Wrist/Hand Pathology
SL Dissociation
Most common carpal instability patterns Symptoms: • Pain on the radial side of the wrist at rest or with activities; • Complaints of decreased grip strength; and • Pain with attempts of wrist and hand weight-bearing (closed chain) activities. Signs: • Tenderness to palpation over the scaphoid tuberosity, waist, or SL joint line; • Laxity of the SL joint with the ballottement test; • Possibly a positive scaphoid shift test; and • Radiographic evidence as noted earlier. Surgeons treat acute ligament injuries w/ primary repair, pinning, and immobilization w/ goal of reestablishing soft tissue integrity Chronic injuries --> dynamic, and then static, conditions --> necessitating more limited treatment options with expectations of only partial mobility, strength, and varying levels of pain relief.
4 Stages of Wrist Sprain
(1) Minor sprain to palmar aspect of SL ligament w/o total disruption (if wrist is RD + hyperextended --> scaphoid fx also occurs). (2) Continuing force --> dissociation of SL ligament (disruption of 1st- palmar and 2nd- dorsal aspect of SL ligament). A lateral view x-ray of wrist would show dorsal angulation of distal surface of lunate relative to scaphoid . (3) Continuing hyperextension --> additional force transmission thru wrist; ulnar limb of arcuate ligament may pull triquetrum dorsally --> failure of LT ligaments . (4) Lastly, RSC ligament forces capitate to collapse into radiocarpal space and pushes lunate in palmar direction until it dislocates into the carpal tunnel in a rotary manner -->result is a complete lunate dislocation.
Effects of DD on Surrounding Tissue
(1) attenuation of the extensor mechanism in zone III due to long-standing PIP joint flexion (2) development of a Boutonnière deformity (3) MP and PIP joints capsular contracture 4) adaptive shortening of digital nerves (5) encasement of digital nerves and arteries in Dupuytren cords, (6) flexor muscle-tendon tightness, (7) intrinsic (lumbrical and interosseus muscle) tightness and adaptive shortening, (8) joint incongruity (9) skin contracture and breakdown.
Late Phase Immobilization Protocol
(4-6 weeks)- dependent on tendon glide. The orthosis is discontinued and the patient begins gentle isolated joint (blocking) exercises Add stress as necessary to improve composite flexion and add light resistance around 8 weeks post-repair. If muscle-tendon unit shortening is a problem = patient wears an orthosis that positions fingers and wrist in extension providing a low-load long-duration stretch. However, the patient does not begin heavy (>10 lbs) resisted activities until 10 to 12 weeks post-repair.
Intermediate Immobilization
(begins at 3 to 4 weeks)- patient progresses to a neutral wrist orthosis and begins passive finger flexion followed by active extension of the IP joints with the MP joints flexed at 60-70deg
Phalangeal and Metacarpal Fx
23% and 18%, respectively, of below elbow fx long insertion sites of FDS tendons on middle phalanx-help stabilize a mid-shaft fx stable fx- buddy-taped to neighboring digit , treated w/ early ROM finger-based orthosis (if needed) designed to maintain IP joints in full ext yet allow ROM of MP. same plan completed if percutaneous pinning needed to reduce an unstable fx or correct rotation and alignment -careful monitoring of alignment loss during early motion Manually supporting middle phalanx during AROM DIP f/ex assist in maximizing tendon glide and fx stabilization. Encouraging flexion tendon glide before scar adhesions develop following middle and proximal phalanx fx
When to begin early ROM
3-5 days post op
Surgical Options
Distal radius fx w/ shear displacement, or articular surface step-offs, tx w/ various hardware techniques (percutaneous pinning, external fixators, to volar or dorsal plating) volar plating - improved restoration of articular surface, radial inclination, and bone length with fewer postoperative complications compared to other fixation techniques. has allowed earlier return to wrist ROM, decreased immobilization time, and positive patient reports volar plating vs closed reduction + cast immobilization in pt >65 -surgery group better wrist function early post-op - at 6 and 12 months - no sig diff in wrist function or pain - better grip strength in the surgical group
Triquetrum Fx
FOOSH w/ hand landing in hyperextension and UD --> drives ulnar head into the triquetrum. Two patterns typically seen: (1) small piece of cortical bone displaced from dorsal surface (2) transverse fx thru body of bone. avulsion fx- wrist cast (3-4 weeks) followed by removable cock-up orthosis and progressive ROM recovery . Though avulsion injury may appear benign --> concern of carpal instability if ignored d/t location close to insertion of dorsal intercarpal ligament and dorsal radiocarpal ligament.
Nerve Regeneration
Following nerve compression, laceration, or surgical repair, the therapist should assess nerve regeneration. A positive Tinel sign distal to the lesion is the first sign of nerve regeneration Begin by tapping distally to proximally along the course of the injured nerve. The level of axonal regeneration corresponds to the point where tapping produces tingling in the nerve's distribution. The therapist can use the Tinel sign repeatedly over time to track the level of axonal regeneration. Monitor motor return through muscle testing or observing individual muscle, strength, hand function, substitution patterns, and postural changes. Sensory recovery can be monitored by testing the patient's ability to sense pain (through use of a pin prick). As recovery progresses, track the individual's response to moving 2PD and then static 2PD. Monofilaments can be used to assess sensory threshold. If using monofilaments, when the patient senses the 4.31 monofilament (diminished protective sensation), there is also a gross appreciation for static 2PD (7-10 mm
Rotational Deformities
Fx of middle and proximal phalanges + metacarpal fractures = evaluated for rotational deformities. assessed w/ fingers in intrinsic plus and the position of distal fingertips observed, fingers observed straight-on - ends of the fingers should be in the same plane 2nd position to assess- FDS-only fist. Places MP and PIP in flexion (no DIP flexion). Now fingers should point to scaphoid tubercle Any scissoring or crossing over of the digits may mean a rotational deformity
Soft Tissue PIP Injury (Collateral Ligament) Grade II
Grade II: partial disruption pain and mild laxity observed w/ stress testing, a firm end point is felt. require immobilization (2-4 weeks) in gutter orthosis w/ involved IP joint in extension. pt can perform early AROM exercises in flexion/extension if medial and lateral forces are avoided. Buddy taping continues for additional 2 wks following removal of orthosis. address fusiform swelling with retrograde massage and compression wraps. Do not neglect DIP joint, which often becomes stiff during PIP rehab.
UCL Disruption of Thumb (Skier's Thumb)
Hyperextension w/ radial deviation @ thumb MP- sprain or rupture the UCL (usually distal attachment on proximal phalanx) skier's thumb- pole forcing hyperabducted or hyperextended with radial abduction position of MP joint during fall) Gamekeeper's thumb used interchangeably, is chronic from repetitive activity--> UCL laxity key to treatment: proper DDX for complete rupture vs grade I or II sprain. Tx for grade I and II: First 2 - 4 wk pt wears a hand-based thumb-spica orthosis or cast w/ IP free. Post immobilization, begin key pinch and gentle thumb strengthening for the next 3 - 4 wks. avoids tip pinch and grasping until 8wks and should not participate in aggressive therapy programs. Stability always given precedence over motion in this early period Grade III disruption >10-15° greater laxity into radial deviation combined w/ absence of endpoint. Complete UCL ruptures (grade III) can be treated nonoperatively if a Stener lesion is ruled out. Stener lesion = UCL that has retracted proximally and dorsally - now laying over adductor aponeurosis. a retracted ligament cannot successfully heal to insertion on proximal phalanx. X-ray may show a bony avulsion (sign of retraction) If no evidence of bony avulsion, and a Stener lesion is suspected, surgical intervention involving exploration and ligament repair typically recommended. Tx begins 4 - 6 weeks post-op, flexion/extension ROM followed by PREs- MP joint stability primary concern as mobility slowly recovers. The patient usually returns to full activities at 3 months following surgery.
