Wrist & Hand Ax and Rx Flashcards
(21 cards)
1
Q
SQs
A
- ?Trauma - FOOSH
- ?surgery
- ?onset/cause
- ?Neuro symptoms
- ?Aggs & Eases
- Red Flags: Infection symptoms, wrist #: localised tenderness, pain on AROM and PROM, on grip and supination + other # signs, RA
- Dominant hand - Overuse
2
Q
CAD signs
A
- 5 D’s – Dizziness, Drop Attacks, Diplopia, Dysarthria, Dysphagia
- 3 N’s – Nystagmus, Nausea, Numbness
- Cerebral or Cerebellar signs, e.g. ataxic gait
3
Q
Red Flags
A
- CAD (Cerebral Arterial Dysfunction)
- Myelopathy
- Infection
- Inflammatory disorders
- Age of onset of new symptoms <20 or >55 years
- Violent trauma, e.g. FOOSH - wrist #)
- Constant, progressive, non-mechanical pain
- Thoracic pain
- PMH – Carcinoma
- Systemic steroids
- Drug abuse, HIV
- Systemically unwell
- Unexplained weight loss
- Widespread neurology
- Structural deformity
- TB
4
Q
Infection symptoms
A
- General feeling unwell
- High temperature (fever)
- IVDU (intravenous drug use)
- Recent surgery / open wounds
5
Q
Cancer signs
A
- Previous Hx of cancer in themselves or family
- Unexplained weight loss
- Non- mechanical, constant pain
- Night sweats
- Generally feeling unwell
6
Q
Fracture signs
A
- Major trauma (FOOSH)
- Minor trauma or strenuous lifting in an older or osteoporotic patient
- Constant pain, worse on weight bearing
- Swelling/ bruising
- Steroid use
- Osteoporosis/ osteopenia
7
Q
Inflammatory Disorders (Ankylosing spondylitis etc.) signs
A
- Gradual onset
- Marked morning stiffness
- Persisting limitation of spinal movements in all directions
- Peripheral joint involvement/tendionpathies/aches
- Iritis, skin irritation (psoriasis), colitis, urethral discharge
- Family history
8
Q
Myelopathy (Central cord compression in cervical (most common), thoracic or lumbar (rare) spine) signs
A
- Neck, arm, leg or lower back pain
- Tingling, numbness or weakness
- Difficulty with fine motor skills, such as writing or buttoning a shirt
- Increased reflexes in extremities or the development of abnormal reflexes
- Difficulty walking (ataxic gait)
- Loss of urinary or bowel control
- Issues with balance and coordination
9
Q
CAD risk factors
A
- Hypertension
- Hypercholesterolemia
- Hyperhomcysteinemia – an alteration in the enzymes responsible to maintaining the metabolism of homocysteine can alter the effects of mechanisms of homocysteine, which include increased peroxidation injury, proliferation of smooth vessel, promotion of monocytic chemotaxis, enhanced cytotoxicity and inflammation, promotion of clotting, inhibition of anticoagulation, direct effects on endothelial cells, and activation of platelet aggregation.[
- Diabetes
- BMI >30 (obesity)
- Family History of MI/Angina/TIA/CVA/PVD
- Upper Cervical Instability
- Latrogenic Causes (Surgery/Medical Intervention)
- Genetic clotting disorders
- Infections
- Smoking
- Direct vessel trauma (previous trauma to Cx spine)
- Repeated injury
- Immediately post-partum
- Absence of plausible mechanical explanation of symptoms
10
Q
Pathology of CAD
A
- Endothelial Atherosclerosis – arteries are narrowed due to plaque formation, which can predispose the vessles to dissection.
- Trauma – Deformation of nerve endings, compression or local structures and/or altered haemodynamics, e.g. Whiplash, intubation, repeated sustained movements, manual therapy
- Connective Tissue Abnormalities – vessel wall weakness leading to spontaneous arterial dissection
- Temporal Arteritis – chronic inflammation of the arteries restricting blood flow. Small arteries are more affected.
- Upper Cervical Instability – Could be associated with RA or acute whiplash.
11
Q
How would you manage the care of a patient with signs and symptoms of CAD?
A
- If signs and symptoms are borderline… monitor closely, avoid end range and/or sustained rotation and extension.
- If post Rx soreness is present consider vascular and haemodynamic response.
- Discuss with senior
- If an arterial injury is suspected send to A&E.
12
Q
List the risk factors for Cervical Instability.
