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Wrist and Hand Pathologies
Terms in this set (33)
True or false, there are clinical practice guidelines published for the wrist/hand.
1.Wrist and Hand Traumatic injury (Screening)
-Fractures or Tendon tears
-Cartilage or Ligamentous injuries
2.Wrist and Hand Pain with Mobility Deficits (post injury/immobilization)
-Soft tissue shortening
3.Wrist and Hand Muscle Power Deficits
-De Quervain's tenosynovitis
-CTS and Guyon's canal syndrome
5.Others - covered by guest presenter
Medical Screen Following traumatic injury:
-what types of fractures to be aware of?
-conditions causing instability?
Fractures: Know indications for imaging!
-Forearm fractures (Monteggia, Galeazzi's, Colle's and Smith's fractures)
-Scaphoid fracture/Presier's disease
-Boxer's fracture/Metacarpal and phalangeal fractures
-Lunate dislocation/Keinbock's disease
-Ulnar collateral ligament tear of thumb/Stener's lesion
What are the 3 indications for elbow/forearm radiographs?
1) FOOSH injury with obvious deformity or bone tenderness
2) Bone tenderness (esp. in adolescent due to growth plates)
3) Traction injury in adolescents (fear of a radial head dislocation)
What are the 4 indications for wrist/hand radiographs?
1) Tender in anatomical snuffbox following FOOSH injury
2) Deformities/tenderness of the wrist and hand
3) Tenderness over bone AND/OR pain with vibration over the bone (can use a reflex hammer or tuning fork)
4) Ligament laxity
What is a Monteggia Fracture? What is it caused by?
-Fracture between proximal and middle 1/3 of ulna
-Anterior dislocation of head of radius
What is a Galeazzi's Fracture? What causes it?
-Fracture at the middle and distal 1/3 of radius
-Combined subluxation of the inferior radioulnar joint
What is the MUGR Mnemonic mean?
Monteggia w/ Ulna (proximal)
Galeazzi w/ Radius (distal)
What is a Colles Fracture? What causes it? How is it fixed? What deformity is caused?
-Distal end of radius displaced dorsally/posteriorly
-cause: FOOSH injury
-Fx through the metaphysis
"Dinner Fork" deformity
What is a Smith's Fracture?
-distal end of radius displaces anteriorly/palmarly
What is more common, a Colles Fracture or Smith's Fracture?
What is the typical cause of a Scaphoid Fracture?
-how is it diagnosed?
-Sxs: pain in anatomical snuffbox
-tenderness in snuffbox
-limited and painful wrist motion (esp w/ radial deviation and wrist extension)****
True or false, a scaphoid fracture always shows on plain film.
BUT, in the presence of acute tenderness to palpation following trauma --> GET IMAGING
-what do you do if radiographs are positive?
If radiographs positive:
-Leave up to MD
If radiographs negative, care is
-Treat it as a fracture: IMMOBILIZE
-Repeat radiographs in 1-2 weeks
What is Presier's Disease? When causes it? Why?
Presier's Disease = Avascular Necrosis of Scaphoid
Cause: scaphoid fracture not treated appropriately
-common due to poor blood supply of scaphoid
What is a Bennett's Fracture?
-common or no?
-pain with what motions?
-fracture dislocation at base of CMC (carpal metacarpal joint) of thumb
-Most frequent of all thumb fractures
-MOI: direct blow, hyperabduction or hyperflexion injury
-Pain is noted with CMC active and passive motion and joint compression (to the carpal MC joint)
-Tx: IMAGING 1st. immobilization or surgery (pinning)
What is a Boxer's Fracture? Cause? Tx?
Boxer's Fracture = fracture near neck of 4th or 5th MC (narrowest area)
-distal end bends in palmar direction
Cause: usually punching incorrectly
Tx: imaging first --> closed reduction --> immobilization
-leads to what ROM limitations?
-Result of hyperextension/ulnar deviation injury
-Subtle to obvious deformity
-May have median nerve parasthesia
TX: Closed reduction and immobilize
What is Keinbock's Disease?
-type of onset?
-more frequent in what population?
-what limitations does this cause?
Keinbock's Disease = Avascular Necrosis of Lunate
-Onset = Frequently insidious but can be related to lunate dislocation as well
-More frequent in young adults
-Workers such as carpenters and jackhammer operators more prone (microfractures?)