2 vs 4 Strand Repairs
Important to know, as protocols more likely to rupture a 2 strand repair studies demonstrated 4-strand repairs can tolerate forces of 40 N and 6-strand repairs forces of 50 to 60 N --> providing a force tolerance sufficient to allow early passive and limited active motions. overall effect of the well-placed sutures should allow decreased resistance (friction) to tendon glide. The stronger sutures combined with good surgical technique should also minimize gap formation between the repair ends
Scapohid fx treatment
Nondisplaced distal pole fx= heal in 8 - 10wks w/ a forearm-based thumb spica cast. Waist (mid-pole) & nondisplaced fx up to 3 mo of cast immobilization. Displaced, unstable, and proximal fractures = surgical fixation. Post-op thumb + wrist in forearm-based thumb spica cast until x-ray union ( 6-12wks) PT fabricates a forearm-based thumb spica orthosis --> pt wears another 4 wks. Post immobilization --> soft tissue, joint capsule, scar, and carpal mobilizations essential. Upon confirmation of healing--> strengthening introduced with attention to endurance and dexterity activities.
UTS Treatment
Nonsurgical for patients with mild UTS without motor deficit and when there is no identifiable structural abnormality rest, activity modification, and use of equipment such as orthoses or gloves to minimize compression. Cyclists should alter hand and upper extremity positioning on longer rides and assure proper body mechanics via appropriate saddle and handle-bar positioning refer patients presenting with motor loss to a hand surgeon for further diagnostic imaging and testing and possible exploration. Surgery indicated in patients who present with compressive lesions, motor deficits, and failed nonsurgical management. Surgery consists of resection of masses thromboses, aberrant fibrous bands, or bony protrusions causing compression. Patients undergoing surgery for UTS regain ROM on their own and are unlikely to have postoperative therapy. Some individuals may develop complications such as hypertrophic or hypersensitive scars, and these may warrant a therapy examination. As with all nerve lesions, the therapist educates the patient to avoid contact with items that may cause damage to the insensate areas. This is especially important in the ulnar aspect of the hand because of its potential for resting on hot, sharp, or rough surfaces
Active Fist
Once active motion is initiated - goal = achieve ~a half composite fist actively 10x/hr increases chance tendon glide can be maintained prior to development of significant adhesions. By not performing a full fist or resisted activities, exercises don't inc load to multi-strand repairs encourages adequate load for tendon to overcome friction - not overload the strength of the repair. place-hold exercise = fingers passively placed in flexion and then the patient asked to actively hold the position evidence tendon may "bunch" w/ passive IP joint flexion and then be jerked through a pulley on the active hold. -Be aware of doing this early on
Post Op Nerve Repair Rehab
Once the surgeon removes the postoperative dressings and clears the patient for activity, AROM and PROM may begin, including place-and-hold activities. PT passively places the limb or fingers in the desired position and asks the patient to hold the position using their own muscle contraction. If needed, th therapist provides assistance with the hold phase. The therapist also initiates gentle wrist, finger, and thumb ROM in a protected range with gravity eliminated and progresses to full range against gravity Care must be taken not to place excess tension on the nerve during this phase when regaining active motion. instruct the patient in maintaining PROM of all affected joints to minimize stiffness and avoid joint contractures, b/c while awaiting motor recovery, pt tend to develop stiffness and contractures in typical patterns Surgeons may choose to use an orthosis for optimal positioning to minimize contractures and preserve function while awaiting return of innervation After median nerve injuries, the patient will tend to develop a thumb adduction contracture or stiffness in the thumb web space. use of a resting hand orthosis with a thumb component or forearm-based opponens (thumb spica) orthosis to support the thumb in opposition. ulnar nerve injuries -- patient uses a dorsal MP joint blocking orthosis positions the ring and small finger MP joints in flexion to minimize the claw-hand deformity. This orthosis helps prevent MP joint extension stiffness and redistributes ED muscle force to the IP joints to minimize IP joints flexion stiffness In radial nerve injuries, the patient uses a palmar resting orthosis to support the fingers and wrist in extension. When motor function begins to return, the therapist instructs the patient in specific exercises as well as functional activities for the involved muscles. Sensory reeducation and dexterity training are important components of the rehabilitation program. The use of alternating current electrical stimulation should be considered as an adjunct to sensory and motor reeducation.
Swan Neck Deformity d/t chronic Mallet Finger
PIP joint hyperextension, DIP joint flexion Individuals w/ ligament laxity & w/ natural mobility into passive hyperextension of the PIP joint = inc risk
Sensory Re Education
Phase 1 -immediately after repair when the patient has no protective sensation. Goal = maintain the cortical hand map in the brain. Activities in this phase include motor and sensory imagery. PT can also instruct the patient in mirror therapy, where the patient hides the involved hand behind a mirror and someone touches the uninjured hand. The patient, looking in the mirror sees touch as if it were happening to the injured hand Phase 2 - when the axons have reached the hand or when the patient can feel, at minimum, the 6.65 (300 g) monofilament in the palm and when touch localization is present. patients perform shape, texture, and object identification activities. Beginning sensory reeducation too early can lead to failure and cause frustration Because pain is the first sensation to recover following nerve injury or repair, many patients will develop hyperesthesia, or allodynia. In these cases, a desensitization program should precede sensory reeducation. patient to expose the hypersensitive area to variety of textures, beginning with soft cotton and progressing to more coarse textures. Additional interventions for hypersensitivity include compression, percussion, vibration (low to high cycle), and dowel textures (moving stimulus), moving the hand through particle bins (static stimulus), transcutaneous electrical nerve stimulation, and ultrasound
Lunate Dislocation
Post wrist strain If lunate does not reduce = visible and/or palpable deformities in wrist. If lunate displaced volarly --> potential median nerve compression. Fx often accompany lunate dislocation High-energy trauma may produce perilunate fracture-dislocation, with trans-scaphoid fracture being the most common injury combination unless dx as fx or dislocation--> may be missed in acute stage. initial pain may resolve --> over time (can be months or years), symptoms will recur. When asked, pt may report hx history of wrist sprain that resolved over time.
Tenolysis Post-Op
Tendon integrity good- initiate AROM Day 1 If possible, see pt 1x/day first 5 days. Treatment: AROM, PROM, pain management, edema control, orthosis positioning, HEP Goal: Recover tendon glide functional resting orthosis early on - reduce inflammatory process & provide comfortable resting posture Hourly repetitions finger flexion AROM Days 1-3. PROM to negate effects of joint stiffness (but active tendon glide = major goal) Wks 1 - 6: ex progressed to differential glide of FDS and FDP if necessary and start return to light ADLs. Orthoses to minimize joint contractures may be used early post-op, PRN. Pt may perform place-and-hold and 4-stage tendon gliding exercises wk 1 (Figure 10). Add joint blocking exercises 2wk post 6wks- gentle resistance activities 8 wks- PREs begin tendon integrity poor: pt only perform gentle flexion AAROM in half-fist position wk 1, AROM wk 2 Extensor Tenolysis: not work on composite flexion too early- avoid development of extensor lag. Rehab must not focus on gaining flexion at the expense of recovering active extension.
Smith Fx
The mechanism of injury is the FOOSH with the wrist in hyperextension and some forearm supination.
Trigger Finger Tx
Trigger fingers are usually idiopathic and occur much more frequently in women than men. The goal of treatment is to restore a smooth, painless, full ROM in the affected fingers. Nonoperative treatment includes ROM and tendon gliding exercises, modalities, orthoses, or steroid injection (BUT ano evidence to support nonsurgical interventions other than orthoses and injection). an orthosis could be used when injection or surgical intervention were not viable options. orthosis should be worn at all times for 6 to 12 weeks, and the decision to block, or immobilize, MP joint flexion versus PIP joint flexion should be determined by the therapist and patient preference. should determine treatment according to the severity and duration of the patient's symptoms. In patients with early, mild symptoms (symptoms < 3 months and no snapping or locking), an orthosis that holds the MP joint in extension (MP blocking orthosis) is indicated. As the duration and severity of the disease progresses, corticosteroid injection or injection plus orthosis use Factors associated with success include female sex and single rather than multiple finger involvement. deleterious effects of corticosteroid injections on subcutaneous fat atrophy, pain, skin depigmentation, transient elevation of urine and blood glucose levels, and tendon tensile strength. Recommend avoiding physical activity and overload to the affected part for approximately 3 weeks following the injection to allow tendon healing to avoid tendon rupture.
