Considerations When Evaluating Hand/Wrist Injuries

Transcription

1 Differential Testing and Treatment for Hand/Wrist Pathologies Presenter: Mary L. Mundrane-Zweiacher, MPT, ATC, CHT EATA Philadelphia, PA January 6, 2004 This workshop will be a combination of lecture and lab designed to familiarize certified athletic trainers and physical therapists with commonly confused hand/wrist injuries. There will be opportunities to practice the evaluative tests and treatment techniques presented. Considerations When Evaluating Hand/Wrist Injuries I. History (focuses your clinical exam and gives insight to the nature of the problem) A. Age B. Dominance C. Occupation and/or Sport D. Date of onset and Circumstances related to the onset 1. If insidious onset a. need to explore potential causes b. new responsibilities at home or work, playing a new position c. increased productivity d. workstation (especially with students) e. new hobby (new class at school) E. Mechanism of injury 1. including a. wrist position b. degree of stress c. direction of stress 2. Examples: a. an acute rotational injury to the forearm or fall on the pronated outstretched upper extremity can result in a TFCC injury b. wrist extension and pronation produce radially initiated perilunate injuries c. wrist flexion and pronation produce ulnarly initiated perilunate injuries d. load applied to the radial side of the palm with the wrist in extreme extension produces a scaphoid fracture F. Signs and Symptoms 1. Characteristics: a. Pain b. Swelling c. Numbness and tingling d. Temperature and color changes e. Abnormal sounds (clicks, grating, clunks) 2. Specifics: a. Location 1

2 II. b. Frequency c. Intensity (Pain Scale) d. Duration 3. Aggravating/Relieving factors G. Past Treatment Interventions (especially important for athletes returning after summer or pre-season) Observation/Inspection A. Posture/Position of the entire injured UE B. Bilateral Comparison 1. dorsallya. the skin, nails, color, and muscle bulk b. watch for dorsal ganglions and/or traumatic/surgical scars c. observe the six extensor compartments for any tubular swelling (tenosynovitis) 2. palmary/volarlya. thenar and hypothenar eminences are observed for muscle bulk b. volar complaints after a radial fracture may indicate a malunion 3. ulnarlya. a prominent distal ulnar head is indicative of a distal radiounar joint disruption 4. radially- C. Circulation D. Edema/Swelling 1. Objectively look for: a. wrinkle and contour alignment b. girth measurement c. volumetric measurement 2. Note the location and type of edema a. the venous system relies on valves, the heart pumping, and muscle pumping to remove low plasma protein swelling (acute edema) b. the lymphatics are the only system that can remove large molecule substances such as excess plasma proteins, hormones, fat cells, and waste products from the interstitium that you see in chronic edema. Then lymphatics are tubes which are in the dermis layer of the skin; they rely on changes in interstitial pressure to open and close (pressures>60 mmhg will collapse the tubes). - squeezing tissue removes the fluid from the lymph but not the large molecules, so the edema becomes more concentrated -the proteins are hydrophilic and when the pressure is removed, the fluid is attracted back into the interstitium c. the treatment goal for acute (low plasma protein) edema is to decrease the fluid flow into the tissue/interstitium by elevation, compression, retrograde massage, etc. d. the treatment goal for chronic edema is to reduce the excess plasma proteins in the interstitium by stimulating the lymphatics. 2

3 This treatment is called Manual Edema Mobilization (MEM) and it incorporates the following: -light proximal to distal, then distal to proximal massage of the skin -specific pre and post exercises -massaging the lymph node areas proximal to the edema -the massage must follow the direction of lymphatic pathways E. AROM/PROM 1. Most reliable method for measuring finger/wrist flexion and extension is the volar/dorsal technique 2. Bilateral comparison F. Strength/Grip testing 1. Submax effort can be ruled out with use of rapid-exchange grip testing and bell curve with five position grip testing with a Jamar G. Sensibility Examination 1. Done to screen for nerve compression 2. Semmes Weinstein light touch threshold is the most sensitive clinical test for detecting nerve compression H. Physical Examination 1. Palpation (Knowledge of anatomy is KEY!!) a. palpate the bony and soft tissue anatomy and determine the area of maximum tenderness. Tender areas are then related to a specific underlying structures such as the bone, tendon or joint 2. Provocative/Special Testing III. Zone Examination of the Wrist A. Radial dorsal zone Structures to palpate: Radial styloid Scaphoid Scaphotrapezial joint Trapezium Base of the first met 1 st MCP joint 1. Radial styloid tenderness may indicate: a. contusion b. fracture c. if tenderness is accentuated with radial deviation (RD) radioscaphoid arthritis 2. Scaphoid tenderness in the snuffbox may indicate: a. scaphoid fracture b. scaphoid non-union c. scaphoid instability 3. Scaphoid and trapezium tenderness may indicate: a. scaphoid instability b. ST arthritis c. if accompanied by central dorsal complaints, see section III B4 3

