Wrist and Hand Sprains/Dislocations
what is the function ROM of the wrist for daily ADLs (flex/ext/UD/RD)
- 5-40 degrees flex - 30-40 degrees wrist extension - 10-20 RD - 15-20 UD
what positions/exercises/motions should you avoid to prevent excessive stress to the UCL of thumb MCP
- active tip pinch - thumb tip loading exercise - grasping
what is the MOI for volar plate injuries
- acute traumatic hyperextension injury - jammed finger - common athletic injury - closed pack position for IPs (ext) - dorsal dislocation or subluxation at the PIP joint (P2 moves dorsal on P1) - injury to volar plate and the collateral ligaments (mild to complete tear)
what are 4 common complications with sprains/dislocations
- chronic instability - joint degenerative changes due to instability - joint contracture - tendon adhesions, decreased tendon glide
what are 4 common complications with skiers/gamekeepers thumb
- instability - joint degeneration due to instability - MCP flexion or extension contractures - tendon adhesions and decreased tendon glide
what are 4 common complications of wrist sprains
- instability - persistent pain - joint degeneration due to chronic instability - requiring wrist fusion
what are 5 common complications of volar plate injuries
- instability if not treated - flexion contracture and loss of extension - tendon adhesions and decreased tendon glide (esp extensor lag) - may require static or dynamic extension splinting to restore full extension ROM - volar plate laxity at PIP joint
where do carpal bones gets stability from since they are intercalated
- ligamentous support - restraint and bony contact
what is the clinical presentation of carpal ligament strains/lunate dislocation
- localized pain - pain w/ ROM (esp end range) - pain w/ WB - snapping, clicking, or clucking w/ wrist movements or w/ gripping - resisted testing typically strong but painful - weak grip strength or giving way w/ forceful grip - swelling - accessory motion testing
what is the clinical presentation of UCL injury of thumb MCP
- pain - swelling - tender to palpation at ulnar MCP joint - possible palpabe superficial mass if UCL detached/displaced - positive ligament stress test - weakness or difficulty w/ pinch due to instability
what is the clinical presentation for a volar plate injury
- pain - swelling at PIP - tender to palpation - limited ROM - pain w/ movement - positive ligament stress testing - weak grip due to pain and dysfunction
what are two categories of wrist ligaments are most commonly injured
- radiocarpal palmar ligaments - proximal row carpal ligaments
what are the most commonly injured ligaments of the carpal bones (and with what forces)
- scapholunate (ulnar deviation) - lunotriquetral (radial deviation)
what is the mechanism of injury for carpal ligament strains
- traumatic event - FOOSH - often hear a "pop"
what is the MOI of skiers/gamekeepers thumb
- traumatic: FOOSH - abd/hyperextension force at thumb MCP joint
how are carpal ligaments strains/lunate dislocations diagnosed
- x-rays - MRI - arthrogram
when is the initial immobilization phase for wrist sprains if non-surgical, if surgical
0-4/6 weeks if non surgical 8-12 weeks if surgical
what is the reactive/inflammatory phase of ligament healing
0-5 days
when is there a decreased potential for wrist sprain (carpal ligament/lunate dislocation) healing
1-6 weeks
how long is the general timeframe for soft tissue/ligament healing
4-6 weeks
what is the remodeling phase of ligament healing
4-6 weeks to months/years
what is the repair phase of ligament healing
5 days to 4-6 weeks
after a wrist sprain, strenuous activities are discouraged for how long
6 months
when is there the best, max healing potential for wrist sprain (carpal ligaments/lunate dislocations) healing
<1 week
when is there poor potential, healing unlikely for wrist sprain (carpal ligament/lunate dislocation) healing
> 6 weeks
describe early wrist ROM w/ wrist sprains
AROM - mid range, controlled, pain free
T or F: wrist fusions result in a great loss of motion but ROM is functional and pain free
F: results in only some loss of motion
T or F: motion of the MCP joint is priority over stability in regard to rehab of UCL of MCP of thumb
F: stability is priority over motion
T or F: severe thumb MCP UCL sprains don't require surgical repair
F: they do
what causes flexion at the PIP joint w/ swan neck deformities
FDP puts tension on the DIP due to extension at the PIP
what type of stabilization is used for severe wrist sprains/tears
ORIF and repair, reconstruction w/ bone-ligament-bone graft or tendon graft
what mob is done to test the integrity of the volar plate
