Flashcards in The Hand Deck (124):
What must be asked during a patient interview of a hand problem?
Mechanism, force, duration of injury
time interval between injury and treatmet
structures damaged, repaired and technique
location, intensity and type of symptoms
behaviour of symptoms
hand dominance, occupation/social issues
What structures could be injured in the hand.?
What injury could occur in the integument of the skin?
what bony injuries could occur in the hand?
What ligamentous injuries could occur in the hand
dislocation +/- fracture
What muscle/tendon injuries could occur in the hand?
What nerve/vascular injuries can occur in the hand?
What is involved in the physical assessment of a hand?
Look at Xrays -fractures/instabilities/non-union/bone necrosis
What does a lateral xray view of the hand show.
Distal radius, scaphoid, lunate and capitate
What xray view assesses the Distal radius, scaphoid, lunate and capitate?
How can SC instability be seen on hand xray?
PA with clenched fist, >3mm gap indicates ligament injury.
What must be observed on a PA hand Xray?
arcs should be a smooth line, note size of scapholunate gap
What can ultrasonography detect in the had?
what observations should be made during the physical examination of the hand
1. upper limb and general posture screen
3. skin condition & colour-red/shiny or dry
When examining a hand, what types o wound could be observed?
tissue loss +/- soft tissue coverage e.g flap
What are some general observations when examining a wound?
Type of closure
Closure: sutures, staples, steri-strips etc
Inflammatory response- normal/abnormal
Exudate - colour, amount,odour
What should be included in an oedema assessment?
Location ad type
- pitting or hard brawny oedema
- any associated infection signs
-circumferential - tape measure
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
What is the error of hand goniometer?
5 degree inter-tester error
How does the American society for hand therapists record ROM?
+ to record hyperextenson
- to indicate inability to fully extend
what is the differential diagnosis for hand ROM
intrinsic vs extrinsic muscle tightness
intrinsic muscle tightness
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
How does MCP extension affect PIP and DIP joints?
They cannot fully flex or extend
What happens if the wrist is passively extend wth MCP and IP extension ?
The fingers are pulled into flexion
What nerve supplies abductor pollicus brevis?
What nerve supplies abd dig minimi and what sign is associated with it?
What is pure PIN palsy?
attempted wrist extension causes radial deviation of the wrist because o the preservation of ECRL and brachioradialis. ECU lost
What does the radial nerve supply?
ECRB, sup, ECU, ext dig minimi, ext dig coommunis, APL, EPL, EPB, extensor indicis.
What does the median nerve supply?
all of the flexors of the forearm except FCU and FDP t little and ring fingers (ulnar nerves)
1st and 2nd (L)umbricals
Muscles of the thenar eminence (O)ppens pollicis, (A)bductor Pollicis Brevis, (F)lexor pollicis brevis)
What could be observed on the palm of someone with median nerve injury?
Wasting of the thenar eminence
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
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
What test assesses ulnar nerve injury in the hand?
grip paper- thumb remains flat, flexion if positive
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)
What are the sensibility tests in the hand?
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
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.
What are the 4 ways that the hand can be evaluated?
Hand function usage patterns
What are the functional usage patterns of the hand?
1. finger-thumb prehension
2. full hand prehension
3. non prehension
4. bilateral prehension
What are the types of finger-thumb prehension?
What are the types of full hand prehension?
What is nonprehension?
What is bilateral prehension?
using palmer surfaces of both hands
What are the treatment prinicples for the hand?
1. wound healing principles
2. oedema control
3. therapeutic exercise/ manua therapy
. scar management
6. sensory re-education
How long does inflammation phase last?
What happens during inflammation phase?
Vascular response, phagocytosis
negligible wound strength
What is the management during inflammation phase?
rest, elevation, oedema control
When in healing does proliferation of fibroplasts occur?
What happens during proliferation of fibroplast
Migrate and bridge wound edges
What is the management during proliferation of fibroplasts?
rest, elevation, oedema, light exercise
What are the phases of wound healing?
Poroliferation of fibroplasts
What is the role of therapy in wound healing?
- minimal bulk
Prevent and control infection
Minimise mechanical inluences
- oedema tensions at site necrotic tise
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
What are the ways to control oedema?
- coban bandage
- lycra finger stall
Why I management of scars important?
Scar can significantly impede gliding and function of a hand
What are techniques to manage a scar?
massage (from 21+ days)
What treatment is used for hypersensitivity?
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
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
What are the aims of splinting?
1. protect healing tissues/prmotehealing
2. maintain optimal anatomic position
3. restrict/control motion
5. PROMOTE FUNCTION
How can splinting be used to stretch?
provides low load, constant stretch and allow for adaptive changes in the scar matrix and remodelling
What three kinds of pathologies occur in the hand?
Systeic - inflammatory/auto-immune disease
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)
What are common degenerative/overuse conditions in the hand?
De Quervain's Tenosynovitis
Carpal Tunnel Syndrome
What common inflammatory/auto-immune condition occurs in the hand?
How common are distal radius fractures (DRF)?
15% of all fractures
Who is prone to a DRF?
predominantly 60-70 age groups from FOOSH
High energy injury in younger people
What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint?
What is a Colles' fracture?
What is a non articular fracture,occuring 3-5 cm proximal to the radiocarpal joint
What is a smith's racture?