4 4. First CMC joint tenderness may indicate: a. with a (+) Grind test (pain with axial compression of the 1 st met with rotation) 1 st CMC joint degenerative arthritis b. with a (+) instability/laxity test (more laxity is present when the 1 st met is distracted and moved side to side or RU direction while the trapezium is stabilized versus on the uninjured side) 1 st CMC joint instability or laxity 5. Extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tenderness in the first extensor compartment (radial border of the anatomic snuffbox) a. with a (+) Finkelstein s test (pain localized to the radial aspect of the wrist when thumb flexion is combined with UD of the wrist) de Quervain s tenosynovitis 6. Extensor pollicis longus (EPL) tendon tenderness may indicate: a. with incomplete thumb interphalangeal extension from pain EPL tendonitis/drummer s Palsy b. with no active extension of the thumb interphalangeal joint EPL rupture 7. EPB and APL muscle belly tenderness or crepitus with active thumb movement or friction and crepitus palpated 4 to 5 cm proximal to the radial styloid during wrist flexion and extension with radial deviation may indicate: intersection syndrome 8. Numbness, tingling, burning, and pain over the dorsal radial aspect of the hand may indicate: a. (+) Tinel s with percussion along the course of the nerve produces tingling and pain which may radiate distally Wartenberg s Syndrome or Neuralgia (irritation of the Dorsal Radial Sensory Nerve) b. with more proximal complaints CN root irritation????? B. Central Dorsal Zone Structures to palpate: Distal radius (dorsal rim) Lister s tubercle Lunate Scapholunate interval Capitate 2 nd and 3 rd metacarpal bases 2 nd 4 th extensor tensons Posterior interosseus nerve (PIN) 1. Distal radius dorsal rim tenderness may indicate: a. (-) X-Ray changes Impingement of the scaphoid on the radius b. (+) X-Ray changes and pain with pressure or with hyperextension and radial deviation of the wrist osteophyte 2. Lunate tenderness only may indicate: a. (+) X-Ray changes Kienbock s disease (avascular necrosis of the lunate) 3. Scapholunate interval tenderness may indicate: 4

5 a. patient history of recurrent nodular swelling in the wrist dorsum and complaints of pain with deep palpation that may not be detected by clinical exam dorsal wrist ganglion (***tenderness may be present with wrist flexion or extension secondary to compression of the ganglion) b. with localized non- nodular swelling scapholunate ligament injury c. with localized non-nodular swelling and a (+) finger extension test (pain in the scapholunate region with resisted finger extension with the wrist in flexion) dorsal wrist syndrome 4. Scaphoid (in the snuffbox) and scaphotrapezial-trapezoid joint tenderness with synovitis a. and dorsal scapholunate synovitis, and (+) finger extension test, and an abnormal Watson/scaphoid shift test scaphoid rotary subluxation C. Ulnar Dorsal Zone Structures to palpate: Ulnar styloid Ulnar head DRUJ TFCC (triangular fibrocartilage complex) Hamate Triquetrum Lunotriquetral interval Fourth and fifth CMC joints Extensor carpi ulnaris (ECU) 1. Ulnar styloid tenderness may indicate: a. ulnar styloid fracture b. ulnar fracture nonunion 2.DRUJ (distal radial ulnar joint) tenderness may indicate: a. with prominence of the distal ulnar head DRUJ instability - may also be associated with a (+) piano key sign or (+) piano key test b. with a (+) ulnar compression DRUJ arthritis 3. Fovea (a groove at the base of the ulnar styloid that serves as an attachment point for the TFCC) tenderness - a. with (+) TFCC load test - Ulnocarpal abutment (ulnar impaction syndrome) b. with (+) TFCC load test and a (+) relocation test TFCC tear/ulnocarpal instability 4. Hamate tenderness on the dorsal aspect may indicate: a. hamate fracture 5

6 Avascular Necrosis of the Lunate Boutienniere Injury De Quervain s Tenosynovitis Dorsal Wrist Syndrome Dorsal Wrist Ganglion Drummer s Palsy EPL Tendonitis Intersection Syndrome Kienbock s Disease Scaphoid Rotary Subluxation Scapholunate Ligament Injury Volar Plate Contracture Wartenberg s Syndrome DIAGNOSES/TREATMENTS SPECIAL TESTS/PROVOCATION TESTS Finger extension test tests for dorsal wrist syndrome. Finkelstein s test tests for de Quervain s tenosynovitis. First CMC joint instability/laxity test - tests for 1 st CMC joint instability or laxity. Grind test for the first CMC joint tests for 1 st CMC degenerative arthritis. Piano key test tests for DRUJ instability Piano key sign tests for DRUJ instability Relocation test tests for TFCC tear/ulnocarpal instability Tinel s Test tests for nerve compression and regeneration. TFCC load test tests for TFCC injury and Ulnocarpal abutment Ulnar compression test - tests for DRUJ arthritis Watson/scaphoid shift test tests for scaphoid rotary subluxation REFERENCES 6

7 Falkenstein N, Weiss-Lessard S: Hand Rehabilitation: A Quick Reference Guide and Review, Mosby, St. Louis, 1999 Gelberman RH, et al: Sensibility testing in peripheral nerve compression syndrome: an experimental study in humans, J Bone Joint Surg 65A:632, 1983 Hunter J, Mackin E, Callahan A: Rehabiliatation of the Hand, ed V, Mosby, St Louis, 2002 Stanley B, Tribuzi S: Concepts in Hand Rehabilitation, Philadelphia,