10/11 - Wrist & Hand Complex Flashcards
(132 cards)
1
Q
what patients are more appropriate to refer out to OT
A
more significant injuries/burns that need splinting
2
Q
what are 3 considerations when thinking ab if pt more appropriate for you or OT
A
scope of practice
skill set
comfort level
3
Q
what bones articulate w the distal radius and how
A
scaphoid and lunate
- radius is concave distally
4
Q
what bones does the distal ulna articulate with and how
A
w the distal radius
- ulna is convex distally
triquetrum
5
Q
what bone is the most fractured carpal and why
A
scaphoid
- has a narrow central waist
6
Q
what bone is the most dislocated carpal and why
A
lunate
- weak volar ligaments
7
Q
what ligament is the pisiform embedded in
A
flexor carpi ulnaris (FCU)
8
Q
what are the proximal row of carpals (radial to ulnar side)
A
scaphoid
lunate
triquetrum
pisiform
9
Q
what is the smallest carpal bone
A
pisiform
10
Q
what are the distal row of carpals (radial to ulnar side)
A
trapezium
trapezoid
capitate
hamate
11
Q
what is a characteristic of the distal row of carpals
A
stable
12
Q
what are the 2 main surfaces of the trapezium for articulation
A
1st CMC joint
volar groove for FCR tendon
13
Q
what does the trapezoid articulate with
A
2nd MC
14
Q
what is the largest and keystone distal carpal
A
capitate
15
Q
what are the proximal and distal articulations of the capitate
A
prox: scaphoid, lunate
distal: trapezoid, hamate, 2-4
16
Q
what attaches at the hook of hamate
A
flexor retinaculum
17
Q
what is the primary motion of the distal radioulnar joint (DRUJ)
A
radius moving over ulna
18
Q
what type of joint is the distal radioulnar joint (DRUJ)
A
uniaxial pivot joint
19
Q
what is the primary goal of the triangular fibrocartilage complex (TFCC)
A
provide stability to DRUJ
20
Q
what are the 5 components making up the TFCC
A
articular disc
wrist UCL
ECU tendon sheath
meniscus homologue
radioulnar ligaments
21
Q
norms for wrist flexion
A
65-90
22
Q
norms for wrist extension
A
60-70
23
Q
norms for radial deviation
A
15-20
24
Q
norms for ulnar deviation
A
30-45
25
what are normal motions at the carpal joint (4)
flex
ext
radial dev
ulnar dev
26
what type of joint is the 1st CMC joint
saddle joint
27
what are the articulations of the 1st CMC joint
trapezium and 1st MC
28
what are the normal motions of the 1st CMC joint and norms
thumb flex (20)
ABD (50-55)
29
what is the difference b/w extrinsic vs intrinsic ligaments of the wrist and carpals
extrinsic - radius/ulna to carpals or carpals to MC
intrinsic - intercarpal (one carpal to the next)
30
how are MCP joints are stabilized
strong collateral ligaments
31
what type of joints are PIP and DIP joints
hinge joints
32
what is the importance of the pulley system with extrinsic flexor ms
sheathes restrain the tendons creating a pulley effect
- prevents bowstringing of tendons w distal movements
- contributes to efficient function
33
what is seen if the tendon sheaths for extrinsic flexors are damaged
pulley system damaged
- bowstringing and limits amt of flex
see limitations in AROM but not necessarily PROM
34
what are 4 intrinsic ms of the hand
lumbrical
interosseous
thenar
hypothenar
35
what is the path of the median n.
crosses the wrist deep to flexor retinaculum
- thru carpal tunnel (of 9 flexor tendons)
36
what is the path of the ulnar n.
superficial to flexor retinaculum
enters ulnar tunnel
- b/w pisiform & hook of hamate
- divides into superficial and deep branches
37
what sx make you think of a nerve distribution
burning
numbness
tingling
38
what are the two branches of the radial n.
sensory branch - superficial
motor - post. interosseous n.
39
what pathology do you usually see as a result of repetitive motion
dequervain's synovitis
40
what are 4 differential dx for proximal origin pain
cervical radiculopathy (C6-8)
thoracic outlet syndrome
cubital tunnel syndrome (ulnar n.)
pronator syndrome (median n.)