Zones of Flexor Tendon Injury I-V
Zone I: fingertip to proximal interphalangeal joint crease; zone II: proximal interphalangeal joint crease to the distal palmar crease; zone III: distal palmar crease to the distal margin of the flexor retinaculum; zone IV: carpal tunnel zone V: rea proximal to the wrist crease in the forearm.
Zone II Injuries
Zone II = area proximal to the FDP tendon insertion (zone I includes the FDP insertion) to the level of the metacarpal heads Zone II is the location of the 2 extrinsic flexor tendons within the fibro-osseous tunnel. reported residual impairment as high as 7 to 20% following tendon repairs in the hand Even small limitations of tendon glide can result in a significant inability to achieve a composite fist.
Bennett's fracture
a fracture-dislocation. triangular portion of bone avulsed from the ulnar side of metacarpal base. occurs from excessive abduction forces combined w/ axial load at first CMC joint avulsed fragment is attachment site of the palmar oblique ligament (stabilizer of metacarpal to trapezium) Without this stability --> remaining metacarpal subluxes or dislocates in a proximal and dorsal direction by deforming force of the APL reduction, pinning or other internal fixation, and lengthy immobilization (8 wks full-time and another 3 or more weeks part-time) typically required Initial rehab focuses on recovery of CMC palmar and radial abduction and opposition motions--> followed by strengthening thenar intrinsics Heavy gripping and pinching activities are typically avoided for at least 3 months
Rolando fracture
also occurs at the base of thumb metacarpal. has 2 or more fragments on t articular surface. comminuted fx more difficult to reduce w/ fixation (percutaneous pinning to plate and screw fixation) After period of immobilization- focus on recovery of functional thumb ROM w/ involvement of CMC joint - consequence can be loss of palmar abduction limiting functional grasp. recommend hand-based orthosis for serial web-space stretching if this complication occurs
Non-Op Care for Dorsal Displaced Distal Radius Fx
attempt at closed manual reduction and stabilization by an orthosis or cast for 6 - 8wks Pts brought back for repeat x-rays in 1st 3wks to assess maintenance of the reduction. Significant loss of radial height or excessive dorsal angulation of distal radius--> surgical fixation.
Mallet Finger
avulsion of the terminal tendon @ base of distal phalanx DIP joint is in a flexed resting posture and loss of active DIP extension. injury may be disruption of soft tissue only, or piece of bone may displace with the tendon. splinted in full DIP extension for 6-8 weeks- may develop extensor lag if can't maintain If large bony fragment disrupting articular surface (>30%) of DIP or if concurrent DIP dislocation cannot be reduced --> bone fragment or distal phalanx may need reduction & fixation A mallet finger injury PLUS hyperextension of PIP = orthosis that stabilizes the DIP in extension and blocks the PIP joint from full extension
Nerve Repair/Regenration
can include a direct, or end-to-end repair, or in cases where the gap between the ends of the nerve is significant, surgeons may use nerve conduits or tubes that serve as a tunnel to bridge nerve ends, and nerve grafting. Axonal regeneration and remyelination begins as early as 2 to 3 weeks after repair. smallest diameter fibers first to show return, thus making pain one of the first senses to reappear following injury or repair, while the large diameter fibers that carry vibration, proprioception, and motor function tend to be the last to recover. following order of sensory recovery: (1) pain measured via pin prick, (2) 30-cycle per second vibration, (3) moving touch and moving 2PD, (4) constant touch and static 2PD, (5) 256-cycle per second vibration. axonal regrowth is about 1 mm per day Factors influencing recovery: (1) age (children under 10 years have superior outcomes) (2) verbal and visio-spatial learning capacity; (3) timing (earlier repair is associated with less cell death, scarring, and Schwann cell atrophy and facilitates easier blood vessel visualization during surgery); (4) pure motor or sensory nerve injury (unlike mixed nerve repairs, there is no chance of a mismatch between fibers); (5) level of injury (distal injuries only have to travel short distances to reach their target tissue); (6) type of injury (a clean, sharp laceration with minimal to no loss of tissue has improved chances at recovery) Early surgical repair and pharmacological agents can help decrease neuronal cell death and in achieving a reasonable outcome, although in adults, there will be some permanent dysfunction. cortical and subcortical (thalamus and brain stem) reorganization occurs almost immediately after transection injuries and may be a factor in the suboptimal recovery of these injuries Another deterrent to complete recovery is misdirection of axons to the incorrect target tissue. a new axon may innervate a different area of the skin or a motor nerve may innervate a sensory area, and vice versa. Clinically, patients complain of problems with touch localization. This misdirection produces additional changes in the cortex, further complicating recovery
Associated Injuries w/ Distal Radius Fx
carpal and distal ulna fractures, intercarpal ligament sprains, TFCC injuries, and median nerve injuries. Rate of SL interosseous ligament injury up to 32% and TFCC injury up to 49%. SL and LT IO ligament injuries occur in ~1/3 -->leading to arthroscopy may be required to adequately assess the integrity of the carpal ligaments. correlation of fx involving lunate facet as a predominant fracture pattern involving the intracarpal ligaments. radial shortening >2mm correlated w/ intercarpal ligament injuries. wrist instability --> increased wrist pain w/ use, decreased wrist motion, and decreased grip strength rupture of EPL- late complication of non-op tx - irritation across fx fragments & necrosis from hematoma that often develops in third extensor compartment.
Tuft Fracture
comminuted fracture of distal phalanx orthosis holding the DIP joint in extension for 2 to 3wks to immobilize Healing may occur w/ fibrous union vs ossification, yet be functionally stable and pain free 2 Common issues: subungual hematoma and hypersensitivity of distal phalanx Tx- fluid drainage of trapped hematoma via hole drilled/burned thru nail /// desensitization orthosis removed after tenderness dec, initiate gentle DIP AROM MP & PIP motion should not be restricted Longitudinal fx or fx of base of the distal phalanx (particularly with joint subluxation) may require reduction and percutaneous pin fixation
Soft Tissue PIP Injury- Grade III collateral ligament
complete ligament rupture + injury to volar plate or dorsal capsule. volar or dorsal dislocation may also occur pts immobilized, preventing ROM in arc where instability present (end range PIP ext (0-25°) same treatment as isolated volar plate injury, but 1 - 2 wk buddy taping added to dorsal finger orthosis- dec medial/lat stresses wears orthosis for a shorter time (3 vs 5wks) if no volar plate avulsion. When finger orthosis is d/c- pt buddy tapes PRN w/ ADLs and esp for more vigorous activities For all collateral ligament sprains and PIP joint injuries: edema management w/ compression, retrograde massage, and active pumping exercises (when indicated) = integral Once joint is stable --> progress ROM ex (intrinsic stretching, w/ gradual return to PREs) PIP injuries that cannot be stabilized using nonsurgical tx or at unstable in angles > 25° of flexion = surgical repair. Note: PIP dislocation may have self-reduced. intraarticular fx may occur @ injury or reduction Recommend x-ray of the involved digit following eduction to confirm a successful reduction & r/o associated intraarticular fx Recovery of ROM after a PIP fx-dislocation can be significantly limited even with acute surgical interventions. missed intraarticular PIP joint fx-dislocation (no x-ray), or delayed repair (wait to the end of a sport season) may have few treatment options --> limited ROM recovered
Ulnar Tunnel Syndrome
compression of the ulnar nerve at the wrist, occurs near the ulnar tunnel, or Guyon canal. incidence is less than both CTS and cubital tunnel syndrome at the elbow. Common causes include ganglia; anatomical abnormalities such as anomalous muscles, fibrous bands or ligaments; fractures of the distal radius, hamate, trapezium, pisiform, or ring and small metacarpals; hypothenar hammer syndrome; and repetitive and prolonged pressure (ie, cyclist's palsy) pain, numbness, tingling, and weakness in the ulnar nerve distribution of the hand that affects grip and pinch strength. more severe, or prolonged compression --> clawing of the ring and small fingers, intrinsic muscle wasting, as well as atrophy of the thumb web space. Patients with motor loss may display a positive Froment sign. Electrodiagnostic studies may confirm clinical diagnosis. Compression proximal to the ulnar tunnel (before branch too superficial and deep) --> sensory loss in hypothenar eminence and small and ulnar half of the ring fingers AND weakness of all ulnar-innervated intrinsic muscles. Compression of superficial branch = sensory loss on the volar aspect of the ulnar-innervated fingers// NO significant motor weakness (superficial branch only innervates the palmaris brevis muscle and weakness is difficult to detect clinically) Compression of the deep motor branch = isolated motor symptoms arterial involvement = may have a positive Allen test. Differentiating between proximal and distal ulnar nerve lesions includes sensory testing the ulnar-dorsal aspect of the hand. dorsal cutaneous branch of the ulnar nerve, which traverses volar to dorsal 4 cm to 5 cm proximal to the ulnar tunnel, innervates this area. ulnar-dorsal sensory loss = proximal lesion retained sensation in this area = lesion distal to the dorsal cutaneous branch
Instability Patterns of Wrist
dynamic pattern- may not be evidence of abnormal carpal mvmt unless carpus is stressed by placing the wrist into different positions for x-ray wrist motion series (x-ray taken in flexion/extension and radial/ulnar deviation) may be necessary for diagnosis. static instability pattern--> at least some of the x-ray signs on routine PA or lateral wrist views Signs: abnormal gaps b/w individual carpal bones, alteration in shape or appearance of individual bones, loss of smooth appearing arcs across midcarpal and radiocarpal rows.
