The Hand Flashcards Preview

Upper Limb Physiotherapy (PHTY206) > The Hand > Flashcards

Flashcards in The Hand Deck (124):
1

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

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

2

What structures could be injured in the hand.?

Integument
Bony
Ligamentous
Muscle/tendon
Nerve
Vascular

3

What injury could occur in the integument of the skin?

Acute/ trauma:
wound/friction burn

Insidious/Overuse
callous

4

what bony injuries could occur in the hand?

Acute/ trauma:
fracture

Insidious/Overuse?
stress fracture

5

What ligamentous injuries could occur in the hand

Acute/ trauma:
dislocation +/- fracture

Insidious/Overuse
instability/laxity

6

What muscle/tendon injuries could occur in the hand?

Acute/ trauma:
rupture/tears

Insidious/Overuse
itis
opathy
osis

7

What nerve/vascular injuries can occur in the hand?

Acute/ trauma:
tear/compression

Insidious/Overuse
compression

8

What is involved in the physical assessment of a hand?

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

9

What does a lateral xray view of the hand show.

Distal radius, scaphoid, lunate and capitate

10

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

lateral

11

How can SC instability be seen on hand xray?

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

12

What must be observed on a PA hand Xray?

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

13

What can ultrasonography detect in the had?

Tendon injury
synovial thickening
ganglions
synovial cysts

14

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

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

15

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

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

16

What are some general observations when examining a wound?

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

17

What should be included in an oedema assessment?

Location ad type
- pitting or hard brawny oedema
- any associated infection signs

Measurement:
-circumferential - tape measure
volumetric

18

What should be examined for when palpating the had?

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

19

What is the error of hand goniometer?

5 degree inter-tester error

20

How does the American society for hand therapists record ROM?

+ to record hyperextenson
- to indicate inability to fully extend

21

what is the differential diagnosis for hand ROM

intrinsic vs extrinsic muscle tightness
intrinsic muscle tightness

22

How does MCP flexion affect PIP and DIPjoints?

They can passively fully flex an extend

They cannot fully flex if the wrist is in neutral

23

How does MCP extension affect PIP and DIP joints?

They cannot fully flex or extend

24

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

The fingers are pulled into flexion

25

What nerve supplies abductor pollicus brevis?

Median nerve

26

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

ulnar nerve
Frornent's sign

27

What is pure PIN palsy?

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

28

What does the radial nerve supply?

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

29

What does the median nerve supply?

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)

30

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

Wasting of the thenar eminence

31

How can q median nerve lesion be assessed in the

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

32

What does the ulnar nerve innervate?

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

33

What test assesses ulnar nerve injury in the hand?

Froment's sign

grip paper- thumb remains flat, flexion if positive

34

What can cause ulna nerve pathology in the hand?

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

Wrist prolonged compression- cyclist

Hypothenar and interosseus atrophy (dorsal guttering)

35

What are the sensibility tests in the hand?

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

36

What is the standard for a grip strength test?

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

37

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

ROM
Strength
Sensibility
Hand function usage patterns

38

What are the functional usage patterns of the hand?

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

39

What are the types of finger-thumb prehension?

tip
lateral
3 point

40

What are the types of full hand prehension?

power
cylindrical

41

What is nonprehension?

pushing objects

42

What is bilateral prehension?

using palmer surfaces of both hands

43

What are the treatment prinicples for the hand?

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

44

How long does inflammation phase last?

0-48 hrs

45

What happens during inflammation phase?

Vascular response, phagocytosis
negligible wound strength

46

What is the management during inflammation phase?

rest, elevation, oedema control

47

When in healing does proliferation of fibroplasts occur?

12-hr-10 days

48

What happens during proliferation of fibroplast

Migrate and bridge wound edges

49

What is the management during proliferation of fibroplasts?

rest, elevation, oedema, light exercise

50

What are the phases of wound healing?

Inflammation
Poroliferation of fibroplasts

51

What is the role of therapy in wound healing?

Appropriate dressing
- minimal bulk
-moist environment

Prevent and control infection

Minimise mechanical inluences
- oedema tensions at site necrotic tise

Scar management

52

What is the position for safe immobilisation of the hand?

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

53

What are the ways to control oedema?

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

Retrograde massage
contrast bathing
appropriate exercise

54

Why I management of scars important?

Scar can significantly impede gliding and function of a hand

55

What are techniques to manage a scar?

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

56

What treatment is used for hypersensitivity?

Desensitization

57

How would desensitization be used for hyperalgesia?

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

Apply 5-10 minutes, 3-4 times day

58

What is the definition of sensory re-education

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

59

What are the aims of splinting?

