wrist and hand injury .ppt
DESCRIPTION
TRANSCRIPT
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Hand Injuries
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Hand therapy concepts
Tissue healing Antideformity positoning Complex Regional Pain Syndrome(CRPS) PROM can be Injurious
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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
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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
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Complex Regional Pain Syndrome(CRPS) Defining features
Evidence of skin changesOedema, Sudomotor, Colour
Pain/hyperalgesia/allodynia Not limited to nerve territoryDisproportionate to injury
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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.
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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
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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•
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PROM can be Injurious ?
disturb healing tissue incite further inflammatory reaction trigger CRPSManagement
low-load & long-duration splintng
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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
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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
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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
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Con’t
Physical Examination posture, guarding & gesturing, atrophy, and edema cervical screening: distal symptoms ( proximal
problem cause)
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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
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Con’t
Scar Assessment location, length, width, height Hypertrophic scar Keloid Tenodermodesis: adherence of skin and tendon Immature & mature scar
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Con’t
Edema Circumferential measurement Volumeter
contraindication:open wound, percutaneous pining
Vascular Assessment capillary refill (apply pressure)
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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)
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Con’t
MMT monitoring progress following peripheral nerve
lesions
Sensibility Semmes-Weinstein sensibility Two-Point discrimination
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Con’t
Dexterity and hand function Moberg Pickup Test Jabsen test of hand function Purdue pegboard test
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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
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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
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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
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Lag vs Contrcature
Leg: a limitation of active motion in a joint that has passive motion available
Contracture: a passive limitation of joint
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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
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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
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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
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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
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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
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Splint Functional splint Buddy straps Dorsal MP flexion blocking splint
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Common Diagnoses
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Stiff hand
Cause: edema Tx
gentle passive motion by joint traction(joint surface gliding)
sustained holding Splint
static splint night splint
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Tendonitis
Cause overuse, cumulative trauma disorder, tendonitis inflammation of tendons and muscle-tendon
attachment repetitive use
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Clinical feature localized pain, tendon sheath swelling secondary weakness( pain) swelling: muscle belly, musculotendinous junction
or origin Vicious system: pain, instability, dysfunction
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Evaluation Pain: typical pain with AROM, resistance, passive
stretch Identify the activity causing pain Ergonomic risk factors: forceful, rapid, repetitive
movement
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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
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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
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Common type
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Tennis elbow( lateral epicondylitis)
common involved: extensor carpi radialis brevis
Pain at lateral epicondyle and extensor wad
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Golfer’s elbow (medialepicondylitis) common involved: flexor carpi radoalis(FCR)pain at medial epicondyle and flexor wad pain with resisted wrist flexion and pronation
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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
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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
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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
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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
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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.
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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
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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
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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.
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Nerve injury
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Multiple areas of neural pathology Mechanism : acute or chronic compression,
stretch ischemia, electrical shock, radiation, injection, laceration
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Nerve compression
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Carpel tunnel syndrome
A. Mechanism: overuse, congenital, traumaB. Pathology: Compression of the median
nerve in the tunnel
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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
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Evaluation Tinel’s sign: tingling or eletric shock Phale’s test: wrist lexion for 60 seconds thenar atrophy of APB
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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)
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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
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Evaluation Atrophy in first web space, hypothenar eminence,
medial forearm Elbow flexion test( passive flex elbow, holding 60
seconds) Grip & pinch/ MMT
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Treatment Conservative therapy: splinting( prevent sleeping
with elbow 30 。 flex), padding elbow, positioning guideline
Ergonomic training, ulnar nerve gliding exercise
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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
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Nerve laceration
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Nerve reconstruction Neuroma( disorganized mass of nerve fibers) Significant nerve pain( elicited by tapping) Hypersensitivity Limit functional use
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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
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Treatment Thumb abduction splint(maintain balance/ substitute
for lost thumb opposition/ prevent overstretching of denervated muscles)
PROM to maintain joint mobility
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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)
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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)
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Treatment Splinting: MP blocking splint Sensory compensation
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High ulnar nerve lesion
Involvement of the earlier listed musclesFDP of ring & small fingerFCUclawing hand less apparent The same low ulnar nerve lesion
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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
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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
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Fractures
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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
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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
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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
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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
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Nonarticular hand fracture
Distal phalanx Crushing injury Thumb, middle finger
Middle phalanx Long immobilization time Treatment: isolated FDS exercise
Proximal Palmar apex
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Collateral ligament injury
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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
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Flexor tendon injury
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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
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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
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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
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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
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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
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Extensor tendon injury
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Anatomy Zone 1~7 1 central band insert MP proximal end 2 lateral band insert DIP proximal end
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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
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Boutonniere Deformity
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Mallet Finger
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Zone V, VI immobilization or controlled early motion
Zone VII development of adhesions specific position and motion guidelines
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Tenolysis
1 wks AROM Tendon gliding exercise Place-hold exercise Blocking exercise PROM Edema control Splinting
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2~3 wks maintain AROMscar managementfunctional use of involved hand
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4~6 wks Maintain AROM Continue scar management Increase grip and pinch strength 7~8 wks maintain ROM maximize strength initiate heavy resistive exercise
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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.
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Swan Neck Deformity
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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
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Intrinsics of the Hand - Thenar Group
Flexor Pollicis Brevis, Median Nerve
Adductor Pollicis, Brevis Median Nerve
Palmaris Brevis Median Nerve
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Thenar Group
Flexor Pollicis Brevis, Median Nerve
Opponens Pollicis, Median Nerve
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Intrinsics of the Hand - Hypothenar GroupOpponens Digiti
Mnimi, Ulnar N.Flexor Digiti
Minimi, Ulnar N.Abductor Digiti
Minimi, Ulnar N.
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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
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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
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Nerve Supply Hand
Radial N. Supplies Dorsal Arch Supply for fingers
Ulnar Nerve, Superficial arch supplies 1st dorsal
interossei
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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
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Balance of Finger Flexors
Extension Flexion
MP joint ED FDS,FDP(wk),Intrinsics
PIP joint ED (wk) FDS, FDP
DIP joint Intrinsics FDP
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Normal Alignment
Lunate = center fingerSign Language A - all fingers point to lunateOn x-ray: scaphoid angled 45 deg (30-60 deg
considered normal)