Early Stage Immobilization Protocol
early stage (3 to 4 weeks post-surgery): cast with the wrist in 20-25° of flexion up to wrist neutral, and the MP joints in 50-60° of flexion.
Colles Fx
extraarticular fx occurring 1.5 - 2 inches proximal to articular surface of the distal radius with angular displacement dorsally MOI = FOOSH w/ wrist in hyperextension and some forearm supination.
Extrinsic Extensor Tendons Affected D/t Metacarpal Fx
extrinsic extensor tendon excursion. may cause injury to the intrinsic muscles as well. Isolating the action of the ED at the MP joint can improve tendon excursion and improve an existing extensor lag. Strength and dexterity usually return with few problems
Trigger Finger Surgery Rehab
fail nonsurgical management may progress to surgery, which includes percutaneous or open release. Patients begin AROM exercises immediately following surgery. Most patients will not need postoperative therapy following trigger finger release unless complications arise. The therapist then focuses the treatment on complications that may include localized pain, swelling, and/or scarring; AROM loss; and joint stiffness. The therapist may perform therapeutic ultrasound, gentle painfree massage, scar compression, and differential tendon gliding while avoiding new signs and symptoms of inflammation. The patient does not begin strengthening or resisted activities until 3 weeks post-surgery. Strengthening begins with submaximal, isometric activity in a pain-free position and progresses gradually to avoid pain and tenosynovitis. Forceful composite fisting should be delayed or minimized in patients prone to triggering in multiple digits
Dupuytren Disease
fibroproliferative disease of digital & palmar fascia // palpable nodule/mass in palm @ level of distal palmar crease. progresses--> cords form + extend distally and proximally. Over time, cords shorten & thicken--> joint flexion contractures at MP and/or PIP (but variable) painful, but pain is often self-limiting, nodules may regress, and contractures may progress rapidly or go through periods of inactivity conflicting evidencere: suspected risk factors (alcohol consumption, smoking, manual labor, hand use, diabetes, and epilepsy) visual observation and palpation of palmar nodules and cords, assess MP and IP A/PROM+ integrity of soft tissue and neurovascular structures.
Typical Tendon Healing Process
following injury significant number of undifferentiated mesenchymal cells from the surrounding epitenon proliferate and migrate into the tendon gap. significant influx of fibroblasts allows for the active formation of scar within the tendon. Some adhesions can also be created between the tendon and the tendon sheath Historically, surgeons immobilized patients post-tendon repair for a few weeks. immobilization allowed tendon healing, and minimized the chance of tendon rupture, adhesions to surrounding tissues limited recovery of tendon glide and finger motion. Joint stiffness exacerbated the issues created from the sustained period of immobilization
Wide Awake Procedure
hand is anesthetized, with hemostasis controlled by epinephrine, but the patient remains awake. During the procedure, the patient may be able to perform active flexion of the involved digit(s) and the surgeon observes successful tendon excursion thru pulleys Can correct bunching or gapping prior to closing skin significantly improved patient outcomes in their practice with less rupturing (decreased rate of 7%) and less need for a future tenolysis
Post Radial Fx Deformity
high probability ofcosmetic wrist deformity w/ nonop tx (malunion up to 89%) low-demand older adults may accept some bone deformity (lack of complete anatomic reduction) yet do very well in desired activities. most appropriate rehab may include eval for balance and fall risk opposed to isolated focus on restoring maximum wrist recovery.
Volar Plate Avulsion
hyperextension injury to PIP joint force across PIP great enough to cause a dorsal dislocation or hyperextension deformity Majority tx non-op finger-based blocking orthosis applied to dorsum of the digit- block PIP in 25-30 flex. Both DIP & MP free. 1wk full-time orthosis then mobility program initiated A/PROM PIP flexion and active ext to level of orthosis. next 4 wks - decreases extension block 5° per week. By the time the orthosis is removed at 4 to 5 weeks, the patient will have near normal flexion and extension.
Radial Nerve Clinical Presentation
in the proximal arm are often associated with a humeral shaft fracture or elbow dislocation. Lesions proximal to the radial head will affect the anconeus, brachioradialis, as well as all the wrist, thumb, and finger extensors. These proximal lesions produce a classic wrist drop deformity due to loss of the wrist and thumb extensors. Also, there will be sensory loss in the radial side of the hand including the dorsal aspect of the thumb and index and long fingers. Lesions distal to the bifurcation of the radial nerve into the PIN and superficial sensory branches produce isolated motor loss (PIN injuries) or isolated sensory loss (superficial sensory branch injuries), respectively. Individuals with injuries to the PIN will be able to extend the wrist with a radial deviation bias due to branching to the ECRL muscle proximal to the bifurcation of the PIN and superficial sensory branch. Otherwise, motor examination of the PIN-innervated muscles in proximal-to-distal order is important to determine the location of the injury. Lesions to the superficial sensory branch have little functional consequences.
Extensor Tendon Zones (1-8)
include mallet finger disruption in zone I. injury may be a soft tissue avulsion, or involve a piece of bone from the distal phalanx. Injuries across the middle phalanx or PIP joint (zones II and III) can affect the conjoined central slip of the ED and/or the lateral bands. adequate healing of the extensor mechanism important before full motion allowed across the PIP joint injury to extensor tendons zones V -VIII requires immobilization in a protected position but, when possible, limited short arc motion may begin prior to adhesions developing Injuries involving dorsal hood, periosteum, or bone itself - interfere with successful outcome d/t scarring b/w adjacent tissues. Extensor tendon adhesions can severely limit function- composite fist requires excursion extensor tendons > flexor tendons d/t inc circumference they travel over metacarpal heads. Motion started too early or performed thru too great of ROM arc = can gap the repair & create extensor lag.
