Wrist and hand injury .ppt

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  • 1.
    • Hand Injuries
  • 2. Hand therapy concepts
    • Tissue healing
    • Antideformity positoning
    • Complex Regional Pain Syndrome(CRPS)
    • PROM can be Injurious
  • 3. Tissue healing
    • Inflammation phase
      • vasoconstriction  vasodilation
      • Tx-- immobilization
    • Fibroplasia phase
      • Collagen fibers  wound’s tensile strength 
      • Tx-- AROM & splint
    • Maturation (remodeling) phase
      • Change architecture, collagen fiber  , tensile strength 
      • Tx—gentle resistive activity, corrective dynamic or static splint
  • 4. Antideformity positoning
    • deformity position
      • wrist flex, MP hyperext, PIP & DIP flex, thumb add & oppoition
      • MP extension  collateral ligament (slack- MP ext, taut- MP flex)
      • IP flexion: volar plate folds on itself
  • 5. Complex Regional Pain Syndrome(CRPS)
    • Defining features
      • Evidence of skin changes
        • Oedema, Sudomotor, Colour
      • Pain/hyperalgesia/allodynia
        • Not limited to nerve territory
        • Disproportionate to injury
  • 6. Terminology: RSD vs CRPS
    • RSD = traditional term
    • Complex regional pain syndrome
    • (CRPS) = more comprehensive term
      • Includes disorders not related to sympathetic nervous system dysfunction
    • CRPS I = RSD
    • CRPS II = causalgia (involves nerve injury)
    Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.
  • 7. 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
  • 8. 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
  • 9. PROM can be Injurious ?
    • disturb healing tissue
    • incite further inflammatory reaction
    • trigger CRPS
    • Management
      • low-load & long-duration splintng
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. Con’t
    • Physical Examination
      • posture, guarding & gesturing, atrophy, and edema
      • cervical screening: distal symptoms ( proximal problem cause)
  • 14. 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
  • 15. Con’t
    • Scar Assessment
      • location, length, width, height
      • Hypertrophic scar
      • Keloid
      • Tenodermodesis: adherence of skin and tendon
      • Immature & mature scar
  • 16. Con’t
    • Edema
      • Circumferential measurement
      • Volumeter
        • contraindication:open wound, percutaneous pining
    • Vascular Assessment
      • capillary refill (apply pressure)
  • 17. 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)
  • 18. Con’t
    • MMT
      • monitoring progress following peripheral nerve lesions
    • Sensibility
      • Semmes-Weinstein sensibility
      • Two-Point discrimination
  • 19.  
  • 20. Con’t
    • Dexterity and hand function
      • Moberg Pickup Test
      • Jabsen test of hand function
      • Purdue pegboard test
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. Lag vs Contrcature
    • Leg : a limitation of active motion in a joint that has passive motion available
    • Contracture : a passive limitation of joint
  • 25. 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 extended
      • Extrinsic : less PIP & DIP passive flexion with MP flexed
  • 26. 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
  • 27. Basic Interventions
    • Edema 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
  • 28.
    • 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
  • 29.
    • 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
  • 30.
    • Splint
      • Functional splint
      • Buddy straps
      • Dorsal MP flexion blocking splint
  • 31. Common Diagnoses
  • 32. Stiff hand
    • Cause: edema
    • Tx
      • gentle passive motion by joint traction(  joint surface gliding)
      • sustained holding
      • Splint
        • static splint
        • night splint
  • 33. Tendonitis
    • Cause
      • overuse, cumulative trauma disorder, tendonitis
      • inflammation of tendons and muscle-tendon attachment
      • repetitive use
  • 34.
    • Clinical feature
      • localized pain, tendon sheath swelling
      • secondary weakness( pain)
      • swelling: muscle belly, musculotendinous junction or origin
      • Vicious system: pain, instability, dysfunction
  • 35.
