What is a colle’s fracture?
Fracture of the distal radius with the distal segment angulated dorsally.
What is a Smith’s fracture?
Fracture of distal radius with the distal segment angulanted ventrally.
What a common mechanism of injury for a colle’s/ smith fracture?
- Falling on an outstretched hand
What are typical surgical procedures for Colle’s and Smith’s fractures?
- Closed reduction if stable
- Open reduction/ Internal fixation (pins, plates) if unstable.
What is the rehab focused on post-surgery for Colle’s/ Smith’s Fractures?
- Strength
- ROM
- Flexibility
What are common complications of Colle’s/ Smith’s fractures?
- Carpal tunnel
- Reflex sympathetic dystrophy
What is the most common carpal fracture?
Scaphoid fracture.
What is the common mechanism of injury for a scaphoid fracture?
- FOOSH with radial deviation.
What are 2 common clinical signs of a scaphoid fracture?
- Pain on snuffbox palpation
- Pain on radial/ulnar deviation overpressure
What is required to diagnose a scaphoid fracture?
- Imaging
What are surgical procedures for scaphoid fractures?
- Closed reduction
- ORIF
What is rehab for scaphoid fractures post-op?
- Strength
- ROM
- Flexibility
What are common complications of scaphoid fractures?
- AVN
- Scapholunate Advanced Collapse
What is SLAC?
OA of the scaphoid, and lunate subluxation.
Why is AVN of the scaphoid common secondary to fracture?
It is an island of bone with a limited blood supply.
What are 2 clinical signs of MC and phalanx fractures?
- Pain on distal end tapping
- Pain on bone palpation
What are common surgical procedures for MC and Phalanx fractures?
- Closed reduction
- ORIF
How does it take for MC and Phalanx to typically reunite?
MC: 6 weeks
Phalanx: 3 weeks
What is common post-op rehab for MC and Phalanx fractures?
- Strength
- ROM
- Flexibility
What are 2 common complications of MC and phalanx fractures?
- Carpal tunnel
- Fixed ROM loss
What is dequervain’s disease?
- Stenosising tenosynovitis of the APL and EPB at radial styloid
What causes DeQuervain’s disease?
- Overuse of the thumb in wrist causing a thickened, tender sheath
In what age group and gender is DeQuervain’s disease most prominent?
- Women (30 - 50)
What is a common test for DeQuervain’s disease?
- Finklestein’s Test
What are 3 conservative treatments for DeQuervain’s disease?
- Refrain from aggravating postures/ motions
- Thumb spica splint ( covers CMC and MCP joint of thumb, but not IP)
- Physical Agents for inflammation (iontophoresis)
What are more aggressive procedures for DeQuervain’s disease?
- Steroid injection
- Surgical release of first dorsal compartment
What is a Dupuytren’s Contracture?
- Plamar fascia thickens with nodules and adheres to flexor tendons and skin
What are 4 predisposing factors for a Dupuytren’s contracture?
- Men
- Northern European origins
- Drinkers and smokers
- Autosomal dominance (maybe)
Which digits are most often affected by a dupuytren’s contracture?
- Digits IV and V
What are 4 conservative treatments that slow progression of Duputren’s contracture?
- Heat or paraffin
- Stretching
- Splints
- Maintain joint ROM
What are 2 surgical treatments of Dupuytren’s contracture?
- Injection of steroids or enzymes
- Surgical relase (make functional gains before scarring begins)
What is carpal tunnel syndrome?
- Compression of median nerve under flexor retinaculum
What is the cutaneous innervation of the median nerve?
- Palmer skin of digits I - III and 1/2 of 4.
What is the motor innervation of the median nerve in the hand?
- Lumbricales I and II
- All intrinsic thumb muscles except adductor pollicis.
What are 5 contributing factors to carpal tunnel syndrome?
- Trauma
- Prolonged wrist extension w/gripping
- Repetitive wrist flexion and extension
- Lunate dislocation
- Fluid retention (pregnancy)
What are 4 clinical signs of carpal tunnel syndrome?
- Toothache pain progressing to numbness along median nerve distribution in hand
- Thenar weakness/ atrophy
- Night pain
- Hand flicking
What are 5 conservative treatments for carpal tunnel syndrome?
- Splinting in neutral/ night splints
- Refraining from aggravating postures and motions
- Physical agents for inflammation control
- Adjusting posture from c-spine –> distally
- Nerve gliding
What are the surgical procedures for carpal tunnel syndrome?
- Open or endoscopic surgical release of the transverse carpal ligament
What is ulnar tunnel syndrome?
- Compression of the ulnar nerve as it passes into the wrist.
