Wrist and hand injury .ppt

Hand Injuries

Hand therapy concepts

Tissue healing Antideformity positoning Complex Regional Pain Syndrome(CRPS) PROM can be Injurious

Tissue healing

Inflammation phase vasoconstriction vasodilation Tx-- immobilization

Fibroplasia phase Collagen fiberswound’s tensile strength Tx-- AROM & splint

Maturation (remodeling) phase Change architecture, collagen fiber, tensile strength Tx—gentle resistive activity, corrective dynamic or static

splint

Antideformity positoning deformity position

wrist flex, MP hyperext, PIP & DIP flex, thumb add & oppoition

MP extensioncollateral ligament (slack- MP ext, taut- MP flex)

IP flexion: volar plate folds on itself

Complex Regional Pain Syndrome(CRPS) Defining features

Evidence of skin changesOedema, Sudomotor, Colour

Pain/hyperalgesia/allodynia Not limited to nerve territoryDisproportionate to injury

Terminology: RSD vs CRPS

RSD = traditional termComplex regional pain syndrome (CRPS) = more comprehensive term

• Includes disorders not related to sympathetic nervous system dysfunction

CRPS I = RSDCRPS II = causalgia (involves nerve injury)

Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.

Checklist for the Diagnosis of RSD: History

• Burning pain• Skin, sensitivity to touch• Skin, sensitivity to cold• Abnormal swelling• Abnormal hair growth

• Abnormal nail growth• Abnormal sweating• Abnormal skin color

changes• Abnormal skin

temperature changes• Limited movement

Checklist for the Diagnosis of RSD/CRPS: Examination

• Mechanical allodynia• Hyperalgia to single pinprick• Summation to multiple pinprick• Cold allodynia• Abnormal swelling

• Abnormal hair growth• Abnormal skin color changes• Abnormal skin temperature (> or < 1 ْ C)• Limited range of movement•

PROM can be Injurious ?

disturb healing tissue incite further inflammatory reaction trigger CRPSManagement

low-load & long-duration splintng

Judicious Use of Heat

Effect Increase edema Degrade collagen Rebound effect

Safer use Elevate extremity With exercise or active movement Continue to monitor for immediate & subsequent

sign of inflammation

Hand evaluation

History medical report( radiographs), hand dominace,

age, occupation Trauma:date of injury, date of surgery, where &

how, mechanism of injury, posture when it was injured, any previous Tx

nontrauma: date of onset, worsening symptoms, sequence of symptoms, functional effect

Con’t

Pain sudden and recent onset local irritation in fascia, muscle, tendon or ligament

(myofascial pain) associated autonomic symptoms Method

graphic representation of pain, analog pain rating scales, palpation

Con’t

Physical Examination posture, guarding & gesturing, atrophy, and edema cervical screening: distal symptoms ( proximal

problem cause)

Con’t

Wounds Size: length, width, depth Wound drainage, odor Three –color concept ( red, yellow, or black)

red: healing, uninfecereircumted, revascularization and granulation tissue

yellow: exudate (cleaning, debridement)black: necrotic, debridement

Con’t

Scar Assessment location, length, width, height Hypertrophic scar Keloid Tenodermodesis: adherence of skin and tendon Immature & mature scar

Con’t

Edema Circumferential measurement Volumeter

contraindication:open wound, percutaneous pining

Vascular Assessment capillary refill (apply pressure)

Con’t

ROM AROM, PROM total active/ passive motion-- 270°

Grip & Pinch Jamar dynomometer dominant & nondominant hand difference three pinch patterns: lat, tip , three-jaw chuck)

Con’t

MMT monitoring progress following peripheral nerve

lesions

Sensibility Semmes-Weinstein sensibility Two-Point discrimination

Con’t

Dexterity and hand function Moberg Pickup Test Jabsen test of hand function Purdue pegboard test

