Wrist and hand Flashcards

Question

Therapeutic exercise of the hand

Answer 1

- Ensure writst extension and combine exercise with elevation - Encourage and reassure patients - Management of patient expectations paramount - Care +++ WITH PASSIVE EXERCISE as it can lead to pain and swelling, creating more stiffness - Ongoing splint use may be required overnight or in between exercise sessions - If post-surgical, adhere to surgeons orders

Answer 2

Aims 1. Protect healing tissues 2. Maintain optimal anatomic position 3. Restrict/control motion 4. Promote/improve range of motion (during later fibroplastic stage to stretch and mobilise the scar matrix) 5. Promote function ``` Position of safe immobilisation - POSI - Wirst 25-30 degrees of extension MCP flexed 60 degrees - IP joints variable - Thumb in palmar abduction - Place hand in this position ```

Answer 3

Scars can significantly impede gliding and hand function Techniques - Scar massage/frictions from Day 21+ - Thermal agents - Electrotherapy - Silicone products

Answer 4

Indications - Hyper/hyposensitivity - If no protective sensation - SAFETY Methods: Education - Taught to avoid excessive temperatures, sharp objects - Avoid excessive force - Change tools frequently - Observe skin for signs of stress - Skin care (soaking, oil, care for blisters etc.) Exercises (5-10 minutes, 3-4x days) - Discrimination of various textures - Discrimination of various sized objects - Finding objects in bowl of rice, sand, etc. - Eyes open, eyes closed then eyes open

Answer 5

- FOOSH or high force+ injury (in younger people) - Colles' #: non-articular, 3-5cm proximal to the RCJ, fall on to extended wrist - Smith's #: 'Reverse Colles' with volar displacement, fall on to flexed wrist - Barton's #: is a displaced, unstable articular fracture-dislocation of RCJ Assessment - Subjective interview (mechanism of injury etc.) - Observe - Palpate - AROM +/- PROM - Extension clearing test Management: 1. Obtain a good reduction (open or closed) 2. Maintain a good reduction (immobilisation + fixation) 3. Early (24-72 hours post op) active mobilisation - Oedema control (elevation and compression) - Finger and wrist AROM - Shoulder, neck and elbow ROM - Remove splint for wrist F/E, RD/UD exercises - Splint stays on for supination/pronation AROM exercises Complications - Significant mal or non-union - Stiffness, OA, pain - Carpal tunnel syndrome (CTS) - TFCC tears - EPL rupture - Complex regional pain syndrome Type 1

Answer 6

Scaphoid Hook of hamate (cycling, golf, FOOSH) Lunate (rare, necrosis more common - Kienbock's disease) - Most carpal # present late - send for imaging confirmation - Overt ligament injury - Assess disruption to (normally smooth) Gilula's arcs on XR Assessment - Observe - Palpate - Imaging - AROM +/- PROM - 10 tests of the hand

Answer 7

Most common carpal fracture MOI = FOOSH or direct blow Classification: Tubercle/Distal - Not usually displaced - Rx: immobilisation Waist - 70-80% - Increased displacement - Increased need for surgery Proximal pole - Increased risk of arterial compromise - High chance of surgery Assessment - Subjective interview (MOI, pain) - Observe - Palpate (snuff box tenderness and swelling) - AROM +/- PROM - Positive Watsons Scaphoid shift - +/- Positive 1st CMC grind test Management Refer for imaging (X-ray) - Follow up XR at 10-12/7 post-injury usually diagnostic - Bone scan at 4/7 post-injury is 100% sensitive - MRI at 72 hours post-injury is 100% sensitive Splint - Closed treatment (stable, non-displaced fracture of waist distal pole) - Contraindications for closed treatment = proximal pole #, delayed union, comminution Open treatment (surgery) - Unstable, displaced fracture of proximal pole - Involves ORIF +/- bone graft - Intra-operative stability will determine commencement of mobilisation Complications - Avascular necrosis - Delayed, incomplete and/or non-union - Associated ligament sprains +/- instability - Due to reduced radial artery supply, originating distally to proximally

Answer 8

Metacarpals - Boxers #: 2nd to 5th metacarpals - Bennett #: 1st metacarpal (base) with dislocation of 1st CMC joint Phalanges - Can be complex - central slip of extensor tendon, volar plate, subungual haematoma +/- infection, crush # Diagnosis: - X-ray - ROM and muscle strengthening of CMC Management: - RICE - Referral to emergency - imaging - reduction - splint (4-6/52) - Upon cast/splint removal, early mobilisation (repeat imaging to check healing) - +/- ongoing use of protective device e.g. neoprene brace

Answer 9

Tear of scapholunate ligament MOI: FOOSH Assessment and special tests: - Subjective interview (MOI, 24/24) - Observe - Palpate - AROM +/- PROM - Dorsal-central pain/swelling, instability, possible clicking - Positive watson's scaphoid shift test - 10 tests (laxity/pain 'lunate on scaphoid' or vice versa ``` Management: Grade 1 tear - Initial immobilisation in splint - Limit gripping, pushing - Progressive wrist strengthening - co-contraction, proprioception, ADL's ``` Grade 2 tear - Possible surgery (arthroscopic repair; ORIF) Grade 3 tear - Untreated leads to progressive degenerative changes and SLAC (scapholunate advanced collapse) - ORIF +/- fusion (permanent loss of wrist ROM)

