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Upper Limb Physiotherapy (PHTY206) > The Hand > Flashcards

The Hand Flashcards

1
Q

What must be asked during a patient interview of a hand problem?

A

Mechanism, force, duration of injury
time interval between injury and treatmet
medical/surgical management
structures damaged, repaired and technique

location, intensity and type of symptoms
behaviour of symptoms
hand dominance, occupation/social issues

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2
Q

What structures could be injured in the hand.?

A 
Integument
Bony
Ligamentous
Muscle/tendon
Nerve 
Vascular
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3
Q

What injury could occur in the integument of the skin?

A

Acute/ trauma:
wound/friction burn

Insidious/Overuse
callous

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4
Q

what bony injuries could occur in the hand?

A

Acute/ trauma:
fracture

Insidious/Overuse?
stress fracture

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5
Q

What ligamentous injuries could occur in the hand

A

Acute/ trauma:
dislocation +/- fracture

Insidious/Overuse
instability/laxity

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6
Q

What muscle/tendon injuries could occur in the hand?

A

Acute/ trauma:
rupture/tears

Insidious/Overuse
itis
opathy
osis

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7
Q

What nerve/vascular injuries can occur in the hand?

A

Acute/ trauma:
tear/compression

Insidious/Overuse
compression

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8
Q

What is involved in the physical assessment of a hand?

A 
Look at Xrays -fractures/instabilities/non-union/bone necrosis
Observation
Oedema
Sensation
ROM
Muscle Testing
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9
Q

What does a lateral xray view of the hand show.

A

Distal radius, scaphoid, lunate and capitate

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10
Q

What xray view assesses the Distal radius, scaphoid, lunate and capitate?

A

lateral

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11
Q

How can SC instability be seen on hand xray?

A

PA with clenched fist, >3mm gap indicates ligament injury.

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12
Q

What must be observed on a PA hand Xray?

A

arcs should be a smooth line, note size of scapholunate gap

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13
Q

What can ultrasonography detect in the had?

A

Tendon injury
synovial thickening
ganglions
synovial cysts

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14
Q

what observations should be made during the physical examination of the hand

A
  1. upper limb and general posture screen
  2. wounds/scars/lacerations
  3. skin condition & colour-red/shiny or dry
  4. oedema
  5. deformity,wasting
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15
Q

When examining a hand, what types o wound could be observed?

A

tidy
untid
tissue loss +/- soft tissue coverage e.g flap
infected

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16
Q

What are some general observations when examining a wound?

A 
Type of closure
Primary
Delayed primary
Secondary intention
Closure: sutures, staples, steri-strips etc
Inflammatory response- normal/abnormal
Exudate - colour, amount,odour
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17
Q

What should be included in an oedema assessment?

A

Location ad type

  • pitting or hard brawny oedema
  • any associated infection signs

Measurement:
-circumferential - tape measure
volumetric

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18
Q

What should be examined for when palpating the had?

A
  • skin temp, sweating
  • scar tethering
  • hypersensitivity- presence and location
  • muscle spasm
  • tenderness over tendons, tendon sheaths, joints
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19
Q

What is the error of hand goniometer?

A

5 degree inter-tester error

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20
Q

How does the American society for hand therapists record ROM?

A

+ to record hyperextenson

- to indicate inability to fully extend

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21
Q

what is the differential diagnosis for hand ROM

A

intrinsic vs extrinsic muscle tightness

intrinsic muscle tightness

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22
Q

How does MCP flexion affect PIP and DIPjoints?

A

They can passively fully flex an extend

They cannot fully flex if the wrist is in neutral

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23
Q

How does MCP extension affect PIP and DIP joints?

A

They cannot fully flex or extend

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24
Q

What happens if the wrist is passively extend wth MCP and IP extension ?

A

The fingers are pulled into flexion

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25
Q

What nerve supplies abductor pollicus brevis?

A

Median nerve

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26
Q

What nerve supplies abd dig minimi and what sign is associated with it?

A

ulnar nerve

Frornent’s sign

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27
Q

What is pure PIN palsy?

A

attempted wrist extension causes radial deviation of the wrist because o the preservation of ECRL and brachioradialis. ECU lost

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28
Q

What does the radial nerve supply?

A

ECRB, sup, ECU, ext dig minimi, ext dig coommunis, APL, EPL, EPB, extensor indicis.

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29
Q

What does the median nerve supply?

A

all of the flexors of the forearm except FCU and FDP t little and ring fingers (ulnar nerves)

Hand: LOAF
1st and 2nd (L)umbricals
Muscles of the thenar eminence (O)ppens pollicis, (A)bductor Pollicis Brevis, (F)lexor pollicis brevis)

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30
Q

What could be observed on the palm of someone with median nerve injury?