"reverse colles" with volar (palm side) diplace
What is barton's fracture?
displaced, unstable articular fracture subluxation with carpus ollowing
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
What are the treatment options for DRF?
immobilisation - non displaced fractures
ORIF +/- bone grafting
Early therapy fr DRF
Oedema control: elevation and compression
Shoulder, neck, elbow ROM
Rehab for DRF once cast removed
writ mobilstions/exs as soon as fracture healing allows
Complications of DRF?
Stiffness, OA, pain
Carpal tunnel syndrome
Complex regional pain syndrome type 1
What could cause a hook of Hamate fracture?
cycling, golf, fall
When could a lunate fracture occur?
Rare, necrosis more common -Kienbock's disase
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
How isscaphoid # diagnosed?
snuff box tenderness/swelling
4 daybone scan 100% sensitive
MRI 72 hrs 100% senstive
What should be done if a scaphoid fracture is suspected?
What is done for fracture of scaphoid tubrcle
not usually displaced
How often is waist of scaphoid fractured and management
increased ned for Sx
What is important to note about fracture of proximal pole of scaphoid?
increased risk arterial compromise
high chance of Sx
What are contraindications for closed treatment of scaphoid fracture?
comminution (breaking skin)
Dx o scapholunate ligament tea
MOI - FOOSH
dorsal central pain/swelling, possible clicking.
scaphoid shift test - Watson's test
Tx grade 1 scapholunate ligament tear
immobilise (splint), therapy
Limit gripping, pushing
progressive wrist strengthening - co contraction, proprioception, ADLs
Tx grade 2 scapholunate ligament tear
possibly surgical ? pinning, ? repair
Tx grade 3 scapholunate ligament tear
open repar, fusion - permanent oss of wrist ROM
Where is the triangular fibrocartilage complex
lies between ulna and carpals
majo stabilier of distal radioulnar joint
What can damage the triangular fibrocartilage complex?
compressive loadswith ulnar deviation
distal radio-ulnar fracture/trauma
Sign of TFCC?
clicking sensation onwrs movement
reduced grip strength
Special tests for TFCC
TFCC grind test, supination lift test
Treatment of TFCC twear
What is De-Quervain's tenosynovitis?
Thickening & stenosis 1s ext compartment - ABd PL and EPL
What is DDx De-Quervain's tenosynovitis?
OA + instability
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
Sporting - racquet sports, rowing, ocupational
Pain (possible swelling) base of thumb
possibly catching or crepitus
Provocative test: finklestein's
rest, EPA, ADL modification, splinting, gentle active ROM exercises, corico-steroid injection
When and how is splinting used in De-Quervain's tenosynovitis?
forearm based thumb spic for 2/52
Rests AbPL, EPB.
thumboform- care with pressure
neoprene t rest EPB, AbPL
Taping - generally limited
What surgical and post op Mx for De-Quervain's tenosynovitis?
Decompression 1st dorsal compartment
Strenghtening after 6/52
What is skier's thumb?
injury to ulnar collateral ligament of the thmb MP joint involving instability
MOI skier's thumb
forced abduction ad hypeextension e.g skier falling on outstretched hand that continues to hold ski pole
Investigation for skier's thumb
xray to exclude avulsion fracture
compare uninjured side
How is skier's thumb stress test performed?
Stabilise metacarpal to prevent rotation that apply radial stress to te phalnx
Grading of skier's thumb
1. microscopic tearing, no loss of ligament continuity
2. partial tear
3. complete rupture
How are grade 1 & 2 managed?
thumb spica splint han based 6/52
Wk 3: Th flex/ext active ROM exercises out of splint 3-4 times a day.
Gentle passive ROM
lateral palmer pinch strengthening
How is grade 3 Skier's thumb managed?
Grade 3 or displaced avulsion # = surgery
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
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
What can pathogenesis of carpal tunnel syndrome be?
1, decreased size of tunel
2. contents of tunnel
4. fluid balance
How can size of carpal tunnel decreas
Examples contents of carpal tunnel that cause syndrome
Muscle bellies: lumbicals, FDS.
-mass: ganglia, lipoma
Inflammatory causes of carpal tunnel syndrom
RA, infection, Gout, overuse
How can fluid balance cause carpal tunne syndrome
pregnancy, hemodalysis, reynaud's, obesity, hypothyroidism
Neuropathic causes of carpal tunnel syndrome?
Dx of CTS?
provocative tests: phalen's, Tnel's
sensibility tests - median nrve distribution
ABdPB muscle power
nerve conduction tests
CTS conservative Mx
Nocturnal splint holdingwrist in neutral
Assess Cx spine/central component
Weight loss, aerobic fitness,stop smoking
Surgical management and postop management of Carpal Tunnel.
endoscopic vs opn
early hand ROM
avoid heav lifting/pushing for 4/52
median nerve and tendon gliding exercise
How can splints help ulnar nerve compression?
change handlebar grip
What is wartenberg's syndrome
neuritis of superficial radial nerve - pin base/length thumn, radiodorsal wrist
What can cause wartenbeg's
tight jewellery, handcuffs, plaster cast
What is the aim of a nerve laceration repair
join as accurately as possible the connective tissue tubes of the peripheral nerve
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
0-3/4 weeks nerve repair
splinted in protected position - usuall flexion
If no other issues involved - commenced active ROM exercise within splint