Tendon Zone III and IV Extensor Surgical Treatment
lacerations = surgical repair Post-op pts w/ combined repairs of central slip and lateral bands = immobilized w/ DIP and PIP in extension 6 wks early AROM short arc 0-30° PIP and 0-25° DIP in 1st wk - full IP extension maintained when not exercising. if lateral bands not repaired = AROM short-arc @PIP and isolated DIP AROM thru any range. minimize load to extensor tendon = flex wrist to 30° during short-arc motion exercises --> decrease tension on extrinsic flexors @ PIP active ext limited motion performed every 2 hours but pt returns to complete PIP and DIP ext in orthosis when not exercising. If no extension lag develops = each week arc of motion inc ~10°. by week 4, the average PIP joint is moving actively 60-70° week 6 near normal extension and flexion is achieved. short-arc motion exercises best performed w/ 2 custom orthoses to guide pt to desired flexion and to perform independent DIP flexion while protecting the PIP during HEP pt performs MP and wrist active motions daily while the PIP/DIP immobilized. A gentle strengthening program begins at 6 weeks post-surgery.
Neurapraxia
least severe form of nerve injury and generally carries a good prognosis. is characterized by a transient reduction, or complete blocking of nerve conduction at the lesion site from etiologies such as compression or repetitive strain. axon continuity remains intact, but there is disruption in neural circulation with formation of endoneurial edema. Resulting ischemia metabolically blocks conduction by interrupting the energy source required for axonal transport. Clinically, it results in sensory dysfunction, the Tinel sign is not present, and electrophysiologic studies are negative. However, long-standing compression can result in fibrosis within the epineurium. In neurapraxic injuries, recovery begins immediately following removal of the compression, recovery is complete, and occurs between hours to 3 months after removal of compression.
DD Treatment
limited/inconclusive evidence on rehab interventions in options include surgical approaches (collagenase clostridium histolyticum (CCH) Xiaflex injection and manipulation, needle aponeurotomy, percutaneous needle fasciotomy, and fasciectomy (open, limited, and segmental)). Indications for surgical treatment: MP joint contracture of >30º or PIP contracture >20º w/ documented progression With CCH- surgeon injects into cord = weakens it. 24hr later, manipulates digit by passively extending finger, disrupting or distending the cord. the manipulation can occur up to 7 days following w/o change in outcome After manipulation, passive stretching exercises and uses an extension orthosis at night for 3 months. Side effects: skin breakage, tendon rupture, pulley and/or ligament damage, nerve injury, and allergic reaction. 5-year recurrence rate of 47% after CCH injection, which is comparable to surgery Post- op tx = edema control, wound care, tendon-gliding exercises, AROM shoulder, elbow, wrist, and scar management post suture removal and wound closure. Gentle PROM 3 to 4 weeks post-op once edema and inflammation subside and no attenuation of the extensor mechanism or PIP joint extension lag. pts wear either a volar or dorsal extension orthosis up to 6 to 8 months. pt with long-standing PIP flexion contractures and attenuation of the extensor tendon at the PIP joint- include PIP joint extension orthosis for several weeks post-op and limiting composite fisting during this time. DIP joint can remain free - pt performs active DIP flexion to maintain the length of the oblique retinacular ligament. The patient gradually begins PIP joint flexion and is able to progress the arc of motion if a PIP joint lag does not occur No-Tension Approach after Facsiectomyh- patient avoids strenuous exercise, stretching, and orthoses that create excessive mechanical stress to the skin and healing tissues - minimize alterations in neurovascular function and tissue nutrition that may in turn facilitate scar hypertrophy and increase edema and inflammation
LT Ligament Disruption
lunate following scaphoid into flexion --> resting posture representative of a VISI (volar intercalated segmental instability)
Zone I extensor Injuries
mallet injuries result from forced flexion of DIP joint --> soft tissue avulsion of terminal tendon from distal phalanx. Radiographs to r/o bony involvement and determine if DIP joint surface affected. soft-tissue mallet injury treated w/ full-time orthosis with DIP joint in full extension. Hyperextension of the DIP joint is not recommended due to potential dorsal skin necrosis During the immobilization period (6 to 8 weeks), no other finger joints, including PIP joint, should be immobilized. Full-time DIP joint extension key even when performing changes of the orthosis and skin checks. Post immobilization, motion into flexion initiated incrementally (wk 1 20-25°, wk 2 up to 35° , etc) if an extensor lag develops = orthosis re-started and motion is delayed for a few more weeks extensor lags (and therefore poorer outcomes and patient satisfaction) associated with increased age, poor patient compliance, and low health literacy
Axonotmesis
more severe type of nerve injury. there is axonal damage but the surrounding connective tissue structures (ie, perineurium and epineurium) are preserved. Axon and myelin degeneration occur distal to the injury, causing complete denervation. The potential for recovery is good in axonotmetic injuries because the uninjured nerve latticework provides a path for subsequent sprouting axons to reinnervate their target organ. there is sensory and/or motor dysfunction and the Tinel sign is positive at the site of the injury Electrophysiologic studies reveal decreased nerve conduction and regional muscle denervation with fasciculations Regeneration occurs almost immediately axonometic injuries
Boxer Fracture
most common fx of metacarpals metacarpal neck fx occurs on small finger MOI -punch w/ clinched fist into solid object w/ axial load placed thru the ulnar side of hand causes flexion of distal fragment (apex-dorsal at metacarpal neck). A flexed position of t distal fragment of as much as 70° may be acceptable. small finger is a mobile ray- mobility of CMC joint of the small finger allows for malalignment w.o compromising function. Tx: attempt at closed reduction followed by cast or orthosis fixation intrinsic plus posture with the IP joints free for movement allows tendon glide exercises surgery for: pt who don't maintain adequate reduction of angular and rotational deformity or who have damage to an adjacent metacarpal
Ganglion Cyst
most common soft-tissue mass wrist and hand firm, palpable mass, usually 1 to 3 cm in size. DDX = solid tumors, proliferative tenosynovitis, and a carpal boss. synovial cysts filled w/ mucoid material - from synovial lining of joint or tendon sheath, d/t repetitive microtrauma associated w/ ligament hyperlaxity (SL instability) generally begin small, progressively inc in size- buy can can spontaneously disappear and reappear later usually asymptomatic but can be painful and interfere with extremes of motion 70% on the dorsal surface and arise from SL ligament or articulation Volar arise from the scaphotrapezial or radiocarpal joints Volar ganglia can adhere to radial artery or cause ulnar or median nerve compression. ganglion cyst remains stationary w/ tendon excursion (vs tenosynovitis) carpal boss = osseous protuberance on dorsal base of 2nd or 3rd metacarpal, may involve trapezoid or X-rays or CTs to confirm carpal boss- but rarely use imaging to dx cyst. Imaging may be used when evaluating for coexisting conditions, (use MRI or ultrasound) Diagnostic US-ganglion cyst vs vascular malformation
scaphoid fx
most fx'ed carpal (68%) scaphoid spans midcarpal joint = vulnerable to tensile force during FOOSH w/ wrist hyperextension+ RD ~70-80% occur @ waist & 10-20% @ proximal pole. occurs most often in young active persons d/t high energy traumas. may @ first be mistaken for wrist sprain --> proper eval/tx delayed --> nonunion & avascular necrosis of proximal fragment. long-term impact of nonunion --> development of scapho-nonunion advanced collapse (SNAC) wrist deformity. SNAC --> complete carpal breakdown w/ loss normal alignment @ radiocarpal + midcarpal joints & b/w carpals in proximal row may need proximal row carpectomy or a partial wrist fusion initial s/s = dull, deep, radial-sided wrist pain. Pain reproduced on direct palpation in the anatomical snuffbox, @ SL joint line, or scaphoid tubercle. If initial x-rays are neg, yet MOI & s/s indicate fx = immobilization in thumb-spica orthosis or cast for 2 wks- then repeat film Advanced imaging may be ordered if definite answer needed sooner (return to pro sports) or when confirmed fx must be further assessed for surgery
Neurotmesis
most severe type of nerve injury, such as a laceration, there is complete disruption to the nerve. complete functional loss. Also, there is no potential for recovery without surgical intervention due to scar formation and loss of the endoneural tube that would otherwise properly direct axonal regrowth. Following nerve laceration, the distal aspect of the nerve disintegrates, Schwann cells lose their myelin sheath, and some Schwann cells die. sensory neurons show greater cell death than motor neurons over time if not repaired. As many as 20% to 50% of neurons in the dorsal root ganglia may also die following an injury to a sensory nerve
Ganglion Cyst Treatment
no tx indicated for asymptomatic pt. electrophysical agents generally ineffective. 3 treatment options for symptomatic: observation, aspiration (often combined with steroid injection), and surgical excision (open or arthroscopic). mean recurrence rate of 21% for open surgical excision vs 59% for aspiration. Post-op- edema control via elevation + finger AROM immediately following surg Wrist ROM may also begin immediately unless there is a ligament repair. Tx continues until pt achieves full finger/wrist ROM and functional activities. Once wound is healed- pt begins scar management via compression and scar mobilization. important to achieve full excursion of the extrinsic wrist and finger flexor (volar ganglia) and extensor (dorsal ganglia) tendons -so there is no loss in ROM or resultant stiffness. Complications: infection, excessive scar formation, arterial or nerve damage, and postoperative stiffness. Open surgical excision carries the highest complication rate, 14%.