-Wrist pain, becomes progressively worse
-Decreased ROM and painful
TX = immobilize
Ulnar Collateral Ligament (UCL) Tear is also called a "_______" thumb.
UCL tear = Gamekeeper's thumb
Ulnar Collateral Ligament (UCL) Tear:
-tear of UCL of the _____ MCP joint
-how is it dx?
UCL Tear = Tear of UCL of the THUMB MCP joint
-MOI: traumatic extension and abduction of the thumb
-Tender over ulnar side of thumb
-Laxity with stress to UCL
-REFER for images to rule out Stener Lesion (next slide)
-immobilization or surgery
What is a Stener Lesion? What injury may it be associated w/? What does it cause?
-what needs to happen if you suspect this?
Stener Lesion = attachment of UCL avulsed from proximal phalanx of thumb instead of UCL tearing
-May be associated with UCL injury
-Fractured end unable to return to original anatomic position by being caught under the adductor aponeurosis
Causes: Gross instability of MCP joint
-Need IMAGING - Accurate Dx early, requires surgical management
Triangular Fibrocartilage Complex Tear (TFCC)
-MOI? (3 potential)
MOI: (most often occurs w/ sports)
1) fall on hyperextended wrist/forearm pronation
2) compression/distraction force of wrist
3) distal radial fracture
-ulnar wrist pain with activity
-limited wrist motion
-pain w/ pronation or supination and gripping
What does the Triangular Fibrocartilage Complex (TFCC) articulate w/?
The TFCC articulates with the Lunate and the Triquetrum
What are some tests/measures for TFCC Tear/Instability? (3)
1. Crepitus, clicking, grinding w/ AROM and RROM
2. Tender to palpation over TFCC (ulnar side of wrist)
3. Pain w/ ulnar deviation w/ overpressure and/or accessory motion of carpal bones w/ wrist in ulnar deviation
How is a Triangular Fibrocartilage Complex (TFCC) treated?
Rest and immobilization 4-6 wks
Summary of ACUTE Wrist and Hand Fractures/Instability:
-When in doubt _____ for ______
-Immobilize vs. Surgery? --> leave it up to ______
When in doubt --> Refer for Imaging
Immobilize vs. Surgery
(Leave it up to MD)
What joint and soft tissue mobility deficits are associated w/ immobilization for the Wrist/hand?
Wrist and Hand Flexion/Extension (especially extension limited)
-MCP and IP joints
Soft Tissue Limits
-Wrist flexor and extensor muscles
-radial thumb muscles
What joint and soft tissue mobility deficits are associated w/ immobilization for the forearm?
Forearm Pronation / Supination (especially supination)
-Proximal/Distal Radioulnar joint
Soft tissue limits
What treatments to give for wrist/hand mobility deficits? (4)
-what to base tx on?
1) Joint Mobilizations
-Accessory/Physiological Mobilizations (arthro and osteokinematic mobilizations)
2) Soft Tissue Mobilizations
-Superficial to Deep Tissue Massage / Pin and Stretch / Instrumented Assisted Mobilizations / etc.
3)Soft Tissue Stretches
•Contract Relax / Sustained Hold / Total end range stretching/ Dynamic Splinting
4) Functional Exercise
-PROM → AAROM → AROM → Resistance exercises
Base tx on tissue irritability and stage of physiological healing
Wrist pain w/ power deficits:
-What is DeQuervain's Tenosynovitis?
DeQuervain's Tenosynovitis = inflammation of APL and EPB and its surrounding sheath
1) Repetitive trauma
2) Excessive grasping
3) Repetitive radial/ulnar deviation
What are the sxs associated w/ DeQuervain's Tenosynovitis? (4)
1. Gradual onset of pain along radial aspect of wrist near radial styloid process
2. Pain associated w/ gripping/pinching
3. Referred pain along thumb and lateral forearm
4. May have crepitus
Atraumatic condition typically
What tests and measures to do for DeQuervain's Tenosynovitis?
1) Resisted thumb extension and abduction --> pain
2) AROM/PROM of thumb flex/add --> limited
3) Palpate APL and EPB tendons --> tender
4) Finkelstein's test --> (+)
-grasp thumb and ulnarly deviate to place passive tension on the APL and EPB
What is the treatment for DeQuervain's Tenosynovitis?
-Multimodal care: STM to the tendons and along muscle belly; graded exercise
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