41
what are the goals for general fracture management (3)
1. obtain and maintain appropriate reduction (closed or ORIF)
2. restore joint congruence
3. optimal pain-free ROM and strength
42
what are 2 important considerations w general fracture management
minimize duration of immobilization
consider healing times of all involved structures
- not just bone
43
why should pediatric fractures be treated w caution
growth plate involvement
44
what is the most common type of fracture seen
distal radius
45
what are the two types of distal radius fractures and their MOIs
colles - fall in hyper-ext & sup
smith - fall in flex & pron
46
why is it appropriate to start wrist ROM @5 weeks after a distal radius fx
people won't be fully heald but looking for enough callus formation for safe ROM
47
what is an important piece in the progression of rehabing a distal radius fx
follow up imaging to see how and the quality of healing
- know this before moving around
48
what is a consideration when first initiating forearm rotation when rehabing a distal radius fx
first needs to be cleared by imaging
second keep elbow at side to dec the lever arm
49
what is the most common type of carpal fracture
scaphoid
50
where is the scaphoid most vulnerable
the waist
51
why is the scaphoid vulnerable at the waist
dec blood supply there -> harder to heal
- can move onto a nonunion and is harder to deal with
52
what is an important PT implication for scaphoid fx
lower threshold for imaging
- even if aligned, won't necessarily heal
53
what is a huge detriment to a PT intervention for a scaphoid fx
has to be immobilized for a long time to heal bc of poor vascularization
54
what is the focus on rehab for a scaphoid fx
endurance and dexterity
55
what is the second most common carpal fx
triquetrum
56
what is MOI for scaphoid fx
fall backward onto hand; wrist hyperext
57
what is MOI for triquetrum fx
fall w hyper-ext and ulnar dev
58
what carpal bone is usually also fx if the triquetrum is fx
trapezium
59
what injuries are trapezium fx associated with (3)
triquetrum fx
1st MC fx
distal radius fx
60
where part of the hamate is often fx
hook
61
what are hamate fx typically associated with
ulnar neuropathy
62
what is the MOI for hamate fx
compressive force at base of palm
63
what is a consideration of diagnostic tools for hamate fx
radiographs will often be (-)
- small bone and fx usually won't look significant
64
treatment for nondisplaced vs displaced hamate fx
nondisplaced = immobilization 6-8weeks
displaced = surgical fixation
65
what is a Boxer's fracture
displaced, apex dorsal fx at 5th MC neck
66
early vs late phase of rehab for a boxer's fx
early phase - ROM to promote tendon gliding
- prevent adhesions
late phase - adequate healing occurs
- strengthening, dexterity, & endurance
67
stable vs unstable fx
stable = buddy taping
unstable = orthotic device or pin fixation
68
what is a concern w a FOOSH
significant soft tissue trauma at the wrist
69
MOI for distal radioulnar joint implication w a FOOSH (3)
fall on pronated & ulnarly deviated hand
forceful twisting
forced hyperpronation or forced supination
70
what are sx of distal radioulnar joint implication w a FOOSH (3)
ulnar sided wrist pain w forearm rotation
ulnar head prominence
instability
71
what injuries can the TFCC be disrupted by
distal radioulnar joint FOOSH
distal forearm fx
72
MOI for a disrupted triangular fibrocartilage complex (2)
axial load to extended, pronated wrist
twisting ulnarly deviated wrist
73
what motions cause ulnar sided pain w a disrupted triangular fibrocartilage complex (3)
pronation
supination
gripping
74
what is the the MOI for a wrist dislocation
fall onto pronated hand
- wrist hyper ext and ulnar deviation
75
what bones are impacted by a wrist dislocation
scaphoid
lunate
lunotriquetral (less common)
76
what is the interventions for carpal instability (3)
protection
examine associated regions
stabilize (isometrics)
77
what is the most common hand injury in sports
thumb dislocation
- via ulnar collateral ligament involvement
78
what are we concerned about with a thumb dislocation
stener lesion
- avulsion that will require surgical repair
79
MOI for a thumb dislocation
hyper ext w radial dev
80
what types of thumb dislocations are there
acute - skier's thumb
chronic attentuation - gamekeeper's thumb
81
what is the key principle of UCL rehab in thumb dislocations
stability over motion
82
why is tip pinch avoided for 8 weeks with a thumb dislocation
tip pinch load to structures that is imposed
83
grade 1 and 2 thumb dislocation rehab guidelines (3)
thumb spica 2-4wks
key pinch and gentle thumb strengthening for next 3-4wks
avoid tip pinch and grasping for 8 weeks
84
grade 3 thumb dislocation rehab guidelines (3)
stener lesion so surgical management
- immobilization in thumb spica for 4-6wks
- gradual mobilization and strengthening
85
CRPS 1 vs CRPS 2
1 - formerly known as reflex sympathetic dystrophy
2 - same sx but cause is partial or complete nerve injury
86
biggest diffference b/w acute and atrophic phases of CRPS
acute - arguably reversible
atrophic - permanent changes within structures
87
sx and timeline of acute phase of CRPS
10days to 2-3mo
- flushed, warm, dry
- diffuse, severe pain
- edema and hair growth inc
88
sx and timeline for dystrophic phase of CRPS
3-6mo
vasomotor instability
- cool limb
- pale, mottled, boggy edema
- severe pain remains
- nails crack
- osteoporosis
89
sx and timeline of atrophic phase of CRPS
6mo +
cold end phase
more of dystrophic phase
- less movement
slightly less pain
permanent changes within structures
90
what are 6 things to exam for CRPS
pain
edema
skin temp
ROM
WB
function
91
what is the importance of including WB in the interventions for someone with CRPS
lot of people can have apprehension w WB in closed chain (esp seen in plantar grade position)
- WB can impact pain and function
- WB help to avoid osteoporotic changes
92
what is an important education point for patients with CRPS
avoid being static
maintain some level of activity
93
what is a key approach to interventions to appropriately manage CRPS
interdisciplinary approach
- pain modulation w meds, psych
94
who are patient at high risk for CRPS
all recent out of cast or injured pts a potential
95
what is the best way to approach PT interventions
prevention
- avoid prolonged immobilization
- early movement after healing
96
what are two key PT interventions for CRPS
work on edema reduction and early motion
normalize sympathetic response
- desensitize, different textures
97
where can the ulnar nerve become entrapped
elbow - cubital tunnel
wrist - guyon's tunnel
98
how does ulnar nerve entrapment present
ulnar motor weakness
- challenges w opposition
99
how can ulnar nerve sx present and change
they are site dependent
- prox to guyon's canal: mixed
- within guyon's canal: motor
- distal to guyon's canal at hook of hamate: motor
- in palmaris brevis: superficial branch (sensory)
100
what is a test for ulnar nerve entrapment
froment sign
101
what are 3 etiologies of carpal tunnel syndrome
sustained flex/ext posture
external pressure on volar wrist
prolonged hand vibration
102
why could direct pressure lead to carpal tunnel syndrome
median n. is so superficial in flexor retinaculum
- direct pressure on median n.
