DD - Scapholunate instability - Lunate necrosis (keinbock's disease) PE - pain snuff box - x ray - UD to RD Tx - conservative cast thumb 6-8 wks tubercle - waist= increased displacement to need surgery - proximal pole= increased risk of arterial comp so likely surgery

Symptoms - Crepitus - pain MC joint - Gradual onset PE - obs movement +/- atrophy - grind test ``` Tx -can splint not wrist ROM reduction -NSAIDs -rest -AROM, isometrics, resisted ABD A & E= heat, avoid pinching ```

FOOSH DD - ECU tendinopathy - Ulnar styloid fracture ' - DRUj arthritis PE - palpation og distal to ulna head and proximal triquetrum - AROM limited by pain - TFCC load test (clicking, pain, snapping) - TFCC integrity test - Press test (push up from chair) Mx: - splint 2-3 wks - painfree ROM, avoid agg activities, strength - RTS 6 wks

Overuse PE: - pain ulnar side distal ulnar and 5th MC - pain resisted wrist ext/ulnar deviation Mx: - deload - addres biomechanics - ADL modification - gradual reload

Same all tendinopathy PE: - palpation most prominent tendon of ulnar polar surface of the wrist - pain on resisted flex and radial deviation - pain after repeated movements and stiffness after periods of rest

Wrist pathologies Flashcards by Lane Mcnaughton

Scaphoid fracture

Scapholunate instability
Lunate necrosis (keinbock’s disease)

pain snuff box
x ray
UD to RD

conservative cast thumb 6-8 wks tubercle
waist= increased displacement to need surgery
proximal pole= increased risk of arterial comp so likely surgery

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1st OA

Symptoms

Crepitus
pain MC joint
Gradual onset

obs movement +/- atrophy
grind test

Tx
-can splint not wrist ROM reduction
-NSAIDs 
-rest 
-AROM, isometrics, resisted ABD
A &amp;  E= heat, avoid pinching

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DeQuervain’s tenosynovitis

DD
Degenerative thickening of the extensor retinaculum and tendon sheath of the APL and EPB tendon (run either side of snuff box). Decreases space for tendon gliding and leads to mechanical impingement.

OA first CMC
Wartenburg syndrom
ECRB/L tendinopathy
FCR tendinopathy

Complains of

pain with ulnar deviation
clenching wrist
pulling from radial side

swelling
palpation localised tenderness and pain at base of thumb
clenching wrist, ulnar dev, resisted contraction ABL and EPB
Finklesteins

A & E
REST
ADL modifications
AROM, tendon glides
Pain management
thermoplastic rigid forearm splint 2 weeks

Px: 6-12 wks resolve

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Dorsal radial sensory nerve (wartenburg’s)

caused by compression of bracioradialis tendon and the extensor carpi radials longus tendon in pronation of hand

Numbness, tingling and pain over dorsal radial aspect of hand

PE
-tinel’s (pins and needles)

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Skier’s thumb

tender over ulnar thumb MP joint
pinching strength
UCL stress test

Mx:
Conservative 1 & 2= thumb spica splint hand based 6 wks
-flex & ext AROM 3-4 per day at 3 wks
-6 wks= gentle Prom, lateral and palmer pinch strengthening

Surgical G3
Post: hand based spica splint 6 wks
2wks AROM, then ROM and strengthening at 4 wks. RTS 6 wks modified splint

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Scapholunate injury

Scaphoid #
Lunate #
TFCC tear

Tenderness over joint
Watson’s test

Tx:

1: immobilise and therapy= splint, dart throwing motion, wrist isometric, FCR, avoid weightbearing/ grip strengthening
2: Surgical pinning
3: open repair, fusion

Proprioception training

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Dorsal wrist ganglion

-in scapolante joint fluid filled cyst

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ERCL/ECRB tendinopathy

tendinopathy grading:

