suspected, individuals are immobilized and X-rays are repeated within 1 to 2 weeks *TREATMENT OF SCAPHOID FRACTURES* -Scaphoid fracture healing times rely greatly on the fracture location and blood supply -With 80% of its articulating surfaces lined with cartilage, a majority of scaphoid vascularity enters at the distal pole. Therefore, injuries that disrupt the blood supply render the proximal pole susceptible to fragment death or avascular necrosis (AVN) -Distal pole and waist fractures that are nondisplaced, stable, and without associated ligamentous injuries are typically managed with cast immobilization for approximately *6 to 10 weeks* -Nondisplaced proximal pole fractures require *6 weeks* in a long arm thumb spica cast (to prevent forearm rotation) followed by at least *6 weeks* in a short arm thumb spica cast -Fractures that are displaced, comminuted, and associated with soft-tissue injuries are reduced and surgically stabilized to prevent malunion and nonunion; various surgical techniques exist, but ORIF with compression screw is the most common approach -Surgery is followed by 2 weeks of cast immobilization, then initiation of active range of motion using a thumb spica orthosis for support between exercises *OTHER CARPAL FRACTURES- DIAGNOSIS AND PATHOLOGY* -*Triquetrum* --A small, pyramid-shaped bone found adjacent to the lunate in the proximal carpal row --Triquetrum fractures can occur with compression between the hamate and ulnar styloid, avulsion from numerous ligament attachments, or perilunate fracture dislocations involving significant injury to the lunotriquetral interval ligament -*Trapezium* --Located between the scaphoid and the base of the first metacarpal --This highly mobile carpal bone plays an integral role in thumb movement, so fracture detection and treatment is paramount in restoring pinch and grip function -These fractures usually occur due to a direct blow to the hand or from a FOOSH injury, and clients typically complain of point tenderness at the base of the thumb and pain with pinching -*Hamate* --Fractures the hook of the hamate occur more frequently than fractures to the body of the hamate --Sudden axial loads, such as with a direct blow to the palm, can fracture the hamate body --Hook of hamate fractures are frequently associated with the forceful swing of a hammer, bat, or golf club resulting in an avulsion fracture --In addition to acute tenderness over the hook, clients may report discomfort with resisted motion of the fourth and fifth digits and paresthesia in the ulnar nerve distribution -*Lunate* --This crescent-shaped carpal is an integral component of wrist motion --These fractures typically occur from a FOOSH injury where the capitate is driven into the lunate --Careful assessments of the attaching scapholunate (SL) and lunotriquetral (LT) ligaments is crucial as their integrity can affect carpal stability --When fractured, the lunate is susceptible to avascular necrosis due to its limited blood supply at the palmar pole --Lunate fractures are associated with *Kienbock's Disease*- a pathological process whereby blood flow to the lunate is compromised, progressing to bone death and carpal collapse -*Pisiform* --Volar to the triquetrum is the pea-sized pisiform bone --Comminuted fractures typically result from a direct blow to the hypothenar eminence, while an avulsion fracture may occur with forceful contraction of the flexor carpi ulnaris --Acute pain over the pisiform is the primary symptom --The pisiform also forms the ulnar border of Guyon's canal, so clients may also present with ulnar nerve dysfunction -*Trapezoid and Capitate* --Isolated fractures to the trapezoid and capitate are infrequent and usually the result of a FOOSH injury or high-velocity axial load through the second and third metacarpals --These fractures are often associated with perilunate dislocations, carpometacarpal (CMC) joint dislocation, or fractures to nearby carpals *TREATMENT OPTIONS FOR OTHER CARPAL FRACTURES* -Due to ligament injuries commonly associated with carpal fractures, the primary goal of treatment is not only to restore bony alignment but to also ensure ligamentous stability -Conservative management of small avulsion or minimally displaced carpal fractures with good blood supply includes short arm cast immobilization for *4 to 6 weeks* -Due to their tenuous blood supply, fractures of the capitate and hamate may be casted for periods ranging from *6 to 12 weeks* or longer *POTENTIAL COMPLICATIONS FOLLOWING ALL CARPAL FRACTURES* -Individuals who receive treatment within *4 weeks* of carpal fractures have improved union rates and outcomes -Displaced fractures with associated ligamentous injury can progress from malalignment to carpal instability to posttraumatic arthritis