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

60

How can splinting be used to stretch?

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

61

What three kinds of pathologies occur in the hand?

Traumatic
Degenerative
Systeic - inflammatory/auto-immune disease

62

What are common traumatic conditions in the hnd?

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

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

Nerve lacerations

Tendon lacerations

63

What are common degenerative/overuse conditions in the hand?

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

64

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

RA

65

How common are distal radius fractures (DRF)?

15% of all fractures

66

Who is prone to a DRF?

predominantly 60-70 age groups from FOOSH

High energy injury in younger people

67

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

Colles' fracture

68

What is a Colles' fracture?

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

69

What is a smith's racture?

"reverse colles" with volar (palm side) diplace

70

What is barton's fracture?

displaced, unstable articular fracture subluxation with carpus ollowing

71

What are the steps to a medical management of DRF?

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

72

What are the treatment options for DRF?

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

73

Early therapy fr DRF

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

74

Rehab for DRF once cast removed

writ mobilstions/exs as soon as fracture healing allows

75

HINT***
Complications of DRF?

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

76

What could cause a hook of Hamate fracture?

cycling, golf, fall

77

When could a lunate fracture occur?

Rare, necrosis more common -Kienbock's disase

78

When should wrist problems be referred on?

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

79

How isscaphoid # diagnosed?

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

80

What should be done if a scaphoid fracture is suspected?

splint

81

What is done for fracture of scaphoid tubrcle

not usually displaced
rx: immobilisation

82

How often is waist of scaphoid fractured and management

70-80%
increased displacement
increased ned for Sx

83

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

increased risk arterial compromise
high chance of Sx

84

What are contraindications for closed treatment of scaphoid fracture?

proximal pole
delayed union
comminution (breaking skin)

85

Dx o scapholunate ligament tea

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

scaphoid shift test - Watson's test

86

Tx grade 1 scapholunate ligament tear

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

87

Tx grade 2 scapholunate ligament tear

possibly surgical ? pinning, ? repair

88

Tx grade 3 scapholunate ligament tear

open repar, fusion - permanent oss of wrist ROM

89

Where is the triangular fibrocartilage complex

lies between ulna and carpals
majo stabilier of distal radioulnar joint

90

What can damage the triangular fibrocartilage complex?

compressive loadswith ulnar deviation
distal radio-ulnar fracture/trauma

91

Sign of TFCC?

clicking sensation onwrs movement
reduced grip strength

92

Special tests for TFCC

TFCC grind test, supination lift test

93

Treatment of TFCC twear

Bracing
strengthening whenable
arthroscopic repair

94

What is De-Quervain's tenosynovitis?

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

95

What is DDx De-Quervain's tenosynovitis?

OA + instability

96

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

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

S&S De-Quervain's

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

98

TxDe-Quervain's tenosynovitis?

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

99

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

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

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

Decompression 1st dorsal compartment

wound/scar Mx
Gentle AROM
Strenghtening after 6/52

101

What is skier's thumb?

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

102

MOI skier's thumb

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

103

Investigation for skier's thumb

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

104

How is skier's thumb stress test performed?

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

105

Grading of skier's thumb

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

106

How are grade 1 & 2 managed?

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

How is grade 3 Skier's thumb managed?

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

What are the symptoms of carpal tunnel syndrome?

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

What can pathogenesis of carpal tunnel syndrome be?

1, decreased size of tunel
2. contents of tunnel
3. inlamatory
4. fluid balance
5. neuropathic

110

How can size of carpal tunnel decreas

bony abnormality
thickened TCL

111

Examples contents of carpal tunnel that cause syndrome

Muscle bellies: lumbicals, FDS.

-mass: ganglia, lipoma
Haematoma

112

Inflammatory causes of carpal tunnel syndrom

RA, infection, Gout, overuse

113

How can fluid balance cause carpal tunne syndrome

pregnancy, hemodalysis, reynaud's, obesity, hypothyroidism

114

Neuropathic causes of carpal tunnel syndrome?

diabetes, alcohlism

115

Dx of CTS?

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

116

CTS conservative Mx

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

117

Surgical management and postop management of Carpal Tunnel.

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

118

How can splints help ulnar nerve compression?

change handlebar grip

119

What is wartenberg's syndrome

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

120

What can cause wartenbeg's

tight jewellery, handcuffs, plaster cast

121

What is the aim of a nerve laceration repair

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

122

How long does nerve surgery take to heal?

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

0-3/4 weeks nerve repair

splinted in protected position - usuall flexion
If no other issues involved - commenced active ROM exercise within splint

124

3/4+ weeks nerve repar

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