Week 9 Wrist Flashcards
1
Q
function of the wrist complex
wrist - allow 2 degrees of freedom
A
- positioning of the hand
- stability for WB
- maintaining optimal length for the muscles responsible for grasp
2
Q
radiocarpal joint
proximally, distally
A
proximally:
concave surface of radius, TFCC
distally:
convex surface of scaphoid, lunate and triquetrum
3
Q
function of triangular fibrocartilage complex (TFCC)
A
- stabiliser of the ulnar carpal bones and distal radioulnar joint
- provides cushion/ load-bearing surface at the wrist joint during WB on hands or pushing
- WB: radius -80%, ulna -20%
4
Q
role of wrist ligaments
A
- provide stability
- transfer forces through and across the carpal bones
- limit unwanted movements
4
Q
describe midcarpal joint
A
- proximal row jointed losely, distal row is bound tightly by strong ligaments
- functional joint
4
Q
wrist complex: midcarpal joint
A
- *lunate is the most commonly dislocated carpal bone *
- important role of scaphoid and proximal carpal row: acts as an ‘intercarpal bridge’
- implication: without the scaphoid and the central radio-luno-capitate link, the wrist would be unstable under compression loads
4
Q
extrinsic wrist ligaments
A
- dorsal radiocarpal ligament
- palmar radiocarpal ligament
- radial collateral ligament
- ulnar collateral ligament
5
Q
intrinsic wrist ligaments
A
- palmar ligaments
- dorsal intercarpal ligaments
6
Q
wrist movement
A
- motion occurs simultaneously at radiocarpal and midcarpal joints
- this allows greater total ROM and more stable arc of motion in all planes
7
Q
wrist complex AROM
degrees of wrist F, E, radial and ulnar deviation
A
wrist flexion: 65-80 degrees
wrist extension: 55-70 degrees
radial deviation: 15 degrees
ulnar deviation: 30 degrees
8
Q
wrist extension movement
A
- proximal carpal bones
slides anteriorly and roll posteriorly - limit to extension: *palmar radiocarpal ligament *, dorsal lip of radius impinges on carpus
close packed position- as the palmar radiocarpal ligaments tighten, creating a sling across the scaphoid/ lunate, causing *proximal and distal rows to rotate together *
- damange to scapholunate/ lunotriquetral ligamnets = instability and decreased range and function at wrist
9
Q
wrist flexion movement
A
slides posteriorly and rolls anteriorly- limit to flexion: tension dorsal radiocarpal ligaments, posterior capsule
10
Q
wrist movement: radial deviation
A
-
roll radially and slide in ulnar direction(in both distal and proximal carpal rows) - also
moves anteriorly in proximal carpal row - anterior movement of proximal row occurs due to ‘pushing’ forces of contacting articular surfaces and ‘pulling’ forces sue to ligament tension
11
Q
wrist movementL ulnar deviation
A
-
roll ulnar side and slide in radial side(in both the distal and proximal carpal bones) - also
moves posteriorlyin proximal carpal row - palmar ligaments play large role in guiding carpal movement
- highly variable and complex
12
Q
if wrist extension was limited by stiffness, which accessory movement of the radiocarpal joint might you consider for mobilisation treatment?
A
PA glide extension
13
Q
wrist musculature 手腕肌肉組織
A
wrist complex provides
- stable base for hand
- optimmal length-tension ratio of long finger muscles
14
Q
wrist musculature: flexors
A
- 6 main muscles
- much stronger than extensors
- flexor retinaculum
~~~ - force in dependent on wrist extension
- finger flexion is modified by intrinsic muscles of the hand
~~~
15
Q
why are extensors so important?`
A
stabilise and position the wrist for effective use of long finger flexors- contraction of long finger flexors causing wrist flexion torque at the same time = active insufficiency
- wrist extends as fingers flex to maintain length tension
16
Q
functional position of the wrist
A
- **15-20 degrees extension and 10 degrees ulnar deviation **
- implications: stiff, painful, weak/ unstable wrist often assumes a posture that interferes 干擾 with the optimal length of finger muscles –> limits effectie hand function
- position for surgical fusion/ immobilisation due to injury
17
Q
common mechanisms of wrist injury
A
- impact
- weight bearing
- twisting
- throwing
18
Q
colles’ fracture
mechanism, diagnosis, management
A
- mechanism: fall on outstretched hand (extension)
- dinner fork deformity
- diagnosis: pain, swelling, restricted wrist ROM
- management:
- GAMP (general anesthetic manipulation or gap)
- non-displaced 無移位 or minimally displaced fractures with only monir comminution 粉碎性骨折, casted for 6/52 until bony union
- ORIF
- plate or pin fixation
- shorter period of immobilisation
- 3-4/52
- potential consequences 潛在後果:
- radial shortening –> wrist to OA and stiffness
epiphyseal fractures are common in children 6-10 years.