A

Wasting of the thenar eminence

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31
Q

How can q median nerve lesion be assessed in the

A

Ring or OK sign - FPL and index FDP working so anterior interosseu branch of the median nerve is okay.

If injury to AIN, fingers make a square instead of circle

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32
Q

What does the ulnar nerve innervate?

A

FCU, FDP ( ring and little fingers), 4 dorsal inteossei, palmar inteossei 2/3/4, lumbrcals 3 and 4, add pol, muscles of the hypothenar eminence - abd digiti minimi, opens digiti minimi and flex dig minimi

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33
Q

What test assesses ulnar nerve injury in the hand?

A

Froment’s sign

grip paper- thumb remains flat, flexion if positive

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34
Q

What can cause ulna nerve pathology in the hand?

A

Hook of Hamate fracture can compress the nerve in Guyon’sCanal

Wrist prolonged compression- cyclist

Hypothenar and interosseus atrophy (dorsal guttering)

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35
Q

What are the sensibility tests in the hand?

A
  1. temperature
  2. tinel’s sign
  3. pressure threshold test - semmes Weinstein monofilaments
  4. static two point discrimination
  5. Moving two point discrimination
  6. mobrg’s pick up test
    - pick up everyday objects with eyed opened and closed while being timed
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36
Q

What is the standard for a grip strength test?

A

Second handle positon
shlder abd, elbow fl 90 degree, forearm and wrist in neutral
average of 3,compare with other side.

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37
Q

What are the 4 ways that the hand can be evaluated?

A

ROM
Strength
Sensibility
Hand function usage patterns

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38
Q

What are the functional usage patterns of the hand?

A
  1. finger-thumb prehension
  2. full hand prehension
  3. non prehension
  4. bilateral prehension
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39
Q

What are the types of finger-thumb prehension?

A

tip
lateral
3 point

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40
Q

What are the types of full hand prehension?

A

power

cylindrical

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41
Q

What is nonprehension?

A

pushing objects

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42
Q

What is bilateral prehension?

A

using palmer surfaces of both hands

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43
Q

What are the treatment prinicples for the hand?

A
  1. wound healing principles
  2. oedema control
  3. therapeutic exercise/ manua therapy
    4.splintage
    . scar management
  4. sensory re-education
    7.functional intergration
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44
Q

How long does inflammation phase last?

A

0-48 hrs

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45
Q

What happens during inflammation phase?

A

Vascular response, phagocytosis

negligible wound strength

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46
Q

What is the management during inflammation phase?

A

rest, elevation, oedema control

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47
Q

When in healing does proliferation of fibroplasts occur?

A

12-hr-10 days

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48
Q

What happens during proliferation of fibroplast

A

Migrate and bridge wound edges

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49
Q

What is the management during proliferation of fibroplasts?

A

rest, elevation, oedema, light exercise

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50
Q

What are the phases of wound healing?

A

Inflammation

Poroliferation of fibroplasts

51
Q

What is the role of therapy in wound healing?

A

Appropriate dressing

  • minimal bulk
  • moist environment

Prevent and control infection

Minimise mechanical inluences
- oedema tensions at site necrotic tise

Scar management

52
Q

What is the position for safe immobilisation of the hand?

A

wrist : 25-30 extension
MCP flexed to 60
IP joints max extension
Thumb: palmar abduction

53
Q

What are the ways to control oedema?

A 
Elevation
Compression
- coban bandage
- lycra finger stall
isotoner gloves
pressure garments

Retrograde massage
contrast bathing
appropriate exercise

54
Q

Why I management of scars important?

A

Scar can significantly impede gliding and function of a hand

55
Q

What are techniques to manage a scar?

A

massage (from 21+ days)
Thermal agents
Electrotherapy
Silicone products

56
Q

What treatment is used for hypersensitivity?

A

Desensitization

57
Q

How would desensitization be used for hyperalgesia?

A

Identify stimuli that provoke a response (texture/immersion particles/maintained pressure/temperature changes)

Apply 5-10 minutes, 3-4 times day

58
Q

What is the definition of sensory re-education

A

Method by which patient learns to interpret patter of abnormal sensory impulses after interruption in the peripheral nervs system

59
Q

What are the aims of splinting?

A
  1. protect healing tissues/prmotehealing
  2. maintain optimal anatomic position
  3. restrict/control motion
  4. promote/improve rom
  5. PROMOTE FUNCTION
60
Q

How can splinting be used to stretch?

A

provides low load, constant stretch and allow for adaptive changes in the scar matrix and remodelling

61
Q

What three kinds of pathologies occur in the hand?