Distal Radius Fx Rehab
noninvolved joints must be moved. Casting = comfortable + allow full finger ROM Include tendon gliding exercises (4-stage tendon glide, superficialis fisting, and blocking) intrinsic muscle gliding (active intrinsic plus (MP flexed and IP extended) --> minus (MP extended and IP flexed). cast distal to distal palmar crease blocks full MP ROM-should be avoided* Edema management initiated in early immobilization Wrist AROM 1-3wk post-op for extraarticular fx w/ ORIF Wrist AROM 4 -6 wk post-op for intraarticular fx w/ORIF Wrist AROM after 5-6wk immobilization for extraarticular fx treated nonsurgically Pt does active tenodesis exercises, gravity-assisted wrist ROM, place-hold technique. Forearm rotation ex begin to regain sup/pro Late rehab- focus on strengthening, endurance, and return-to-work activities common substitution patterns- humerus add and shoulder ER (compensate for lack of supination) and use of ED muscle to extend wrist (sub for weak wrist ext) frequent complaints post radius fx = ulnar column pain and swelling. occurs b/c ulnar styloid fx and DRUJ injuries are common in displaced distal radius fx. ulnar styloid usually not repaired if fragment is small and asymptomatic --> pinning necessary w/ significant fragment. Ulnar wrist pain increases w/ isometrics or gentle strengthening d/t force relationships (normally are 80% thru radius, 20% ulna) d/t shift to ulnar side if radius shortened post fx. must ascertain if pain w/in expectations post fx or d/t other complications (DRUJ instability, nonunion or malunion of styloid fx, median/ ulnar nerve inj, CRPS, hardware problems, or carpal ligament injuries) uncomplicated fractures may have good outcomes w/ independent programs but pts >60 or w/ patients complications/comorbidities are found to benefit from a clinically supervised program
Hook OF Hamate Fx
not seen often occurs d/t compressive force thru base of palm or shear forces during active torque of wrist, (using tennis racquet, baseball bat, or golf club.) Pt w/ undiagnosed fx may c/o pain w/ gripping activities and WB thru palm & TTP over the hook. Conventional x-rays do not properly reveal the fx A carpal tunnel view (hand in full extension, and beam angled through carpal tunnel) = best to reveal fx Immobilization in cast 6-8wks for nondisplaced fractures; displaced fractures require surgery Distal ulnar neuropathy - possible consequence of missed hook fx hook forms radial border of Guyon's canal. displaced fragment may compromise ulnar nerve and artery as they move into the enclosed space. Exam for suspected hook fx should include thorough neurovascular assessment of ulnar nerve+ artery. Also, if a distal ulnar neuropathy is obvious on exam, consider hook fx as possible cause.
Acute Zone III and IV Extensor Tendon Injuries
occur 2/2 closed injury (PIPJ dislocation) or open injury (laceration) These injuries may disrupt some or all contributors to the extensor hood Disruptions involving triangular ligament, lateral bands, and/or the central slip --> lateral bands migrate to palm/volar to PIPj axis of rotation --> become flexors rather than extensors. loss of balance b/w flex/ext --> Boutonnière deformity Treatment: PIPj extension orthosis on dorsal surface of the finger, the DIPj free to move The patient uses the orthosis at all times 6 weeks (complete rupture) and 3 weeks (partial)
Zone VII (Dorsal Wrist) Extensor Tendon Injury
particularly problematic Scar formation b/w tendon, sheath, and dorsal retinaculum limit wrist/finger ROM + limit functional activities. After primary repair, some surgeons prefer immobilization orthosis to place wrist and MPj in ext 3 -4 wks. pt should not actively extend PIP joints w/ wrist and MP joints in extension d/t greatly inc force needed to extend in that position. A/PROM extension of the PIP joints completed when wrist neutral or slightly flexed. early motion programs- dynamic orthosis allows pt to flex fingers actively, elastic bands assist MPj into ext motion started early yet minimal force thru repair site Other protocols may not use dynamic orthosis- begin motion when active assistive program of wrist & finger tenodesis can be safely performed. static orthosis w/ wrist in 35-45° of ext, MP + IP @ 0°. progressive wrist motion to 10-20° wrist flex, but less if wrist ext were also repaired. If > 1 ED tendon repaired- differential extensor tendon gliding helpful to reduce adhesions- actively flexion 1 finger at a time, others held in ext long and ring finger tendons interconnected @ wrist = may move together first 3 wks: w/ wrist ext, pt actively flex MP joints 30-40° --> 40-60° wk 4 --> 70-80° wk 5 4th wk pt begins gentle wrist flexion w/ 50% composite finger flexion --> progressing to complete wrist flexion + composite finger flexion by wk 6 as the patient weans away from the orthosis.
Following Immobilization (1-2 weeks post)
patient begins active motion and differential tendon gliding exercises while the wrist is extended to 10° to make use of synergistic wrist motion (tenodesis). The therapist assesses movement after 3 to 4 days, and if the difference between passive and active composite flexion is > 50° = considerable adhesion formation and is ready to progress to the next phase
Proximal Phalanx Fx
tend to angulate volarly d/t tension from intrinsics primary rehab concern = scar adhesions limiting flexor tendon excursion. Angled, rotated, and displaced fx often require (ORIF) ORIF can enhance outcomes = may allow early tendon glide ex Decreased flexion tendon glide = decreased IP AROM and PIP joint contractures (2 common complications)
Zones V and VI Extensor Tendon Injuries
primary repair pts immobilized for 4 - 6 wks post-op like other zones = evidence of difficulty to recover motion/tendon excursion post immobilization vs early ROM program Safe active/passive mvmt @ MP of index/long fingers= slight hyperextension --> 30-45° flexion ring/small fingers, slight hyperextension--> 40-50° of flexion enough mvmt to allow positive effects of stress b/w repaired and adjacent tissues w/o attenuating the repair IPj mobilized thru full A/PROM flexion w/o compromising repair if wrist and MP joints held in extension dynamic custom orthosis in wk 1, wrist in slight extension --> graded AROM of MPj into flexion w/ P/AAROM return to extension wrist in 20° flexion during AAROM MP joint ext - minimize resistance from antagonistic finger flexors AAROM extension performed by pt opposite hand. As IP in the static orthosis at least first 4 wks, active IP joint flex/ext w/ MP manually supported encouraged during session. @ 4wks post-op, orthosis may be altered- allow IP joints free, maintaining wrist/MPj support protective orthosis typically removed week 6. pt discontinue composite flexion if extensor lag appears
Ulnar Nerve Clinical Presentation
proximal forearm (high injuries) and wrist or hand (low injuries) usually result from lacerations, fractures, or dislocations, and suicide attempts. may occur along with injuries to muscles, tendons, or arteries that complicate prognosis and rehabilitation. High injuries result in sensory loss in volar and dorsal surfaces of the small and ring (ulnar half ) fingers. Motor loss occurs in the FCU, FDP (ring and small fingers), hypothenar, dorsal and palmar interossei, lumbricals to the ring and small fingers, AP, and FPB (deep head) muscles. Lower injuries spare sensation on the dorsal-ulnar aspect of the hand due to branching of the dorsal branch of the ulnar nerve in the forearm. In low lesions, the sensory and motor patterns are dependent on the specific location of the injury with relation to the ulnar tunnel. Lesions proximal to the ulnar tunnel will result in sensory loss in the ulnar aspect of the hand (volar only) and motor loss in the hand similar to high lesions (excluding the FCU and FDP muscles). Lesions distal to the bifurcation of the ulnar nerve into its deep and superficial branches will have different clinical manifestations. Patients with injuries to the deep branch will have normal sensation but lose motor function of the ulnar-innervated hand intrinsic muscles. Lesions to the deep branch that occur distal to the abductor digiti minimi branch will affect the interossei but spare the hypothenar muscles. Injuries to the superficial branch of the ulnar nerve result mostly in sensory loss to the volar-ulnar aspect of the hand. at risk for developing a claw-hand (intrinsic minus) deformity in the ulnar fingers. Loss of the muscles of the hypothenar eminence = ED muscle unopposed at the MP joints --> excessive MP joint extension. Loss of intrinsic muscle contribution to PIP joint extension allows the FDS and FDP muscles to overpower the ED muscle, resulting in excessive PIP joint flexion. difficulty grasping around objects with the ulnar aspect of the hand. Patients also lack the ability to key pinch and have a positive Froment sign, in which they attempt to substitute for loss of the thumb adductor by activating the FPL muscle (innervated by the AIN) that produces thumb IP joint flexio There is also atrophy in the thumb web space.