Con’t

Special tests Phalens

Hold wrist flexed for 60 seconds Tinel

Tap over nerve Finklestein

Hold thumb in palm, then ulnar deviation of wrist. A positive response is extreme pain in wrist

Froment Grasp paper in lateral pinch of both thumb. A positive

response is an increase in flexion of IPJ

Clinical Reasoning

What Structures Are Restricted

PROM Exceed AROM disruption of musculotendinous units, adhesions

restricting excursion of tendon, weakness

PROM=AROM joint or musculotendinous or both restrict

Joint vs Musculotendinous Tightness

Joint tightness: PROM of particular joint does not change with reposition of joints proximal and/ or distal to it

Musculotendinous tightness: PROM of particular joint dose vary with repositioning of joints crossed by that multiarticulate structure

Lag vs Contrcature

Leg: a limitation of active motion in a joint that has passive motion available

Contracture: a passive limitation of joint

Intrinsic vs Extrinsic Tightness

Compare PROM of digital PIP and DIP flexion with MP flexed & again with MP extended Intrinsic: less PIP & DIP passive flexion with MP MP

extendedextended Extrinsic: less PIP & DIP passive flexion with MP

flexed

Tightness of Extrinsic Extensor or Extrinsic Flexor

extrinsic extensor tightness: less passive composite digital flexion available with wrist in flexion than extension

extrinsic flexor tightness: less passive composite digital extension available with wrist in extension than flexion

Basic InterventionsEdema control

elevation, active exercise, contrast baths, compression

retrograde massage, string wrapping, compressive garments (too tight), modality(such as intermittent pressure pump)

Scar management compression, desensitization/ silicone gel

Differential digital tendon gliding exercise maximize total gliding

Blocking exercise blocking tool/splint intrinsic stretch: MP extend & IP flexed isolate MP flexion & extension:digital cylinders

blocking DIP isolated flexion/ FDP exersion: PIP

cylindrical blocking frequent, slowly: holding 3~5 seconds

Place-and-hold exercise increased ROM( while PROM>AROM) combination blocking exercise

End-feel and splinting soft (spongy)

low-load, long-duration dynamic splint prolonged, gentle force

hard serial casting or static progressive splinting

Splint Functional splint Buddy straps Dorsal MP flexion blocking splint

Common Diagnoses

Stiff hand

Cause: edema Tx

gentle passive motion by joint traction(joint surface gliding)

sustained holding Splint

static splint night splint

Tendonitis

Cause overuse, cumulative trauma disorder, tendonitis inflammation of tendons and muscle-tendon

attachment repetitive use

Clinical feature localized pain, tendon sheath swelling secondary weakness( pain) swelling: muscle belly, musculotendinous junction

or origin Vicious system: pain, instability, dysfunction

Evaluation Pain: typical pain with AROM, resistance, passive

stretch Identify the activity causing pain Ergonomic risk factors: forceful, rapid, repetitive

movement

Treatment acute phase

rest, ice, compression, elevation anti-inflammatory physical agent modality Night splinting

subacute phase (inflammation subside ) tendon gliding exercise in pain-free range isometric

exercise isotonic exercise low-load, high-repetition strengthening in short arcs of motion

Con’t

Reinjury education—avoid reaching & gripping with extened

elbow or a flexed or deviated wrist pacing to avoid fatigue prevent unsupported upper

extremity( nonsymmetrical use, nonfrontal trunk or U/E alignment, unilateral extremity work)

ergonomic adjustment: bilateral with proper body mechanics, telephone headset

Common type

Tennis elbow( lateral epicondylitis)

common involved: extensor carpi radialis brevis

Pain at lateral epicondyle and extensor wad

Golfer’s elbow (medialepicondylitis) common involved: flexor carpi radoalis(FCR)pain at medial epicondyle and flexor wad pain with resisted wrist flexion and pronation