19
Q
position of safe immobilisation
POSI of colles’ fracture
A
- wrist 20-30 degrees extension and slight ulnar deviation
- MCP joints: 45-70 degrees flexion
- IP joints: extension volar plate taut
- flexion for prolonged period = contractures of volar plate
**- thumb: 45 degrees abduction **
20
Q
opposite to colles’ fracture
smith’s fracture
A
- mechanism: backward fall on the palm of an outstrected hand (flexion)
- classification:
- type I: extra articular
- type II: crosses into the dorsal articular surface
- type III: enters radiocarpal joint
21
Q
scaphoid fracture
A
- mechanism: fall on outstretched hand (wrist extension and radial deviation)
- diagnosis: pain on wrist and thumb movement (tender snuffbox palpation)
- can be missed on x-ray in early stages - may not show for 10-14 days (need to repeat X-rays or CT scans)
- management: cast including thumb for 6-12 weeks (unstable fractureL internal fixation)
- complications: non union 骨折不癒合, avascular necrosis 缺血性壞死 due to poor blood supply, wrist instability
- physio aims: same as colles
22
gaining ROM post fracture
- focus on AROM
- **no overpressure **
- be very **wary 警惕 of pain at # site **
- **be careful of added resistance **
- **no strength testing/ strength exercises until # union**
23
lunate fractures
- mechanism: wrist hyperextension
- surgery required
24
ligament injuries of the wrist
- scapholunate ligament tear --> results in 'Terry Thomas sign'
- Watson's test --> positive if pain
- conservative or surgical management --> decrease ROM wrist complex
## Footnote
conservative management: eg: muscular strengthening, proprioceptive training, and coordination training
25
triangular fibro-cartilage complex (TFCC)
- *major stabiliser of ulna and carpus and distal R-U joint *
-** common site of ulnar wrist pain **
- mechanism: **high compressive loads with ulnar deviation**
- MRI
- surgery: shorten ulna
26
**carpal tunnel syndrome (CTS) **
## Footnote
causes, sings and symptoms, special tests, management
- neuropathy due to **compression of median nerve in carpal tunnel**
- common causes: **gripping, overuse of wrist/ finger flexors** (typing)
- conditions with increased fluid retention eg: pregnancy, lymphoedema
- signs and symptoms: **numbness and pain** in **palmar aspect lateral 3.5 fingers**, **wrist and hand weakness** - thumb (median nerve), **worse through night and in morning**, **eased with activity**, **wasting of thenar muscles** (thumb)
- special tests: **Tinel's sign, Phalen's sign** (wrist in full flexion for 30-60 seconds), nerve conduction tests of medial nerve
- management: **convervative** (RICE, NSAIDS), **surgical** (decompression of carpal tunnel)
## Footnote
more common in women 40-60 years old
27
6 steps that causes CTS
step 1: increase pressure in carpal tunnel
step 2: reduce blood to median nerve
step 3: reduce oxygen to nerve
step 4: inflammation of perinurium
step 5: blocking of neural transmission/ axoplasmic transport
step 6: atrophy of median nerve
28
De Quervain's Tenosynovitis
## Footnote
signs and symptoms, diagnosis, management, complications
- **tendinopathy of ther APL and EPB tendons **
- signs and symptoms: **pain, swelling**, **history of repetitive forceful gripping coupled with ulna deviation** - most cases
- diagnosis: **Finkelstein's test** (ulnar deviation of the wrist with the fist closed over the flexed thumb, positive if pain)
- management: **decrease pain/ inflammation**, **increase flexibility** EPB/ APL (massage and stretch), increase **strength** EPB/ APL (use eccentric and concentric with caution)
- complications: painful scars, tendon adhesions, subluxation of tendons
## Footnote
corticosteroid injections are often required, if these treatments fail, surgical release maybe necessary
29
wrist injuries - aims of physio management
- increase/ restore joint ROM
- increase/ restore muscle length, strength
- increase/ resotre function (gross motor and fine motor)
- proprioceptive retraining
- decrease pain/ swelling