Double Crush/Reverse Double Crush Syndrome
proximal interference with axonal transport will make the distal aspect of the nerve more susceptible to injury, such as in the case of a patient with a cervical lesion who develops CTS With reversed double-crush syndromes, retrograde transport from the axon to the nerve cell body is disrupted making the proximal aspect of the nerve more susceptible to injury. This awareness allows more accurate diagnosis of patients with cervicalr adiculopathy who present with mixed nerve symptoms and patients with nerve compression syndromes who do not demonstrate classic patterns of nerve injury.
Traumatic Nerve Injury Management
require surgical management, if only for purposes of exploration and neurolysis, and if explored early (within 5-7 days) most sharp lacerations can be primarily repaired gaps can be bridged using allografts, conduits, or grafts immobilization should prevent over stretching of the denervated muscle-tendon units and typical deformity that result from nerve injury early rehabilitation focus on edema control through elevation and active movement of noninvolved joints use of ice controversial at or distal to the repair because it slows nerve conduction and may harm insensate tissues. It is imperative for the therapist to educate the patient throughout rehabilitation to prevent injuries, such as burns, to the fingers because of sensory loss.
Normal Wrist Function
ring system- bones in each carpal row tethered by interosseous ligaments ring only complete by the inclusion of midcarpal ligaments--> connection b/w proximal & distal carpal rows. as long as ligaments are intact = bones move together as unit. extrinsic ligaments from radius and ulna and distally from metacarpals further support carpals. Disruption of portions of the unit --> instability
Passive Flexion + Active Extension
same joints at this first visit. Passive individual joint motion first--> composite passive finger flexion within pt tolerance. Self-adhered compression wrap or a gauze circumferential wrap - used as needed for edema control. greater force needed during active flexion requires PT to delay active motion in the presence of edema, continuing with passive motion while aggressively addressing the edema as needed.
% of Carpal Fx
scaphoid 68%, triquetrum 18%, trapezium 4%, lunate 4%, capitate 2%, hamate 2%, pisiform 1%, and trapezoid 0.5%.
Soft Tissue PIP Injury (Collateral Ligament) Grade I
vulnerable to excessive hyperextension, axial loading, and rotational stress d/t of long lever arms Grade I: produce excessive tensile stress in collateral ligament- do not disrupt continuity of ligament. These are stable through full AROM , but the ligament is TTP and pain is reproduced with stress testing. treat w/ 1 - 2 wks buddy taping- allows desired early motions in IP flex/ext yet prevent medial/lateral stresses
Radial Nerve Compression (Wartenburg Syndrome/cheiralgia paresthesia)
sensory changes in the radial aspect of the wrist, dorsal thumb, thumb web span, and radiodorsal aspect of the hand. nerve is very superficial in this area and can easily be compressed by external forces. Causes of injury or compression include trauma, diabetes, repeated exposure to cold, hand exertion, a tightly worn wristwatch or handcuffs, lipoma, surgeries, or compression between the brachioradialis and ECRL -Anomalous fibrous or fascial bands arising from these muscles can also cause compression Compression can also result from a cast that is applied too tight, or from a surgical intervention around the base of the thumb, such as an interposition arthroplasty for first CMC joint osteoarthritis or De Quervain decompression. pain, numbness, tingling, or hypersensitivity in the distribution of the nerve along the dorsal aspects of the thumb and radial hand. There may be a positive Tinel sign over the radial side of the wrist, at the radial styloid, or distal radius. Manual muscle testing of the brachioradialis or radial wrist extension may elicit symptoms. Differential diagnosis- cervical radiculopathy (particularly C6 nerve root entrapment), De Quervain tendinopathy, first CMC joint osteoarthritis, intersection syndrome, and lateral antebrachial cutaneous nerve neuritis. Patient education for care of the insensate area and prevention of further injury is important. Management includes eliminating compression and avoiding wrist positions that recreate symptoms. Gentle nerve gliding may be beneficial; however, any treatment should not recreate an inflammatory response or reproduce symptoms. Surgical intervention includes release of fascial bands or restrictions between the brachioradialis and ECRL, or removal of space-occupying lesions (eg, lipomas or bone spurs) Therapy post-surgery is rarely indicated in these patients unless there is a need for wrist or thumb ROM exercises, scar or nerve mobilization, or desensitization.
Scapholunate Advanced Collapse (SLAC)
significant gap b/w scaphoid & lunate + abnormally rotated scaphoid. scaphoid has free mvmt d/t lack of association w/ lunate = flexing excessively--> creating view where distal portion appears as base of a ring and proximal pole becomes the stone = the ring sign. lateral view hows abnormally rotated lunate (tilted dorsally) creating a DISI pattern. Dorsal Intercalated Segmental Instability develops-lunate loses flexion tendency d/t ligamentous separation from scaphoid instead follows triquetrum --> pulls lunate into extension. dorsal tilt indicative of a SL ligament dissociation.
Tendon Repairs in Other Zones (Flexor)
similar activities should be followed for repairs in other zones. Zone I injuries only involve the FDP tendon. A soft tissue repair, whether the tendon was lacerated or avulsed (jersey finger), can follow the same rehab protocol A zone I injury that includes significant bony avulsion (a Type III jersey finger) may be treated as a fx w/ surgical fixation of the avulsed bone to the distal phalanx followed by period of immobilization. Repairs in the proximal zones III-V do not have the same concerns about tendon gliding in fibro-osseous tunnels or restrictions at the pulley levels = positive outcomes more reliable. Multiple tendons repair in zone V (area proximal to the wrist crease) often results in significant tendon scarring --> may limit tendon excursion and finger/ wrist mvmt. Early active glide exercises in zone V injuries can be helpful Zone V lacerations also often involve injuries of the local neurovascular structures, potentially complicating the recovery process.
Active Tendon Glide
started on 1st or 2nd visit - once improved ease of passive motion obtained. Most protocols -passive IP flexion & active IP extension with the MP remaining in flexion (>50°) important to teach each pt - work on active IP extension as tendency is to develop PIP flexion contracture as healing progresses. B/c tendon is on slack by the wrist and MP joint positions in the orthosis, typically, full PIP motion obtained w/ active extension in the confines of the orthosis. If not = have the patient come out of the orthosis to work on PIP extension while the MP joints remain flexed.