Assessment of Wrist Fractures

-Indications for referral to hand therapy at the acute phase of healing (*0 to 6 weeks following injury or surgery) are the presence of moderate to severe edema, poor finger motion, concerns regarding elbow or shoulder motion, initiation of early wrist ROM following rigid fixation, and/or management of function while in the cast -If an individual is managing quite well in the acute phase, they will usually be referred in the *subacute period* once the cast has been removed (*at approximately 6 weeks*) *EVALUATION TIPS*: -Observe how the client holds their injured extremity throughout the interview- comfortable/relaxed or in pain/guarded/protective? -Observe and compare sympathetic changes with the noninjured wrist/hand including vasomotor (temperature, color, swelling), sudomotor (decreased or excessive sweating), pilomotor (absence of "gooebumps"), and trophic (skin texture, nail and hair growth) differences. Also note any muscle wasting, incisions, scars, rashes and bruising -Rate pain at rest and with activity -Perform a global ROM assessment of the client's shoulder and elbow to highlight any areas of limitation -If edema is present while in the cast, measure it- and keep track of edema measurements both pre- and postexercise as therapy progresses -Perform sensory testing if indicated -Assess/describe the wound and scar following an open injury or postsurgical case -Measure isolated finger A/PROM as pain, surgery, edema, and lack of exercise while immobilized can contribute to reduced motion -Evaluate the integrity of the extensor pollicis longus tendon by placing the client's hand palm down on the table. Ask them to raise and hold their extended thumb off the tabletop. If they are unable to do this, determine whether adhesions limit this action or query rupture of the tendon -If able, measure isolated wrist and forearm AROM as well as combined wrist/digit AROM in both extension and flexion to determine the presence of extrinsic tightness -Once the physician has noted sufficient bone healing and the client's swelling and pain allows, evaluate grip and pinch strength using a Jamar dynamometer and pinch gauge. In addition, the push-off test is a valid and reliable test used to quantify weight-bearing ability through the palm

Rehabilitation of Distal Radius and Carpal Fractures: *Acute Phase (0-6 weeks)*

-The initial HEP often includes ROM exercises, edema control techniques, pain management strategies, use of orthoses, and guidelines for participation in functional activities *Treatment Guidelines:* *ACUTE PHASE (0-6 WEEKS) -Immobilization is common following wrist fractures- and it can lead to deleterious effects such as loss of muscle strength, decreased motion, impairment of fine motor function, and eventual representation loss in the motor and sensory cortex -Unfortunately, less than 10% of clients are referred to therapy in the acute phase -Ideally, clients treated with casts, external fixators, or ORIFs will be referred to hand therapy within the first week of casting or surgery -*Cast/Orthotic Use*: --A primary goal during the acute phase is protection of the healing fracture --The client with an ORIF of the distal radius will need a wrist orthosis for protection following surgery -*Edema Management*: --Stiffness starts with edema. Moderate to severe swelling that persists is a silent enemy, and will infiltrate every tissue and alter the normal gliding of joints and tendons --Over time, there can be increased collagen formation and progression from moveable edema to more fibrous protein-rich edema that ultimately turns to scar tissue; this dense edema can take months to resolve and is the foundation of all stiffness --Early management of edema is essential --Edema is constantly laying the groundwork for scar, and time spent managing edema in this early phase will save the client and therapist hours of work and frustration down the road --AROM, elevation, cold application, compression, and lymphatic drainage are all used to manage edema -*Range of Motion* --Clients should be instructed in a program of active (and passive, if needed) ROM exercise to all noninjured joints in the affected UE, including the shoulder, elbow and fingers --Active wrist ROM following stable distal radius ORIF can be initiated as early as *7 to 10 days* postsurgery, whereas wrist motion must be delayed until the cast is removed (at approximately *6 weeks) in the case of closed treatment --Individual finger blocking exercises at the interphalangeal (IP) joints will promote differential gliding of the flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), and flexor pollicus longus; these exercises are particularly important in the case of volar plating --External fixation presents its own set of challenges for ROM. The points of contact of the external fixator on the metacarpals can cause pain with motion exercises. This pain is to be respected, but ROM exercises are encouraged --Obviously it varies, but most clients do well with 5 to 10 repetitions of each exercise performed 5 times a day. Instruct the client to hold stretches for at least 5 seconds to give tissues time to stretch -*Pain Management*: --Pain management is crucial during the acute phase when proper management can reduce the client's longer-term disability level and risk for CRPS -*Wound Management and Scar Desensitization* --Scar massage should be initiated when pink scar tissue is present --Scar tissue can feel thick and may cause decreased mobility by adhering to underlying tissues --Clients should massage scar with unscented lotion using circular motions and enough pressure to challenge the tissue; this will mobilize the scar tissue and desensitize the area --Scar massage can be performed 2 to 3 times per day for approximately 5 minutes -*Use of Orthoses to Address Adherence and Tissue Shortening* --Volar plate fixation can lead to extrinsic flexor tightness, as the application of the plate involves separation of flexor tendons; teaching the client to actively glide flexor tendons and passively stretch the flexors helps reduce this tightness --Also, progressive thermoplastic volar hand orthosis use with the fingers in comfortable extension helps; the orthosis can be used at night when fingers would normally sit in flexion and further contribute to tightness --Dorsal plating can cause the extrinsic extensor tendons to become thethered as a result of scar tissue from the surgical procedure; this presents as decreased ability to actively extend the digits, resulting in the fingers resting in a flexed position. A volar orthosis can also be used in this situation to support the digits in extension and decrease the development of flexor tightness -*Functional Use* --During the acute phase, lifting and carrying is usually limited to 1 to 2 pounds, and no weight bearing is allowed on the extremity --Light functional use of the arm and hand is permitted and encouraged, but overuse may cause increased pain and swelling, which may interfere with the client's ability to perform ROM exercises -*Strengthening* --Strengthening is *not* initiated in the acute phase, as bony healing has not progressed to allow force through the bone --Strengthening during this phase can cause mechanical failure of plates and/or loss of fracture alignment