103
sx of carpal tunnel syndrome (3)
pain
paresthesia
numbness
104
what is the significance of weakness/atrophy in thenar musculature in CTS
if atrophy, happen long enough and significant enough that needs to be addressed
105
why is nocturnal numbness an important question to ask about
does it wake you up at night?
want to understand the severity
- get a feel for the need of a potential carpal tunnel release
106
what are 4 tests for CTS
tinels
phalens
monofilament testing
2 point discrimination
107
what is the biggest differential dx to be considering w CTS
cervical spine involvement (specifically C6)
- often can see CTS and c spine involvement
108
what are 4 differential dx for CTS
C-spine involvement
thoracic outlet syndrome
diabetic neuropathy
pronator teres syndrome
109
what are 5 education points for pts w CTS
eliminate aggravating factors
neutral wrist position
avoid prolonged wrist pressure
avoid vibration
avoid forceful gripping (esp w combined wrist flex/ext)
110
what are 2 conservative management interventions for CTS
splinting/bracing - neutral splint at night
neural mobilizations
111
why use neural mobilization w CTS? what is a consideration?
using a nerve glide technique
- general mobility to move nerve within sheath that might have gotten bogged down
important to be gentle bc can cause irritation
112
what are the most concerning signs when assessing severity of CTS and might mean surgery is the best option
atrophy
weakness
113
why should you refrain from forceful gripping or lifting in post op management of CTS or in general
flexor tendons run thru that flexor retinaculum also
- the more you use those flexors, the more irritation to those tendons in the retinaculum
114
what are 3 exercises to avoid in post op management of CTS and why
repetitive gripping/pinching
use of theraputty
use of hand grippers
contributes to inflammation in flexor sheath
115
why is strengthening not an included intervention in post op management of CTS
strengthening occurs thru daily use
116
what are 3 post op CTS interventions and general timeline
early mobilization (ie gentle fist)
2 weeks - scar mob after suture removal
4-6 weeks - full activity
117
what is a differential dx often overlooked when treating CTS
cervical radiculopathy
- that is what could be causing the sx
could be concurrent w CTS but CTS may be less severe than cervical involvement
- need to address both
118
why is early identification key with CTS
sx >1yr is a factor that is associated w poor outcomes
esp if atrophy and weakness - more severe
119
what are 3 main presentations of RA at the wrist/hand complex
ulnar drift
boutonniere deformity
swan neck deformity
120
what damage causes ulnar drift in RA
damage to collateral ligaments & extensor mechanism
- first at the MCP then at wrist
121
what does ulnar drift in RA look like
ulnar deviation, pronation, palmar subluxaiton
122
what damage causes boutonniere deformity in RA
damage to common extensor tendon of PIP
123
what does a boutonniere deformity in RA look like
flexion of PIP, hyper ext of DIP
124
what damage causes a swan neck deformity in RA
to oblique retinacular ligament leading to dorsal displacement of extensor mechanism
125
what does a swan neck deformity in RA look like
flexion at DIP and hyper-ext at PIP
126
what is the most important intervention during a flare up of RA
pain reduction - want to avoid overstressing tissues
127
what is the most important intervention after a flare of RA
teach joint conservation techniques
128
where in the wrist/hand is OA the most common and why
1st CMC or scaphoid articulations
- likely d/t amt of mobility that is there
129
what is the goal of interventions in OA
maximize mobility and strength
- try to redistribute load so that nearby ms can do more work and dec load at joint
130
what should be avoided with interventions for OA and why
end range positions
- more load on joint
131
why is imaging so important
is fx in vulnerable area - blood flow?
quality of healing?
132
what should be considered ab soft tissues when managing hand/wrist complex injuries
trying to unload these tissues
- when tissue calm down, can work on gradually changing overall mechanics