    • Evaluation
      • Pain: typical pain with AROM, resistance, passive stretch
      • Identify the activity causing pain
      • Ergonomic risk factors: forceful, rapid, repetitive movement
  • 36.
    • 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
  • 37. 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
  • 38. Common type
  • 39. Tennis elbow( lateral epicondylitis)
    • common involved: extensor carpi radialis brevis
    • Pain at lateral epicondyle and extensor wad
  • 40. Golfer’s elbow (medialepicondylitis)
    • common involved: flexor carpi radoalis(FCR)
    • pain at medial epicondyle and flexor wad
    • pain with resisted wrist flexion and pronation
  • 41. De Quervain’s disease( most common)
    • Abductor pollicis longus(APL), extensor pollicis brevis(1 st 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
  • 42. 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
  • 43. Extensor pollicis longus tendonitis (drummer body palsy)
    • less common
    • repetitive use of thumb and wrist
    • tendonitis of EPL
    • tendon rupture( rheumatioid, Colles’ fracture)
    • Management
      • forearm-based thumb spica
  • 44. 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
  • 45. 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.
  • 46. 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
  • 47. 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
  • 48. 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.
  • 49. Nerve injury
  • 50.
    • Multiple areas of neural pathology
    • Mechanism : acute or chronic compression , stretch ischemia, electrical shock, radiation, injection, laceration
  • 51. Nerve compression
  • 52. Carpel tunnel syndrome
    • A. Mechanism: overuse, congenital, trauma
    • B. Pathology: Compression of the median nerve in the tunnel
  • 53. 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
  • 54.
    • Evaluation
      • Tinel’s sign: tingling or eletric shock
      • Phale’s test: wrist lexion for 60 seconds
      • thenar atrophy of APB
  • 55.
    • 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 intervention
        • postoperative therapy; edema control, sar management, desensitization, nerve & tendon gliding, strengthing( ~6wks)
  • 56. Cubital tunnel ( second most common)
    • Ulnar nerve 在 medical epicondyle & olecranon
    • Mechanism
      • repeated elbow flexion
      • Trauma: fracture or dislocation of supracondylar or medial epicondylar
    • Typical complaint
      • aching or sharp pain( night) in proximal and medial forearm
      • decreased sensation
      • weakness
  • 57.
    • Evaluation
      • Atrophy in first web space, hypothenar eminence, medial forearm
      • Elbow flexion test( passive flex elbow, holding 60 seconds)
      • Grip & pinch/ MMT
  • 58.
    • Treatment
      • Conservative therapy: splinting( prevent sleeping with elbow 30 。 flex), padding elbow, positioning guideline
      • Ergonomic training, ulnar nerve gliding exercise
  • 59. Posterior interosseous nerve syndrome( radial n. compression)
    • Purely motor
    • Clinical picture—inability to extend MP of thumb, index, long
    • Can wrist extension( 僅 radial side)
    • Common site: supinator muscle
    • Treartment: maintain ROM, splinting to prevent deformity and promote function
  • 60. Nerve laceration
  • 61.
    • Nerve reconstruction
      • Neuroma ( disorganized mass of nerve fibers)
      • Significant nerve pain( elicited by tapping)
      • Hypersensitivity
      • Limit functional use
  • 62. 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
  • 63.
    • Treatment
      • Thumb abduction splint(maintain balance/ substitute for lost thumb opposition/ prevent overstretching of denervated muscles)
      • PROM to maintain joint mobility
  • 64. High median nerve lesion
    • Elbow level: denervation of FDP( 2,3), 1~4 FDS, pronator teres, pronator quadratus
    • Most important sensory nerve
    • Treatment: splinting( maintain PROM of pronation, MP flexion, IP extension, thumb CMC abduction)
  • 65. 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)
  • 66.