PA accessory motion
what is the most commonly injured joint in the hand
PIP
describe the dart throwing motion
RD/slight extension to UD/slight flexion
T or F: 6 months after a wrist sprain, you should continue wearing your wrist brace for sports, work, and/or heavy tasks
T
T or F: for volar plate injuries, most often the dislocation is reduced immediately
T
T or F: you still have a firm end feel with a moderate sprain
T
describe a severe sprain of the UCL of thumb MCP
UCL detaches from P1
what type of stabilization is used for mild wrist sprains
cast or splint, typically able to remove for exercise
what is the hand positioning for carpal ligament strain/lunate dislocation x rays
clenched fist
wrist sprains/dislocations tend to be injured when in the (open/closed) pack position
closed
what type of splint is used with a volar plate injury/swan neck deformity (what position are the joints in)
dorsal blocking finger splint - PIP at 20-30 degrees flex
what treatments should you avoid during the mobilization phase of wrist sprains
end ranges, aggressive PROM, aggravating motion, or aggressive joint mobs
what is the closed pack position of the wrist
extension
what is the mechanism of injury (force direction) for lunate dislocations that cause dorsal intercalated segment instability
extension
what is the mechanism of injury (force direction) for lunate dislocations that cause volar intercalated segment instability
flexion
when wrist sprains are casted/splinted, it is (hand/forearm) based and the wrist is at _____ degrees (flex/ext)
forearm based, wrist 20-30 deg extended
a wrist carpal ligament strain/lunate dislocation often mimics what type of injury
fx
what does it mean to be an intercalated segment
having no muscles attach onto those bones
what position does the silver ring figure 8 splint prevent
hyperextension
when would surgery be required to repair the volar plate
if it's a complete tear or if associated w/ a fx
during the late phase of volar plate injury management, at what rate would you adjust the dorsal blocking splint
increase ext ~10 degrees per week
what causes hyperextension at the PIP joint w/ swan neck deformities
lateral bands become dorsal to PIP joint, extensors activiate
in what conditions may someone require a wrist fusion
longstanding instability and pain that severely limits function
a grade I sprain is what classification
mild sprain
a grade II sprain is what classification
moderate sprain
in the late phase of skier thumb management, what does progression depend on
painless MCP ROM
what type of stabilization is used for moderate wrist sprains
percutaneous pinning, arthroscopic debridement/repair w/ pinning
what is the function of the volar plate
prevent hyperextension
the wrist is predisposed to sprains in the (proximal/distal) row of carpal bones
proximal
ligaments attached to which carpal bone are the most commonly injured ones
scaphoid
what bone is the bridge between the two rows of carpals
scaphoid
a grade III sprain is what classification
severe sprain/ complete tear
during the mobilization phase of wrist sprains, there is an emphasis on (mobilization/stabilization) exercises
stabilization
grade III/complete tear of UCL of thumb MCP requires what treatment/splinting
surgical repair, pinning w/ K-wires, and cast/splint ~4-6 weeks
volar plate injury of the PIP joint leads to what deformity
swan neck deformity
what is sprained in "skier's" / "gamekeeper's" thumb
thumb MCP ulnar collateral ligament
what is the position for immobilization for skiers/gamekeepers thumb. describe the splint
thumb spica cast w/ IP joint free, thumb slight abd and flex
in what population do we often see carpal ligament strains
younger people
when is the early phase of management for volar plate injuries
~0-4 weeks
when is the initial phase of management for UCL injury of thumb MCP
~0-4 weeks
with skier's thumb, there is a full return to functional activities at what point
~12 weeks
grade I and II skier's/gamekeepers thumb sprains are immobilized for how long
~2-4 weeks
w/ volar plate injuries/swan neck deformities, how long do you limit full ext at the PIP
~4 weeks
when does the late phase of skiers thumb begin
~4 weeks
when does the late phase of volar plate injury management start
~4 weeks
in the late phase of volar plate injury management, you can achieve full ROM when
~6 weeks
strengthening and lateral/key pinch exercises for skier's thumb can begin when
~6 weeks
when can you start progressive strengthening after volar plate injuries
~6 weeks
active tip pinch, thumb tip loading exercise, or grasping is avoided until medically approved, about how long is that
~8+ weeks