Answer 10

- MCP ulnar collateral ligament tear +/- instability - MOI forced abduction and hyperextension (e.g. FOOSH still holding pole) Assessment and special tests - HX and palpation - Compare to other side - XR to rule out avulsion # - UCL stress test Management Grade 1/2: conservative management - Thumb spica splint hand based 6/52 - Wk 3- flex/ext AROM, out of splint 3-4 times a day - Wk 6 - gentle PROM, lateral and palmar pinch strengthening Grade 3 (+/- displaced avulsion #) - Surgical repair - postoperative management includes - Hand based thumb spica until 6/52 - 2/52 flex/ext AROM - 4/52 general ROM and strengthening 6+/52 modified splint for contact sports/manual work

Answer 11

- MOI: hyperextension and/or longitudinal compression - One or more collateral ligaments and volar plate disruption - Imaging is preferred to rule out associated fractures - PIP/DIP collateral ligament stress test - If volar dislocation at PIP, may observe Boutonniere deformity - If volar dislocation at DIP, may observe mallet finger deformity (can develop swan neck deformity) Diagnosis - Observe - Subjective interview - Palpation - XR Management - RICE - Buddy tape - Splinting (+/- dorsal extension block if severe) - Depending upon severity, surgery may be required

Answer 12

- Require microsurgery - Aim of repair is to join as accurately as possible the connective tissue tubes of the peripheral nerve - Healing - the nerve sheath takes 3-4/52 to gain sufficient strength to withstand stress - Need to protect with splint until then Diagnosis - Subjective interview (tingling, parasthesia, numbness) - neurodynamic test - neurological test Management 0-3/4 weeks - splinted in protected position (usually flexion) 3/4+ weeks - Gradual active regaining of ROM - Sensory re-education - Prevention of joint contracture - exercise, splintage

Answer 13

- Refer patient to the ED (imaging and surgical repair) - Broadly either a flexor or extensor tendon repair - Jersey finger: disruption FDP off distal phalanx - Mallet finger: disruption extensor digitorum +/- bony fragment of distal phalanx (untreated leads to swan neck and/or boutonniere deformity) Post operative therapy has 4 main aims: 1. Restore maximal active tendon gliding (rupture vs adhesions) 2. Prevent flexion contractures 3. Maintain full ROM of adjacent joints 4. Return to previous level of function Post operative therapy has 3 main approaches: 1. Immobilisation - rare today 2. Early passive mobilisation 3. Early active mobilisation (PREFERRED)

Answer 14

- OA - De Quervain's Tenosynovitis - Carpal Tunnel Syndrome (CTS) - Ulna and radial nerve compresison - Dupuytren's disease

Answer 15

- Progressive degenerative joint disease Diagnosis - Subjective - Observe - Grind test of 1st CMC joint Treatment - conservative vs surgical - Splinting - Strengthening exercises - Joint mobilisations - ADL modifications - Advice and education

Answer 16

Thickening and stenosis of 1st extensor compartment - abductor pollicis longus and extensor pollicis brevis - Females > males - pregnancy onset - More common 30-55 years Causes - Chronic trauma: more motor control of thumb abd-ext, wrist RD-UD - Unaccustomed use - Sporting: racquet sports, rowing - Occupation: common overuse injury in manual tasks Assessment - Pain and possible swelling at base of the thumb - Possible catching or crepitus - Positive finkelstein's test Conservative management - Rest (splintage, ADL modification) - EPA - tendinopathy strengthening program - +/- corticosteroid injection Surgical management - Decrompression of 1st dorsal compartment - Post Op: - Wound/scar Mx - Gentle AROM - Strengthening after 6/52

Answer 17

Signs, symptoms and diagnosis - Numbness, P & N in median nerve distribution - Nocturnal symptoms - Weakness and loss of dexterity in hand - Sense of congestion/finger swelling - Positive Phalen's and/or Tinel's test Pathogenesis 1. Decreased size of Tunnel (bony abnormality, thickening TCL) 2. Contents of Tunnel (9 tendons and 1 nerve; mass/ganglion/lipoma; haematoma) 3. inflammatory (RA, infection, gout, overuse) 4. Fluid balance (pregnancy, haemodialysis) 5. Neuropathic (diabetes, alcoholism) Management - Work/ADL modifications - Night splint holding wrist in neutral - Median nerve and finger tendon gliding exercises - Electrotherapy - Oedema control - Assess cervical spine/central component - Address pathogenesis - +/- surgical decompression

Answer 18

- Most commonly seen in cyclists or baseball players - HX pisiform and/triquetral # - Months for weakness to be noticed - Tinel's sign Management - Address cause - Splinting - NSAIDs - +/- surgical decompression

Answer 19

- Radial nerve vulnerable 5-7cm proximal to wrist - Hx of radial styloid #; tight jewellery; handcuffs; plaster cast; overuse (e.g. volleyball) - Positive Tinel's sign Management - Address causes - Splinting to offload/reduce supination/pronation - +-/- refer for CSI +/- surgical decompression

Answer 20

- Usually in older adults and more common in men - Frequently bilateral and asymptomatic/painless - Patients present with nodular thickening of the palmar fascia and flexion contracture of the fingers (usually the 3rd, 4th and 5th) - Palpation and observation of lumps and rods - Lack of finger flexion Management - Local heat and stretching - Splintage - Referral to specialist if joint contracture and/or pain developing

Answer 21

- Pathologies of the wrist and hand: systemic - Autoimmune inflammatory disorder - Pain, multijoint swelling (+/- pitting oedema) and stiffness - Can be acute and/or chronic (relapsing/remitting) onset - Boutonniere and/or swan neck deformity Diagnosis: - Observe - Palpation (swelling) - Blood test Management - Conservative measures to manage pain (e.g. massive) - Referral to GP (FBE and management)

Wrist and hand Flashcards

(45 cards)