De Quervain’s disease( most common) Abductor pollicis longus(APL), extensor pollicis

brevis(1st dorsal compartment) Sign’s and Symptoms

Pain with thumb movement in abduction Pain during eccentric wrist activities of the extensors of the

thumb Positive Finkelsteins test : exquisite pain with passive wrist

unlar deviation while flexing thumb Treatment

Immobilization : Forearm-based thumb spica ( IP free) ice Physician referral for meds if needed

Intersection syndrome

Pain, swelling crepitus of APL, EPB bellies to proximal to wrist( ECRB, ECRL intersect)

Repetitive wrist motion in weight lifter, rower Management

Education: avoid painful or resisted wrist extension, forceful grip

Splint- the same as for De Quervain’s disease

Extensor pollicis longus tendonitis (drummer body palsy)

less commonrepetitive use of thumb and wristtendonitis of EPL tendon rupture( rheumatioid, Colles’ fracture) Management

forearm-based thumb spica

Extensor carpi ulnaris tendonitis

repetitive unlar deviation pain & swelling distal to unlar head

pain & swelling distal to unlar head

Management Splint: forearm-based ulnar gutter/ wrist cock-up

splint

Trigger Finger

The tendons that bend your fingers run through a tunnel or sheath. Trigger finger is caused by a thickening on the tendon catching as it runs in and out of the sheath.

Trigger Finger

Can be felt in the palm the finger moves. The system is very similar to bicycle brake cable. If the wire becomes bent or rusty, the brakes work badly

Trigger Finger

A-1 pulley( fibro-osseous tunnel: prevent bow-stringing of digital flexor )

Tenderness—A-1 pulley +pain with resisted grip or painful catching or locking of finger in composite flexion

OT management splint( MP in neutral), tendon gliding, place-and-

hold fisting

Trigger Finger Treatment

Two Ways to treat: Inject & Surgical Injection: A small amount of steroid is

injected around the tendon. Surgery

This is needed if the steroid injections do not work.

The condition can occur in any finger and therefore the triggering may return in the affected or other fingers. This is, however, very unusual if you have had surgery.

Nerve injury

Multiple areas of neural pathology Mechanism : acute or chronic compression,

stretch ischemia, electrical shock, radiation, injection, laceration

Nerve compression

Carpel tunnel syndrome

A. Mechanism: overuse, congenital, traumaB. Pathology: Compression of the median

nerve in the tunnel

Carpal tunnel syndrome(most common) carpal tunnel: carpal bone, transverse ,carpal

ligament, nine flexor tendons(FDS, FDP, FPL), median nerve

Age: 40~60yrs frequently bilateral typical complaints: hand numbness( night, driving

car) with pain, parasthesias in distribution, clumsiness or weakness

transient carpal tunnel syndrome—pregnancy

Evaluation Tinel’s sign: tingling or eletric shock Phale’s test: wrist lexion for 60 seconds thenar atrophy of APB

Treatment conservative medical management : steroid

injection, night splint( neutral wrist), exercise( median nerve gliding), ergonomic modiication, postural training

Education: avoid extrmes of forearm rotation, wrist motion/ sustained pinch or forceful grip

surgical interventionpostoperative therapy; edema control, sar

management, desensitization, nerve & tendon gliding, strengthing( ~6wks)

Cubital tunnel( second most common)

Ulnar nerve 在 medical epicondyle & olecranon Mechanism

repeated elbow flexion Trauma: fracture or dislocation of supracondylar or

medial epicondylarTypical complaint

aching or sharp pain( night) in proximal and medial forearm

decreased sensation weakness

Evaluation Atrophy in first web space, hypothenar eminence,

medial forearm Elbow flexion test( passive flex elbow, holding 60

seconds) Grip & pinch/ MMT

Treatment Conservative therapy: splinting( prevent sleeping

with elbow 30 。 flex), padding elbow, positioning guideline

Ergonomic training, ulnar nerve gliding exercise

Posterior interosseous nerve syndrome( radial n. compression)Purely motorClinical picture—inability to extend MP of

thumb, index, longCan wrist extension( 僅 radial side)Common site: supinator muscleTreartment: maintain ROM, splinting to

prevent deformity and promote function

Nerve laceration

Nerve reconstruction Neuroma( disorganized mass of nerve fibers) Significant nerve pain( elicited by tapping) Hypersensitivity Limit functional use

