Common hand injuries

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Hand therapy for common hand innjuries

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Common hand injuries

  1. 1. Dan PurtellHand / Occupational Therapist
  2. 2. Trigger finger / thumbDe Quervain’sMallet FingerPIPJ DislocationsDupuytren’s diseaseSimple #’s
  3. 3.  Not clearly / consistently defined Triggering of the digital flexor tendons at the fibrooseous tunnel formed by the metacarpal neck and A1 pulley In thumb the sesamoid bones may also be site of constriction Generally affects FDS rather than FDP because it lies directly under A1 pulley
  4. 4.  Primary trigger finger most commonly found in middle aged women, 2–6 X more than men Most commonly affects thumb (30- 50%) Then ring, long, index, & little
  5. 5.  Stenosing tendovaginitis Digital flexors susceptible to compression and shear at level of wrist and MP joints where they enter fibrooseous tunnels Blunt trauma or sustained tool use causing direct compression at A1 pulley Secondary TF in individuals with connective tissue disorders
  6. 6.  Discrepancy between the size of the A1 finger pulley lumen and tendon volume Hypertrophy of the pulley Poor tendon vascularity between A1 and A2 pulley makes tendons more susceptible to degenerative changes Tendons develop nodules from tenosynovitis
  7. 7.  Pain over site of tendon disorder aggravated by movement Symptoms vary from stiffness, to uneven movement, catching, blocking, or complete locking of tendon Pain can also be referred to distal joint or proximally up forearm Local swelling and thickening creating a palpable nodule over distal palmar crease (A1 pulley area) Local tenderness over A1 Patient may present with acute, subacute or chronic disorder
  8. 8. Patients often reluctant tohave cortico-steroid injection,even more reluctant to havesurgeryConservative measures shouldbe trialled for 4-6 weeks Thermoplastic hand based splint to limit MCP flexion (stops triggering through A1 pulley) Splinting works better for fingers than for thumbs
  9. 9.  Trigger Thumb - Thermoplastic barrel splint, IP joint at 10 degrees flexion Passive tendon gliding exercises Soft tissue massage of nodule and tendon. +/- Ultrasound +/- NSAID gel
  10. 10.  Cortisone injection for trigger fingers and thumbs relieves symptoms in 47% to 94% of affected digits.
  11. 11.  Most reported success rates are above 90%. Decompression of pulley to allow flexor tendon to glide Turowski, 1997: n=59, 97% complete resolution. No post-op nerve or tendon damage. Eastwood, 1992: Percutaneous release, n=35, 94% complete resolution. No complications. Not for thumb Thorpe, 1988: n = 53, 60% complete resolution, success correlated with surgeon skill.
  12. 12.  Oedema and wound management Scar management once wound healed Active tendon gliding exercises Stretching long finger flexors Strengthening only if necessaryConclusion Surgery remains the most successful treatment option Splinting and exercise program good alternative for those patients reluctant to consider a CSI or surgery
  13. 13.  de Quervain’s tenosynovitis is the entrapment tendonitis/tenosy novitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius
  14. 14.  Most cases it is a tendinopathy like trigger finger, tennis elbow etc that leads to tenosynovitis.
  15. 15.  Finklesteins test and clinical Hx confirm diagnosis.
  16. 16.  10 x more Common in Women than men. Common in pre-post natal and menopause. Often caused by repetitive strain or sustained posture of the wrist = strain on EPB and APL. Can occur post direct trauma to the area (rare)
  17. 17.  Treatment:  Steroid (won’t fix tendinopathy)  Splint and rest  Kinesio tape  Surgery (last resort)
  18. 18.  Surgery
  19. 19.  Any injury that causes a mallet deformity of the distal phalangeal joint
  20. 20.  Disruption of the terminal extensor tendon as it inserts into distal phalanx +/- fracture
  21. 21. MECHANISM OF INJURY Flexion force on extended DIP joint Direct crush Ball to tip of finger Often occurs in ball sports.
  22. 22. Signs & Symptoms Inability to extend distal phalanx actively Can still passively extend within pain limits Swelling Bruising Redness
  23. 23. Volar plate laxity = swan neck deformity
  24. 24.  depends on size of fragment and position of joint  If complete tendon rupture without fracture  If # is less than 30% joint surface → Conservative management - splinting If # greater than 30% joint surface or joint is significantly displaced needs surgical intervention
  25. 25.  Mallet splint reduces the fragment
  26. 26.  Splint DIP in hyperextension 6 – 8/52 Splint strictly 24/24 Clear instructions and demonstration re changing and wearing routine Advice re skin care PIP flexion exercises May return to sport with splinting
  27. 27.  Off the shelf stack splint often fit poorly Patient may end up with a lag at DIP joint
  28. 28.  Wean splint slowly after 6-8 weeks Keep on at night and for work a further 2 weeks Initially active flexion exercises to gain full flexion Start off 30 degrees flexion first week and increase slowly ie 20 degrees per week May take 4 – 6 weeks to regain full flexion If lag reoccurs → RESPLINT Passive flexion only added if needed
  29. 29.  Large Fragment Fixed with K-wire or 2
  30. 30. - Conservative approachonly if small fragment withno joint subluxation. - Splint for 6/52 in barrelsplintDIPJ can be free.- Larger fragments with jointsubluxation can be ORIF’d.
  31. 31. = Boutonniere Deformity = FFD of PIPJ = Very hard to fix
  32. 32.  Mechanism of Injury – hyperextension of the PIP joint with or without dislocation often initial injury seems trivial
  33. 33.  Dislocation of the PIPJ Avulsion # of middle phalanx Disruption of volar plate over the PIP joint
  34. 34. Signs & Symptoms• Swelling• Bruising• Pain volar aspect of PIP joint• Instability or pain on stress of volar plate• Decreased range of motion particularly flexion
  35. 35.  If dislocation without # OR If # fragment less than 30% joint surface→ reduce then manage conservatively in dorsal blocking splint (DBS)
  36. 36. Dorsal blocking splint• PIPJ in 30 degrees flexion•volar structuresoffstretch•slowly increaseout to neutral
  37. 37.  splint 4 - 6/52  weekly adjustments PIPJ from 30 flexion → full extension as stability increases• Coban for swelling• Flexion exercises within splint• Isolated FDP & FDS flexion important to prevent adherance to volar plate• Early mobilisation also assists oedema
  38. 38. • If collaterals involved need to buddy strap when out of splint• Tape/splint for work for 6 -8/52• Watch for FFC PIPJ in late stages → may need to include extension splinting
  39. 39.  If volar plate repaired post surgical management same but progress slower Occasionally flexion exercises are delayed if stability is a concern
  40. 40.  5th Metacarpal  Assess ROM and digit Rotation  Usually managed conservatively
  41. 41.  4th Metacarpal Spiral #  Assess ROM and digit Rotation  Tendency to rotate  Impacted #’s result in extension lag = poor function.
  42. 42. Treat conservatively in splintunless joint subluxationoccurring
  43. 43. Treat conservatively in splintunless joint subluxation orstenners lesion is present.- Usually characterised bylots of oedema, nil end pointof stability.- Very difficult to assess withcertainty- U/s scan to confirm

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