A

Traumatic
Degenerative
Systeic - inflammatory/auto-immune disease

62
Q

What are common traumatic conditions in the hnd?

A

Fractures ( distal radial #, carpal # (especially scaphoid) metacarpal and phalangeal #)

Ligament Injuries (carpal instability, skier’s thumb, inter phalangeal)

Nerve lacerations

Tendon lacerations

63
Q

What are common degenerative/overuse conditions in the hand?

A

OA
De Quervain’s Tenosynovitis
Carpal Tunnel Syndrome
Dupuytren’s Disease

64
Q

What common inflammatory/auto-immune condition occurs in the hand?

A

RA

65
Q

How common are distal radius fractures (DRF)?

A

15% of all fractures

66
Q

Who is prone to a DRF?

A

predominantly 60-70 age groups from FOOSH

High energy injury in younger people

67
Q

What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint?

A

Colles’ fracture

68
Q

What is a Colles’ fracture?

A

What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint

69
Q

What is a smith’s racture?

A

“reverse colles” with volar (palm side) diplace

70
Q

What is barton’s fracture?

A

displaced, unstable articular fracture subluxation with carpus ollowing

71
Q

What are the steps to a medical management of DRF?

A
  1. obtain a good reduction
  2. maintain a good reduction
  3. early motion as fracture estability allows
72
Q

What are the treatment options for DRF?

A

immobilisation - non displaced fractures
cloed reduction
external fexation
ORIF +/- bone grafting

73
Q

Early therapy fr DRF

A

Oedema control: elevation and compression
Finger ROM
Shoulder, neck, elbow ROM

74
Q

Rehab for DRF once cast removed

A

writ mobilstions/exs as soon as fracture healing allows

75
Q

HINT***

Complications of DRF?

A 
Significant malunion
Stiffness, OA, pain
Carpal tunnel syndrome
TFCC tears
EPL rupture
Complex regional pain syndrome type 1
76
Q

What could cause a hook of Hamate fracture?

A

cycling, golf, fall

77
Q

When could a lunate fracture occur?

A

Rare, necrosis more common -Kienbock’s disase

78
Q

When should wrist problems be referred on?

A

Most wrist problems present late - send for xray tor rule ut #
If in any doubt, send for second xray

79
Q

How isscaphoid # diagnosed?

A

snuff box tenderness/swelling
xray
4 daybone scan 100% sensitive
MRI 72 hrs 100% senstive

80
Q

What should be done if a scaphoid fracture is suspected?

A

splint

81
Q

What is done for fracture of scaphoid tubrcle

A

not usually displaced

rx: immobilisation

82
Q

How often is waist of scaphoid fractured and management

A

70-80%
increased displacement
increased ned for Sx

83
Q

What is important to note about fracture of proximal pole of scaphoid?

A

increased risk arterial compromise

high chance of Sx

84
Q

What are contraindications for closed treatment of scaphoid fracture?

A

proximal pole
delayed union
comminution (breaking skin)

85
Q

Dx o scapholunate ligament tea

A

MOI - FOOSH
dorsal central pain/swelling, possible clicking.

scaphoid shift test - Watson’s test

86
Q

Tx grade 1 scapholunate ligament tear

A

immobilise (splint), therapy
Limit gripping, pushing
progressive wrist strengthening - co contraction, proprioception, ADLs

87
Q

Tx grade 2 scapholunate ligament tear

A

possibly surgical ? pinning, ? repair

88
Q

Tx grade 3 scapholunate ligament tear

A

open repar, fusion - permanent oss of wrist ROM

89
Q

Where is the triangular fibrocartilage complex

A

lies between ulna and carpals

majo stabilier of distal radioulnar joint

90
Q

What can damage the triangular fibrocartilage complex?

A

compressive loadswith ulnar deviation

distal radio-ulnar fracture/trauma

91
Q

Sign of TFCC?

A

clicking sensation onwrs movement

reduced grip strength

92
Q

Special tests for TFCC

A

TFCC grind test, supination lift test

93
Q

Treatment of TFCC twear

A

Bracing
strengthening whenable
arthroscopic repair

94
Q

What is De-Quervain’s tenosynovitis?

A

Thickening & stenosis 1s ext compartment - ABd PL and EPL

95
Q

What is DDx De-Quervain’s tenosynovitis?

A

OA + instability

96
Q

Who is more likely to have De-Quervain’s tenosynovitis?

A

females > males (3-10 x
- pregnancy onet
More common 30-55 yrs
Chronic trauma: movement patterns - thumb abd & ext, RD and UD of wrist
Uaccustomed use
Sporting - racquet sports, rowing, ocupational

97
Q

S&S De-Quervain’s

A

Pain (possible swelling) base of thumb
possibly catching or crepitus
Provocative test: finklestein’s

98
Q

TxDe-Quervain’s tenosynovitis?

