Musculoskeletal Impairments III

Transcription

1 Wrist and Hand Pathology 1 Objectives Identify signs and symptoms of musculoskeletal issues that can be addressed by PT including: RA/OA Fractures TFCC lesions Intercarpal instabilities MCP joint injuries Tendon rupture 1

2 / Pain Rheumatoid Arthritis 2

3 1. Ulnar drift Results from damage to extensor mechanism and lateral l ligaments Occurs initially in the MCP joints, pulling fingers into ulnar deviation, pronation and palmar subluxation Causes include: Synovitis and weakening of radial collateral ligament Damage to extensor hood Displacement of extensor tendons to ulnar side Radial deviation of wrist Secondary contracture of intrinsic muscles on ulnar side Dysfunction of intrinsic muscles on radial side Displacement of flexor tendons to ulnar side Appositional pinch Gravity Boutonniere Deformity aka buttonhole deformity Describes a finger with flexion of the PIP and extension of the MCP and DIP joints Occurs as a result of? Injury to the central slip with lateral bands slipping in the volar direction Allows the PIP joint to buttonhole between the lateral slips into a flexed position RA 3

4 Swan Neck Deformities Injury primarily to the PIP and sometimes the DIP joint as well Finger will hyperextend at the PIP joint and flex at the DIP and MCP joints Overstretching of palmar plate Bowstringing of lateral bands of extensor hood Often present with? Patients with chronic RA RA Swan Neck Deformities Causes include: Injury to the volar plate FDS injury Chronic mallet finger Intrinsic muscle contracture RA 4

5 Fractures Fractures Distal radius/ulna fractures Colles Extra-articulararticular fracture of distal radial shaft with dorsal/posterior displacement Fall on wrist in flexion and pronation of forearm Smiths Reverse colles (extra-articular) with volar/palmar displacement of distal radius Fall on back of hand Barton Intra-articulararticular fracture with displacement of dorsal lip of radius 5

6 Fractures Carpal bone fractures Scaphoid More frequently overlooked and sometimes dismissed as sprain Clinical features: Pain on raidal side, particularly with RD/F Slight swelling Significant local anatomical snuff-box Importance of repetitive imaging Non-union Fractures 6

7 Carpal bone fractures Scaphoid More frequently overlooked and sometimes dismissed as sprain Clinical features: Pain on raidal side, particularly with RD/F Slight swelling Significant local anatomical snuff-box Importance of repetitive imaging Non-union Bloodsupply Fractures Carpal bone fractures Scaphoid More frequently overlooked and sometimes dismissed as sprain Clinical features: Pain on raidal side, particularly with RD/F Slight swelling Significant local anatomical snuff-box Importance of repetitive imaging Non-union Bloodsupply Pinning Fractures 7

8 Metacarpal fractures Boxer s fracture 5th metacarpal Fractures Metacarpal fractures Boxer s fracture 5th metacarpal Fractures 8

9 TFCC injuries Comprised of: Articular disc Ligamentous fibers from the articular disc to the lunate and triquetrium Dorsal radioulnar ligament Palmar radioulnar ligament Tendon sheath of the extensor carpi ulnaris Functions to stabilize the radioulnar and ulnotriquetral joints of the wrist TFCC injuries Supination and pronation occur around the distal radioulnar joint which depends on the TFCC for stability Injury to the TFCC will result in: Decreased supination/pronationpronation Instability at end range of these 2 motions Increased mobility of the distal ulna Mechanism of injury: Severe traumatic wrist injury Forceful wrist flexion or extension with ulnar dev. Patient presentation: Pain in the ulnar aspect of the wrist Pain with pronation/supination of the forearm Palpation of FCU tendon while the wrist is in flexion Possibly a clicking sound with repeated all wrist motions but most notably wrist extension and ulnar deviation 9

10 Distal Radial Fracture and TFCC Injury Two types: Dissociative Intercarpal Instabilities Instability patterns that occur within the same row Two types: dorsal and ventral Dorsal Scapholunate dissociation Occur due to? FOOSH Wrist extension and ulnar deviation Patient presentation: Difficulty and weakness with grasping Chronic, vague wrist pain Tenderness over scaphoid/lunate + scaphoid-shift shift test (Watson s test) 10

11 Two types: Dissociative (Con t) Intercarpal Instabilities Ventral Lunatotriquetrum dissociation Ventral tilt of distal end of lunate Patient presentation: Tenderness over lunate and triquetrum Difficulty and weakness with grasping Chronic, vague wrist pain Nondissociative Occurs from? Injury to the dorsal intercarpal ligaments May not be symptomatic Patient may be able to sublux and reduce at will Clunk at extremes of ulnar deviation Gamekeeper s thumb Aka skier s thumb Injury to the ulnar collateral ligament of the 1 st MCP joint Mechanism of injury? Forceful ABD of the 1 st MCP joint Patient presentation Excessive ABD of the thumb with the inability to stabilize the thumb in this position for weight bearing Pain at end range of ABD + mobility tests for hypermobility medially in the 1 st MCP joint 11

12 Gamekeeper s Thumb Mallet finger Aka baseball finger Occurs from? Injury to the extensor mechanism at the DIP joint resulting in the inability of the patient to extend the DIP Typical mechanism of injury? Forceful finger flexion while the DIP is extended Possible injuries include: ED tendon injury Laceration of the dorsal aspect of the DIP Rupture of the tendon Avulsion of the tendon from the distal phalanx Rupture of the oblique retinacular ligament or distal tendon wing Presentation: Patient presents with the inability to fully extend the DIP 12

13 Mallet Finger Jersey Finger Injury to? Flexor digitorum profundus tendon or avulsion fracture resulting in the inability to flex the DIP joint Mechanism? Forceful extension of the DIP joint while the DIP is flexed Patient presentation Patient is unable to actively flex the DIP 13

14 Tests and Measures Special Tests Instability Finger/thumb collateral ligament *Ballottement test *Ulnomeniscotriquetral dorsal glide *Watson test/scaphoid scaphoid shift test Scaphoid fractures Snuff box tenderness Pain with supination against resistance Pain with longitudinal compression of thumb * Indicates video available in text Tests and Measures Special Tests Muscle/Tendon rupture: Sweater Finger sign Test for extensor hood rupture/central slip rupture Boyes test 14