1: pain during exercise that may go with warming up or be present a short while later.
2: Pain during exercise that does not subside but does not interfere with ADL
3: pain starting to limit physical activities and ADL
4: Pain interfering with ADL and consistent not constant

Reactive: overload
Degenerative: failed healing –> cellular changes and neovascularisation

pain and tenderness
local swelling
pain resisted wrist ext
pain after repeated mvmt with stiffness after period of rest

Mx:

deload
address biomechanics
ADL mod
grad reload to facilitate healing

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Dorsal radioulnar joint instability

Extreme pronation and ext /degenerative

DD
-TFCC tear

Palpation: between radius and ulna
pain pronation/ supination
snapping or subluxation of ulna
Ballottment test/ Piano key : glide radius and ulna P/A, A/P in various ranges of supination/pronation
pain or excess mobility

Mx:

Splinting elbow cast 6 wks
strengthening & ROM

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TFCC

FOOSH

ECU tendinopathy
Ulnar styloid fracture ‘
DRUj arthritis

palpation og distal to ulna head and proximal triquetrum
AROM limited by pain
TFCC load test (clicking, pain, snapping)
TFCC integrity test
Press test (push up from chair)

Mx:

splint 2-3 wks
painfree ROM, avoid agg activities, strength
RTS 6 wks

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Extensor carpi ulnari subluxation

ECU tendinopathy
DRUJ instability
TFCC tear

subluxes in volar and ulnar direction not dorsal
palpation between ulna and base of 5th, mild swelling
dislocated supination
relocates w/ pronation
Wrist in sup flex–> palpable snap +

Mx:
Immobilisation w forearm in pronation and radial deviation

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ECU tendinopathy

Overuse

PE:

pain ulnar side distal ulnar and 5th MC
pain resisted wrist ext/ulnar deviation

Mx:

deload
addres biomechanics
ADL modification
gradual reload

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Carpal tunnel syndrome

Median nerve compression

Pronator teres syndome
cervical radiculopathy
Diabetic peripheral neuropathy

Complains of:

pins and needles, numbness and pain in fingers
Night pain
dead hand or loss of circulation
dry skin, swelling, colour changes
loss of sensation
Sense of congestion or finger swelling

Wasting of thenar eminence
weakness and loss of dexterity in hand
reduced strength in thenar (pinch/gripping), APB power
Sensibility tests
Tinnels
Phalens
reverse phalanx
durkans (30 sec hold)
durkans + wrist flex

Mx:

work and ADL mod (awk wrist positions, prolonged repeated grip, vibrations and force
night splinting
nerve and tendon gliding
oedema control
Surgical: decompression- wound management, early ROM, avoid heavy lifting for 4 wks, no splint

Px:
-surgery highest benefits 6-12 mths and highest likelihood of recovery

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FCU tendinopathy

Same all tendinopathy

PE:

palpation most prominent tendon of ulnar polar surface of the wrist
pain on resisted flex and radial deviation
pain after repeated movements and stiffness after periods of rest

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Ulnar nerve compression

-Guyon’s canal

FCU, FDP weakness
Muscle weakness Hypothenar, dorsal and palmar interossei, lumbrical of 3rd and 4th finger

DD
-Carpal tunnel syndrome

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Pisiform OA

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Crepitus

location of pain

Hook of hamate fracture

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2cm distal and centrally from pisiform

x-ray

Mallet finger

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Avulsion of ext tendon
Forced DIP flex with resisted ext

Jersey finger
FDS rupture

PE:

palpation
inability to extend DIP

Mx:

Splint 0-6 wks in 5-15 H-ext 24/7
PIP free unless swan neck for 6-7 wks
ROM of other joints
After 6-8 wks gentle active flex and wean from splint

Intrinisic tightness

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Ax = extend MCP and Flex DIP, then slightly flex MCP and flex dip. IF you can now do it then there is tightness
Can’t do claw, but can do fist

Extrinsic tightness

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Ax = flex MCP and extend IPs, then Extend MCP and extend IPS. If can’t extend IPS 2nd time then extrinsic tightness