A

conservative Mx

rest, EPA, ADL modification, splinting, gentle active ROM exercises, corico-steroid injection

99
Q

When and how is splinting used in De-Quervain’s tenosynovitis?

A

Acute:
forearm based thumb spic for 2/52
Rests AbPL, EPB.

Subacute:
thumboform- care with pressure
neoprene t rest EPB, AbPL
Taping - generally limited

100
Q

What surgical and post op Mx for De-Quervain’s tenosynovitis?

A

Decompression 1st dorsal compartment

wound/scar Mx
Gentle AROM
Strenghtening after 6/52

101
Q

What is skier’s thumb?

A

injury to ulnar collateral ligament of the thmb MP joint involving instability

102
Q

MOI skier’s thumb

A

forced abduction ad hypeextension e.g skier falling on outstretched hand that continues to hold ski pole

103
Q

Investigation for skier’s thumb

A 
xray to exclude avulsion fracture
MOI
compare uninjured side
palpation
stability tests
104
Q

How is skier’s thumb stress test performed?

A

Stabilise metacarpal to prevent rotation that apply radial stress to te phalnx

105
Q

Grading of skier’s thumb

A
  1. microscopic tearing, no loss of ligament continuity
  2. partial tear
  3. complete rupture
106
Q

How are grade 1 & 2 managed?

A

Conservative.
thumb spica splint han based 6/52
Wk 3: Th flex/ext active ROM exercises out of splint 3-4 times a day.

Wk 6
Gentle passive ROM
lateral palmer pinch strengthening

107
Q

How is grade 3 Skier’s thumb managed?

A

Grade 3 or displaced avulsion # = surgery
Post op:
Hand based thumb spica 6/52

Week 2: thumb MP fl/ext AROM
Week 4: General thumb ROM and strengthening
Week6: modified splint for contact sports/manual work

108
Q

What are the symptoms of carpal tunnel syndrome?

A

Pan, paraesthesia & numbness - media nerve distribution
Nocturnal symptoms (hand will drift into flexed position while sleeping
Weakness and loss dexterity in hnd
Sense of congestion or swelling in fingers

109
Q

What can pathogenesis of carpal tunnel syndrome be?

A

1, decreased size of tunel

  1. contents of tunnel
  2. inlamatory
  3. fluid balance
  4. neuropathic
110
Q

How can size of carpal tunnel decreas

A

bony abnormality

thickened TCL

111
Q

Examples contents of carpal tunnel that cause syndrome

A

Muscle bellies: lumbicals, FDS.

-mass: ganglia, lipoma
Haematoma

112
Q

Inflammatory causes of carpal tunnel syndrom

A

RA, infection, Gout, overuse

113
Q

How can fluid balance cause carpal tunne syndrome

A

pregnancy, hemodalysis, reynaud’s, obesity, hypothyroidism

114
Q

Neuropathic causes of carpal tunnel syndrome?

A

diabetes, alcohlism

115
Q

Dx of CTS?

A

provocative tests: phalen’s, Tnel’s
sensibility tests - median nrve distribution
ABdPB muscle power
nerve conduction tests

116
Q

CTS conservative Mx

A 
Work/WDL modifications
Nocturnal splint holdingwrist in neutral
Electrotherapy
Oedema control
Assess Cx spine/central component
Weight loss, aerobic fitness,stop smoking
117
Q

Surgical management and postop management of Carpal Tunnel.

A 
endoscopic vs opn
wound management
early hand ROM
avoid heav lifting/pushing for 4/52
median nerve and tendon gliding exercise 
scar managemen
118
Q

How can splints help ulnar nerve compression?

A

change handlebar grip

119
Q

What is wartenberg’s syndrome

A

neuritis of superficial radial nerve - pin base/length thumn, radiodorsal wrist

120
Q

What can cause wartenbeg’s

A

tight jewellery, handcuffs, plaster cast

121
Q

What is the aim of a nerve laceration repair

A

join as accurately as possible the connective tissue tubes of the peripheral nerve

122
Q

How long does nerve surgery take to heal?

A

Nerve sheath takes 3-4 weeks to gin sufficient strength to withstand stress
Need to protect with splint until then
*** EDUCATON - particularly young people - high rerupture rate

123
Q

0-3/4 weeks nerve repair

A

splinted in protected position - usuall flexion

If no other issues involved - commenced active ROM exercise within splint

124
Q

3/4+ weeks nerve repar

A

gradual active reginingf ROM
sensoryre-education
prevention o joint contracture - exercise splintage

Upper Limb Physiotherapy (PHTY206) (8 decks)

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