Trigger Finger
stenosing tendovaginitis snapping or locking of a finger or thumb during flexion, with or without pain occurs in the palm at the level of the distal palmar crease, or MP joint, due to a size mismatch between a swollen flexor tendon and a thickened A1 pulley tendon sheath extends more proximally than the pulley system and a palpable, tender nodule may develop at the proximal edge of the sheath. During finger flexion, flexor tendon glides proximally, then as the patient tries to extend the finger, the tendon (or nodule) gets "stuck" on the proximal border of the pulley, momentarily preventing finger extension. In more severe cases, the patient reports the need to manually straighten the finger. Differential diagnoses include DD, ganglia, lipomas, and other flexor tendon masses, such as tumors abnormal cellular changes result in hypertrophy causing constriction in the fibro-osseous A1 pulley// excess hyaluronic acid synthesis and an edematous collagen matrix are involved in the condition's progression.
Tendon Repair Goals
strong repair with minimal gapping between the tendon ends at the repair site providing adequate venting, which is partial or complete excision of areas in the pulley system to allow sufficient space through which the repaired tendon can slide; minimizing interference with tendon vascularity; and maintaining a smooth gliding surface at the repair site
Current Tendon Repair
surgeons typically request postoperative rehabilitation involving early but protected motion, knowing that motion, not load, is the critical factor to optimize tendon glide. Longer periods of immobilization are now reserved for pediatric patients, patients who cannot comply with early motion programs, and those with concomitant bony or soft tissue injuries requiring additional protection
DeQuervain tendinopathy
tenovaginitis AKA tendon entrapment impaired tendon gliding under thickened retinaculum in 1st dorsal extensor tendon compartment (APL and EPB) clinical diagnosis more common in women than men. (esp in later stages of pregnancy and during lactation) Studies shown inconsistent inflammatory findings- may relate to different stages of disease.1 levels of estrogen receptor expression correlated to disease activity. pain in 1st dorsal compartment, TTP along tendon course, sometimes TTP 1 -2 cm proximal to radial styloid. Special tests: Finkelstein and Eichoff, resisted thumb extension (special tests alone lack sufficient diagnostic accuracy) Rarely use imaging; may be necessary to r/o arthritic changes @ 1st CMC and STT joints or w/ trauma to r/o distal radius or scaphoid fx DDX: irritation of radial sensory nerve and intersection syndrome. Diagnostic ultrasound can be used to ID anatomical variations. multi-modal tx approach incl both corticosteroid injection and orthosis. ultrasound-guided injection--> better outcomes Wearing a thumb-spica orthosis full time vs as-desired = no sig diff in pain, grip strength, DASH, or tx satisfaction Factors assoc w/ poor outcomes = metabolic syndrome and hypothyroidism, use of growth hormone, hx of trigger finger or CTS, extensor tendon triggering, and presence of pain anxiety, depressive symptoms, and catastrophizing Some pts may require surgery. Rehab goals post-op: full wrist and thumb ROM and tendon gliding, a mobile, non-painful scar, and full return to activity.
Tenolysis
the surgical removal of adhesions limiting tendon excursion that formed after tendon repair. potential complications: tendon rupture, further degradation of neurovascular system, possibly worsening symptoms/function might be considered when: no improvements in ROM after 3 months of adequate therapy. patient's PROM w/in functional range, and > AROM AND evidence soft tissue scar production has stabilized. strength of extrinsic flexors should also be a consideration prior to surgery. Patients should be instructed that they will need to commit to therapy and a time-intensive home program to maximize the benefits of surgery
Factors influencing tendon repair
type of injury (eg, a simple laceration, a torn or shredded tendon, insertion site avulsion); location or zone of injury; concomitant injuries; and patient age, motivation, general health, occupation, and propensity for scar formation.
Metacarpal Shaft Fx
typically displace with an apex-dorsal angulation d/t the pull of the intrinsic muscles. Considerations again include assessment for rotation or angulation. Rotation is poorly tolerated- must be addressed Fx of index and small metacarpals, being on the radial and ulnar borders of the hand - inherently less stable than long or ring metacarpals. long and ring metacarpals - some natural stability from intrinsic muscles + neighboring metacarpals/ transverse metacarpal ligaments. Nonreducible fx and fx of multiple metacarpals are usually candidates for surgical reduction and fixation
Median Nerve Clinic Presentation
usually open injuries. pattern of sensory deficit involving volar aspect of the thumb and index, long, and radial half of ring fingers. Motor loss more extensive when the injury in proximal forearm vs distal forearm. Motor loss in proximal median nerve injuries can include pronator teres, FCR, palmaris longus, FPL, and FDP (index and long) muscles, and the hand muscles including the lumbrical muscles I and II, FPB (superficial head), APB, and OP muscles. Distal injuries will preserve function of the forearm, wrist flexor, and extrinsic finger flexor muscles, but there will be weakness of opposition and pinch due to involvement of the median-innervated thenar muscles. Loss of thenar musculature results in an ape hand deformity, ie, loss of thumb opposition causes the thumb to rest in the plane of the palm. This deformity impairs fine motor function, including writing, prehension, fine motor manipulation, dexterity, coordination between the thumb and index finger, and stereognosis
Jersey Finger
volar surface of distal phalanx, avulsion of the insertion of the FDP tendon can be tear of soft tissue only or piece of distal phalanx may have avulsed from insertion site Most common @ ring finger inability to actively flex DIP joint. PIP often has near full flexion w/ intact FDS, must not miss deficit @ DIP MOI = active DIP flexion (grasping football jersey) followed by large force pulling finger into extension (unable to hold onto jersey) soft tissue only = tendon-to-bone suture repair or tendon-to-tendon repair rehab similar to flexor tendon injuries rare occasions large piece of bone from distal phalanx avulses w/ tendon fragment can be pinned in place - treated as a fx (immobilization 4 wks in intrinsic plus cast or orthosis) w/ bony avulsion fragment may get stuck on flexor pulley system --> prevent tendon from retracting - makes it easier to return the tendon to its proper length, even in a slightly delayed repair. In a soft tissue injury -active flexion forces on the muscle/tendon unit may cause tendon to retract proximally, sometimes as far as the distal palm. causes concern w/ timely repair (within 1 week) d/t loss of nutrition to tendon. A plain lateral view x-ray of the affected digit will often reveal bone avulsion vs the soft tissue tear
Rehab Course
weeks 1 to 3: Exercises may be completed out of the orthosis if pt compliant w/ precautions. suggested exercise: passive IP flexion with the wrist in flexion, maintaining the IP joints in flexion as the wrist moved into extension. fingers passively held in the flexed posture thru wrist mvmt weeks 3 to 6: combined wrist tenodesis and finger motion. Active flexion exercises progress from the halffist toward a full fist. Extension position of MP joint during ex progressed incrementally. Interventions for scar / edema control used PRN ROM measurement allows regular but small improvements to be documented. Most protocols: discontinue protective orthosis @ 6 weeks. - Allows initiating recovery of full MP and IP joints extension. Differential tendon glide may be used at this point Light ADLs are typically tolerated at this point. Resistance exercises may begin 8 weeks post-surgery. Return to work, even for manual laborers, can occur by 12 weeks.
Flexor Repair ROM Protocol
wrist in slight flexion or neutral --> slight extension position over the following weeks of protection. Some protocols allow for wrist motion in a tenodesis manner - releasing the distal straps of orthosis, or orthosis designed ww/ wrist hinge. fingers in intrinsic plus posture (MP joints flexed 70° to 90° and IP joints in full extension) - repaired flexor tendons on slack while at rest Full IP joint extension may not be immediately obtained if the tendon was repaired under tension = make full or near full IP joint extension an early goal of therapy address edema of each digit and stiffness in the finger joints prior to performing active tendon glide (to minimize friction and load)