Low median nerve lesion Wrist level—denervation of opponens pollicis(OP),

APB, lumbricals of index & long finger Motor recovery usually occur before sensory

recovery Symptom

clawing(2,3 finger) sensation loss of radial side of hand thumb rest in adduction

Treatment Thumb abduction splint(maintain balance/ substitute

for lost thumb opposition/ prevent overstretching of denervated muscles)

PROM to maintain joint mobility

High median nerve lesion

Elbow level: denervation of FDP( 2,3), 1~4 FDS, pronator teres, pronator quadratus

Most important sensory nerveTreatment: splinting( maintain PROM of

pronation, MP flexion, IP extension, thumb CMC abduction)

Low ulnar nerve lesion Hand intrinsic

fine manipulation skills Denervation

adductor digiti minimi, flexor digiti minimi, opponens digiti minimi: flattening hand( loss ulnar transverse metacarpal arch)

adductor pollicis & FPB: thumb adduction dorsal & volar interossei: digital abd & add lumbricals(4,5): extrinsic imbalance( clawing hand deformity)

Treatment Splinting: MP blocking splint Sensory compensation

High ulnar nerve lesion

Involvement of the earlier listed musclesFDP of ring & small fingerFCUclawing hand less apparent The same low ulnar nerve lesion

High radial nerve lesion

Humeral fracture sensory loss on dorsal-radial hand tricep intact supinator & wrist+ finger extensor effect: tenodesis

lost

Treatment Splint: maintain tenodesis

Low radial nerve lesion( posterior interosseous palsy)

Preservation: brachioradialis & ECRLAffected: extend wrist into radial deviation,

MP extend, sensation on dorsal radial handTreatment: 同 radial nerve compression

Fractures

Distal radius fractureMain complication

Traumatic arthritis( poor articular congruency) Tendon rupture Median or ulnat nerve compression CRPS

Decreased wrist ROM, grip strength, alteration of carpal alignment,instability

Recovery factor Restoration of motion and strength Maximizing the length-tension relationship of digital

Therapy during immobilization例 Colles’ fracture

Cast immobilization: above-elbow with elbow 90° flexion/ prevent rotation for 3 wks

Biceps tightness

internal vs external fixatorShoulder restrictions should avoid

Treatment goal Control edema Nearly normal AROM of uncasted area Joint or musculotendinous tightness

Blocking splint, night static progressive splint, low-load , long-duration dynamic splinting

Tendon gliding exercise

Therapy after cast or fixator is removed Deformity position

MP ext, PIP flex, Thumb add & ext Volar wrist splint

Important goal Retrain wrist extensors to function

independently of extensor digitorum Progressive grasp-release activity Gradually upgrade therapy

Nonarticular hand fracture

Distal phalanx Crushing injury Thumb, middle finger

Middle phalanx Long immobilization time Treatment: isolated FDS exercise

Proximal Palmar apex

Collateral ligament injury

PIP joint sprain Grade I, II Therapy focus

Edema control, joint protection, ROM Splint

Skier thumb Acute radial deviation Ulnar logament Begin lateral pinch then tip pinch

Flexor tendon injury

Anatomy

Flexor tendon zone I ~ zone V Zone II: FDP, FDS within flexor sheath( no man’s land) Zone III: lumbrical muscle Zone IV: transver carpal ligament, medial & ulnar nerve

Pulley system A (annular) pulley C (cruciform) pulley

Postoperative management

Early phase1~4wks, early controlled mobilization To fabricate a splint or change the postoperative cast to

protect repair but allow early motion To instruct patient in early motion exercise program To instruct patient in edema control & prevent technique