What is the location of zone 1, zone 2, and zone 3 ulnar tunnel syndrome?
Zone 1: By pisiform: motor and sensory
Zone 2: Towards radial aspect on palmar side: motor only
Zone 3: By hook of hamate: Sensory
What is the cutaneous innervation of the ulnar nerve in the hand?
- Skin of half of 4th and all of 5th digit
What is the motor innervation of the ulnar nerve in the hand?
- Hypothenar eminence
- All interossei
- 3rd and 4rh lumbricales
- Adductor pollicis
- Flexor pollicis brevis
What pathology is ulnar tunnel syndrome treated similar to?
Carpal tunnel.
.What modality can be used to improve nerve conduction velocity in tunnel syndromes?
Low-level laser with splinting.
What deformities are caused by terminal tendon ruptures?
- Mallet finger
- Swan neck
What deformity is caused by a central slip rupture?
- Boutonniere
Why are finger flexor tendon injuries more difficult to treat?
- Complex anatomy
- Cruciate and annular pulleys
- Vincula
- FDS splits
- FDS/ FDP sliding
What zone is no man’s land, and what anatomy is found there?
- Zone 2
- Underside of digits
What is post surgical rehab based on?
- Tissue healing
- Functional anatomy
Who determines the specific post-op ROM allowed?
- The surgeon
What are the 3 focuses of the PT during rehab following tendon injuries?
- HEP and Pt Ed
- Move anything not immbolized
- Deal with sensory problems as well
What are 5 treatments for partial tears and fractures?
- Splinting
- Isometric contractions ASAP
- Adjunctive interventions
- PROM/ AAROM/ AROM
- Strengthening exercises
What other issues should be considered with hand pathology? (Other anatomical areas/ problems)
- Upper quarter screen
- Comorbidities
- Medical history
What are 5 relevant scales for wrist and hand pathology?
- VAS
- DASH (Disabilities of the Arm, Shoulder, and Hand)
- PSFS (Patient Specific Functional Scale)
- UEFS (Upper Extremity Functional Scale)
- Boston Questionnaire (for carpal tunnel)
What are 7 general observations that should be considered with wrist and hand pathology?
- Posture - head and neck
- Muscle tone
- Quality, color, temperature of skin
- Quality of the nails
- Swelling
- Resting position of the hand
- Ability to use the limb
What are 8 unusual resting positions of the hand?
- Swan-neck deformity
- Boutonniere deformity
- Ulnar drift
- Clubbing of DIPs
- Heberden’s or Bouchard’s nodes
- Claw fingers
- Dupuyten’s contracture
- Mallet or trigger finger
What pathology is related to an ulnar drift resting position?
- Rheumatoid Arthritis
What pathology are clubbed fingers indicative of?
- Clubbed fingers
- Low levels of oxygen due to lung or heart problems
What pathology are associated with claw fingers?
- Ulnar nerve lesions
- Tendon lascerations
What joints should be cleared with hand and finger pathology?
- Elbow
- C-spine
- Distal finger joints
What are the two methods of expressing overall finger ROM? What is their relationship?
- TAM and TPM
- Total active/passive motion
- If TAM < TPM, tendon gliding problems are implicated
What are 3 methods of measuring Wrist and Hand muscle performance?
- MMT
- Grip and Pinch force measurements
- Performance Based Functional Measures
What are 3 specific performance based functional measures?
- Arthritis hand function test
- Hand mobility in scleroderma test
- Keitel functional test
What is the hand grip testing protocol using a JAMAR unit?
- Measure each hand grip with a maximal for 2 - 3 seconds in positions 1 - 5, averaging 3 different measurements at each position if possible to ensure a proper reading. (Readings should be different at different positions)
- Compare bilaterally
What determines normal readings for Jamar grip testing?
- Age
- Gender
What tests besides muscle strength can be performed at the wrist and hand? (list 4)
- Ligament stability
- Soft tissue mobility
- Neurologic status
- Functional status
What are special tests for instability of the hand and/or wrist?
- Gamekeeper’s Thumb Test
- Varus/ Valgus Stress
- Watson Scaphoid Test
- Ulnomeniscotriquetral Dorsal Glide
What a test for arterial filling of the hand?
- Allen test
What are 6 tests/ signs of carpal tunnel syndrome?
- Katz Hand Diagram
- Phalen’s test
- Reverse phalen’s test
- Flick maneuver
- Tinel’s sign
- Median nerve compression
What is a test for an ulnar nerve lesion?
- Froment’s Sign
What test is used to test intrinsic and ORL shortening?
- Bunnel- Littler Test