A
- Whiplash/Acceleration injuries
- Spondylosis
- RA
- Sustained Neck Flexion
- Downs Syndrome
- Tonsilitis
- Nasopharyngitis
13
Q
Identify the Subjective signs and symptoms of cervical instability
A
- Feeling of instability, ‘head may fall off’
- Neck/Shoulder pain
- Symptoms of VBI/CAD
- Chronic Headaches
- Episodes of locking
- Paraesthesia of lips, tongue, bilateral hands and feet
- Lump in throat
- Metallic test
- Inflammation or local surgery
14
Q
How would you objectively assess a patient with signs and symptoms of Cervical Instability?
A
- AROM & PROM limited
- Hypertrophy of ant neck musculature
- Overactive SCM
15
Q
Functional Assessment
A
- ? Interference with job, home, social life or sports.
- Turning doorknob, holding key, key grip, opening a jar, turning a tap, lifting a saucepan.
- Obtain * to reassess after intervention.
- This will help aid and direct your objective assessment.
16
Q
Observation
A
- Guarding / Function
- Posture
- Swelling – RA: MCP
- Deformity – OA: Herbeden’s nodes (DIP), Bouchard’s nodes (PIP), RA: Swan neck deformity, ulnar deviation at MCP, nodules along tendon sheaths, Dupuytren’s contracture
- Splints or Aids
- Skin
- Muscle wasting – Median nerve: thenar eminence and radial side 3 and ½ fingers, Radial nerve: dorsal hand, Ulnar nerve: hypothenar eminence and ulnar side 1 and ½ fingers
17
Q
AROM & PROM
A
- Wrist – Flexion/extension 0-90, radial deviation 0-25, ulnar deviation 0-65
- Thumb CMC jt. palmar abduction 45, radial abduction 60, opposition
- Thumb MCP jt hyperextension/flexion 10H - 55
- Thumb IP jt hyperextension/flexion 15H – 80
- Finger PIP jt flexion/extension 0 – 120
- Finger DIP jt flexion/extension 0 – 80
- Finger MCP jt hyperextension/flexion 45H – 90, abd 0-25
18
Q
Muscle Tests
A
Strength – via resisted AROM &/or isometrics
- Wrist flexors, extensors
- Forearm pronators, supinators
- Grip strength, Key and pinch grip strength
19
Q
Neurological Testing
A
Myotomes:
- C1/C2 neck flexion/extension
- C3 Lateral flexion
- C4 shoulder elevation
- C5 Shoulder Abduction
- C6 Elbow flexion/wrist extension
- C7 Elbow extension/wrist flexion
- C8 Thumb extension
Dermatomes:
- Pin Prick
- Vibration
- Proprioception
Reflexes
- Biceps Reflex
- Triceps Reflex
- Brachioradialis Reflex
ULTT’s
- ULTT1 – Median Nerve
- ULTT2a – Median Nerve
- ULTT2b – Radial Nerve
- ULTT3 – Ulnar Nerve
20
Q
Special Tests
A
-
Finkelstein’s Test
- Tests: To detect pain and limitation caused by inflammation between the tendons of abductor pollicis longus and extensor pollicis brevis and their shard synovial sheath at the distal end of the radius. (De Quervain’s tenosynovitis)
- Positive Sign: pain over the radial aspect of the wrist
- Procedure: Patient actively flexes the thumb and wrap fingers around thumb. Examiner take the wrist into ulnar deviation passively.
-
Phalen’s Test
- Tests: for carpel tunnel syndrome
- Positive Sign: Paraesthesiae is reproduced in the cutaneous distribution of the median nerve as a result of sustained narrowing at the carpel tunnel during flexion of the wrist. If severe, pain may also be reproduced.
- Procedure: With the patient relaxed and hand resting on a table. Examiner takes wrist into full wrist flexion and hold.
-
Tinel’s Test (aka median nerve percussion test)
- Tests: to help diagnosis of carpal tunnel syndrome.
- Positive Sign: paraesthesiae and/or pain in the median nerve distribution of the hand.
- Procedure: with patient facing you and their arm fully supinated, use a percussion hammer to tap over the mid-point of the carpel tunnel.
- Scaphoid Fracture:
- Positive sign: Anatomical snuff box tenderness, scaphoid tubercle tenderness, axial loading of thumb
21
Q
Palpation
A
- Bony Landmark: Radial/Ulnar Styloid, Scaphoid, 1st MC/Trapezium joints, Lunate, Lister’s Tubercle, Triquetrum/Pisiform, Hook of Hamate
- Bone alignment: metacarpals – 5, phalanges – 14 (palpate for swelling, tenderness)
- Soft Tissue – Muscle belly, tendons: FCR, FCU, Dorsal compartment 1 (de Quervain’s) & 2 (intersection syndrome); thenar eminence (carpal tunnel syndrome); Hypothenar eminence and Guyon’s Tunnel (ulnar nerve compression); Palmar aponeurosis (Dupuytren’s contracture)