Con’t

Controlled mobilization splint wrist flex 30°, MP flex 70°, IP ext 0°

Duran protocol-- active extension & passive flexion( 3-5mm tendon excursion)

Kleinert protocol( passive flexion-active extension): rubber band attachment to the fingernail

Chow protocol: combination Duran & Kleinert techniques

Con’t

Early immediate phase 5~~6wks To increase gliding potential by starting “ place-

hold” exercise To dischange patient from dorsal protective splint

into wrist To continue edema control, scar management and

prevention of PIP contracture

Con’t

Intermediate phase 7~8 wks To achieve full active glide and maximal differential

glide of both tendons

Late phase 9~12wks To improve strength and endurance

Extensor tendon injury

Anatomy Zone 1~7 1 central band insert MP proximal end 2 lateral band insert DIP proximal end

Specific deformityMallet deformity (zone I, II), baseball finger

lateral band rupture finger gutter DIP extensor lag

Boutonniere deformity (zone III, IV) central band rupture finger gutterisometric exercise

Boutonniere Deformity

Mallet Finger

Zone V, VI immobilization or controlled early motion

Zone VII development of adhesions specific position and motion guidelines

Tenolysis

1 wks AROM Tendon gliding exercise Place-hold exercise Blocking exercise PROM Edema control Splinting

2~3 wks maintain AROMscar managementfunctional use of involved hand

4~6 wks Maintain AROM Continue scar management Increase grip and pinch strength 7~8 wks maintain ROM maximize strength initiate heavy resistive exercise

Swan Neck Deformity

Caused by a Volar plate rupture Lateral bands drift dorsally and exacerbate the

hyperextension at the PIPI joint. They become ineffective in extension at the DIP joint and the unopposed action of the profundus causes flexion at the DIP joint.

Swan Neck Deformity

Anatomy

Nerves Radial - extensors of the

wrist, sensation of the dorsal web space

Median - wrist flexion on the radial side, finger add

Ulnar - wrist flexion on the ulnar side, hand squeeze

Sensory Nerves

Intrinsics of the Hand - Thenar Group

Flexor Pollicis Brevis, Median Nerve

Adductor Pollicis, Brevis Median Nerve

Palmaris Brevis Median Nerve

Thenar Group

Flexor Pollicis Brevis, Median Nerve

Opponens Pollicis, Median Nerve

Intrinsics of the Hand - Hypothenar GroupOpponens Digiti

Mnimi, Ulnar N.Flexor Digiti

Minimi, Ulnar N.Abductor Digiti

Minimi, Ulnar N.

Intrinsics of the Hand - Muscles Controlling the DigitsIntrinsics: Lumbricales

R N. on palmar side Left 2 Median N. Medial 2, Ulnar N.

Interossei - Ulnar N. Dorsal 4 ABD Palmar (3) ADD

Blood Supply Forearm

Cubital Fossa - split Radial Artery

Superficial & Lateral Lies in Anatomical

Snuff Box Supplies Dorsal Arch

in Hand Ulnar Artery Deep and Medial Blood

Supply Main blood supply runs

palmar – superficial Arch

Nerve Supply Hand

Radial N. Supplies Dorsal Arch Supply for fingers

Ulnar Nerve, Superficial arch supplies 1st dorsal

interossei

Extensor Expansion of the Hand

Interossei Attach Dorsal MC ABD, Palmar MC ADD Lumbricales attach radial palmar side MC

Extensor Digitorum Attach base Distal Phalanx Central Slip at base Int. Phalanx

Attached by Triangular Ligament

Balance of Finger Flexors

Extension Flexion

MP joint ED FDS,FDP(wk),Intrinsics

PIP joint ED (wk) FDS, FDP

DIP joint Intrinsics FDP

Normal Alignment

Lunate = center fingerSign Language A - all fingers point to lunateOn x-ray: scaphoid angled 45 deg (30-60 deg

considered normal)