Oblique reticular ligament tightness

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Ax = lack of DIP flexion when PIP extended compared to when it is flexed

Acute central slip injury

Boutonnieres deformity

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Inability to extend PIP

Mx: 
-splint into full ext so tendon heals
-6 wks grade; AROM
night splinting between exercises
-7 wks if flex loss, start passive PIP flex

PIP dislocation

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Collateral ligament injury
Avulsion # +/-
Volar plate rupture +/-

PE:

painful palpation
swelling

Tx: 
-control oedema (coban)
-splint in ext at night 
-Kinda stable: immobilise 10-20 flex for 4 wks 
unstable: surgery
Early active flex and ext is important

RTP: buddy strap

Phalangeal #

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Xray
movment

Tx:

Immobilise 4 wks ext
AROM stability permits
Oedema control (coban)
buddy strap

Distal phalanx

usually crush #
pain and swelling
if affects 30% intraarticular joint space, surgery required

Trigger finger

flexor tendon trapped in A1 pulley fo flexor tendon sheath mechanical catch--> friction--> inflammation - Painful straightening with a catch - locking and jamming ``` Mx: -splint t restrict MCP flex, IP free, 2-3 weeks Full PROM daily Oedema control Education Pain management ```

Metacarpal #

MC neck common 3-5 week healing, Rx based on head, neck, shaft or base Boxer’s # (volarly displaced head) -Oedema control and splint to facilitate reduction and prevent MCP extension stiff Metacarpal neck # -Hand based brace, MC head supported volarly -Gentle AROM -Wean from splint after 4-6 weeks -Buddy strap

Distal radial #

Foosh Colles# - non articular Smiths # - reverse colles with volar displacement Barton’s # - displaced, unstable articular subluxation with carpals PE - swelling - tender - loss of wrist motion - x ray Mx: Conservative -immobilise for non-displaced fracture Surgery Get good reduction – maintain good reduction – early motion as stability allows – oedema control (elevation and compression) hand ROM, shoulder and elbow ROM, wrist mobilisation as heals ``` Complications -malunion =pain stiffness OA CTS TFCC tears EPL rupture CRPS type 1 ``` Manual -PROM, AROM,

Complex regional pain syndrom

- vasomotor dysfunction - allodynia DD - Compartment syndrome - RA - Carpal tunnel syndrome 3 phases: Acute: pain, swelling, red, sweating, heat, stiffness Sub acute: continued pain, stiffness, organised oedema, decreased redness Chronic: very stiff, reduced pain ``` Mx: -Reduce pain and swelling Improve function and mobility Reduce stress Gentle active exercises Mirror therapy Functional use Shoulder and elbow ROM ```

-MP ulnar drift -Boutonniere and swan neck and mallet Reduce inflammation Maintain stability and mobility Acute: rest, position to prevent contracture, gentle ROM, cold therapy, education Subacute: exercise as tolerated, heat, joint protection/splinting Chronic: joint protection, strength exercises, educating and splinting Joint protection = respect pain, avoid deforming positions, avoid prolonged positions and use stronger joints when possible, use adaptive equipment

Nerve lesion

``` Low level medial - Weak: FPB, FO, lumbricals 1 and 2, APB - Ape hand - Can’t oppose thumb - Can’t chuck pinch - Decreased power grip - Sensation affected Low level ulnar - Weak: ADM, FDM, ODM, interossei, 4th and 5h lumbricals, AP, FPB - Claw hand - Loss of lateral pinch (Froment’s sign) - Decrease power grip - Flattened MC arch Low radial - ED or EPL High median - FCR High ulnar - FCU High radial - ECRB and ECRL ```

Nerve lesion Mx

``` Splint in flexion for 3-4 weeks until sheath strengthens AROM of other joints After 3 weeks gradual AROM Prevent joint contracture Sensory re-education ```

Wrist pathologies Flashcards

(31 cards)