    • Treatment
      • Splinting: MP blocking splint
      • Sensory compensation
  • 67. High ulnar nerve lesion
    • Involvement of the earlier listed muscles
    • FDP of ring & small finger
    • FCU
    • clawing hand less apparent
    • The same low ulnar nerve lesion
  • 68. 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
  • 69. Low radial nerve lesion ( posterior interosseous palsy)
    • Preservation: brachioradialis & ECRL
    • Affected: extend wrist into radial deviation, MP extend, sensation on dorsal radial hand
    • Treatment: 同 radial nerve compression
  • 70. Fractures
  • 71. Distal radius fracture
    • Main 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
  • 72.
    • Therapy during immobilization
    • 例 Colles’ fracture
      • Cast immobilization: above-elbow with elbow 90 ° flexion/ prevent rotation for 3 wks
      • Biceps tightness
    • internal vs external fixator
    • Shoulder restrictions should avoid
  • 73.
    • 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
  • 74.
    • 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
  • 75. Nonarticular hand fracture
    • Distal phalanx
      • Crushing injury
      • Thumb, middle finger
    • Middle phalanx
      • Long immobilization time
      • Treatment: isolated FDS exercise
    • Proximal
      • Palmar apex
  • 76. Collateral ligament injury
  • 77.
    • 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
  • 78. Flexor tendon injury
  • 79. 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
  • 80. 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
  • 81. 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
    •  
  • 82.  
  • 83. 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
  • 84. 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
  • 85. Extensor tendon injury
  • 86.
    • Anatomy
      • Zone 1~7
      • 1 central band insert MP proximal end
      • 2 lateral band insert DIP proximal end
  • 87. Specific deformity
    • Mallet deformity (zone I, II), baseball finger
      • lateral band rupture
      • finger gutter
      • DIP extensor lag
    • Boutonniere deformity (zone III, IV)
      • central band rupture
      • finger gutter  isometric exercise
  • 88.  
  • 89.  
  • 90. Boutonniere Deformity
  • 91. Mallet Finger
  • 92.
    • Zone V, VI
      • immobilization or controlled early motion
    • Zone VII
      • development of adhesions
      • specific position and motion guidelines
  • 93. Tenolysis
    • 1 wks
    • AROM
    • Tendon gliding exercise
    • Place-hold exercise
    • Blocking exercise
    • PROM
    • Edema control
    • Splinting
  • 94.
    • 2~3 wks
    • maintain AROM
    • scar management
    • functional use of involved hand
  • 95.
    • 4~6 wks
    • Maintain AROM
    • Continue scar management
    • Increase grip and pinch strength
    • 7~8 wks
    • maintain ROM
    • maximize strength
    • initiate heavy resistive exercise
  • 96. 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.
  • 97. Swan Neck Deformity
  • 98. 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
  • 99. Intrinsics of the Hand - Thenar Group
    • Flexor Pollicis Brevis, Median Nerve
    • Adductor Pollicis, Brevis Median Nerve
    • Palmaris Brevis Median Nerve
  • 100. Thenar Group
    • Flexor Pollicis Brevis, Median Nerve
    • Opponens Pollicis, Median Nerve
  • 101. Intrinsics of the Hand - Hypothenar Group
    • Opponens Digiti Mnimi, Ulnar N.
    • Flexor Digiti Minimi, Ulnar N.
    • Abductor Digiti Minimi, Ulnar N.
  • 102. Intrinsics of the Hand - Muscles Controlling the Digits
    • Intrinsics: Lumbricales
      • R N. on palmar side
      • Left 2 Median N.
      • Medial 2, Ulnar N.
    • Interossei - Ulnar N.
      • Dorsal 4 ABD
      • Palmar (3) ADD
  • 103. 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
  • 104. Nerve Supply Hand
    • Radial N. Supplies Dorsal Arch
      • Supply for fingers
    • Ulnar Nerve, Superficial arch
      • supplies 1st dorsal interossei
  • 105. 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
  • 106. Balance of Finger Flexors
  • 107. Normal Alignment
    • Lunate = center finger
    • Sign Language A - all fingers point to lunate
    • On x-ray: scaphoid angled 45 deg (30-60 deg considered normal)