The hand & wrist Band 5 IST 28 th September 2009

Plan Anatomy – brief overviewAnatomy – brief overview Assessment (case studies)Assessment (case studies) –Altered hand sensation –Thumb pain –Wrist pain Common hand conditions and special testsCommon hand conditions and special tests Wrist fracturesWrist fractures

Anatomy

Anatomy

Assessment LookLook MoveMove FeelFeel Special testsSpecial tests

Case study 1: sensory change in the hand 63 year old female complains of a 9 month history of tingling, pain and numbness in both hands intermittently during the day and worse at night time.

History … what do you need to know?

Case study 1: sensory change in the hand History ……. What do you need to know? 24 hour pattern. Associated with activities?24 hour pattern. Associated with activities? Agg/easing factorsAgg/easing factors DistributionDistribution

Case study 1: sensory change in the hand –LOOK Muscle wasting Colour change Deformity Sympathetic response

Case study 1: sensory change in the hand MOVEMOVE Patterns of movement Motor function Active range of movement Pain on movement Trick movements

Case study 1: sensory change in the hand FEELFEEL Sensation distribution Sympathetic response Altered sensation Passive ROM

Case study 1: sensory change in the hand Special testsSpecial tests –Tinels Cubital tunnel Guyons canal Carpal tunnel Radial tunnel –Phalens –Wadsworth test –Froments test

Case study 1: sensory change in the hand Differential diagnosis Carpal tunnel syndrome Cubital tunnel syndrome Ulnar nerve compression at wrist level Radial tunnel syndrome

Case study 2: Thumb pain 46 year old male complaining of pain at the base of his right, dominant thumb following an intensive bout of gardening 2 months ago

History … what do you need to know?

Case study 2: Thumb pain History ……. What do you need to know? 24 hour pattern. Associated with activities?24 hour pattern. Associated with activities? Agg/easing factorsAgg/easing factors DistributionDistribution Pain on certain movements?Pain on certain movements? Pain level (NRS)Pain level (NRS) Trauma?Trauma?

Case study 2: Thumb pain LOOKLOOK Swelling Deformity Colour change Resting position

Case study 2: Thumb pain MOVEMOVE Active ROM Wrist and thumb Pain on movement? Stiffness

Case study 2: Thumb pain FEELFEEL Joint tenderness IP, MCP, CMC STT, RCJ,DRUJ Tendon tenderness APL/EPB, EPL, FCR ECR Temperature Sensitivity Laxity

Case study 2: Thumb pain SPECIAL TESTSSPECIAL TESTS –Grind test –Finkelsteins test –Hitchikers sign

Case study 2: Thumb pain Differential diagnosis: OA thumb (CMC joint OA) STT joint OA Radio-scaphoid (RCJ) OA De Quervain’s tenosynovitis

Case study 3: wrist pain 24 year old female massage therapist complains of 8 month history of left, non dominant ulnar sided wrist pain.

History ….. What do you need to know?

Case study 3: wrist pain History ……. What do you need to know? 24 hour pattern. Associated with activities?24 hour pattern. Associated with activities? Agg/easing factorsAgg/easing factors DistributionDistribution Pain on certain movements?Pain on certain movements? Pain level (NRS)Pain level (NRS) Trauma?Trauma?

Case study 3: wrist pain LOOKLOOK Colour Deformity Resting position Swelling

Case study 3: wrist pain MOVEMOVE Active wrist ROM Pain on movement? Patterns of movement

Case study 3: wrist pain FEELFEEL Passive ROM Over pressure Laxity / stability Palpation of joints RCJ, DRUJ, STTJ Palpation of soft tissues Cartilage Tendons Ligaments Temperature

Case study 3: wrist pain SPECIAL TESTSSPECIAL TESTS Stressing tendons DRUJ shear test DRUJ compression test TFC shear test TFC compression test

Case study 3: wrist pain Differential diagnosisDifferential diagnosis ECU tendonitis ECU instability FCU tendonitis DRUJ instability TFC tear or perforation GanglionHypermobility

other common hand conditions and assessment Dupuytren’s diseaseDupuytren’s disease InfectionInfection Trigger finger / thumbTrigger finger / thumb GanglionGanglion

Wrist fractures

Radial length or height measured on the PA radiograph as the distance between one line perpendicular to the long axis of the radius passing through the distal tip of the radial styloid. A second line intersects distal articular surface of ulnar head. This measurement averages mm.

Radial inclination or angle Radial inclination represents the angle between one line connecting the radial styloid tip and the ulnar aspect of the distal radius and a second line perpendicular to the longitudinal axis of the radius. The radial inclination ranges between 21° and 25°. Loss of radial inclination will increase the load across the lunate.

Radial tilt Radial tilt is measured on a lateral radiograph. The radial tilt represents the angle between a line along the distal radial articular surface and the line perpendicular to the longitudinal axis of the radius at the joint margin. The normal volar tilt averages 11° and has a range of 2°-20°.

Guidelines for non-acceptable reduction are (8):Guidelines for non-acceptable reduction are (8): Radial shortening > 5 mmRadial shortening > 5 mm Radial inclination < 10°Radial inclination < 10° Tilt on lateral projection > 10° dorsal tilt and > 20° volar tiltTilt on lateral projection > 10° dorsal tilt and > 20° volar tilt Intra-articular step-off 2 mm or moreIntra-articular step-off 2 mm or more Articular incongruity 2 mm or more of the sigmoid notch (articular surface of distal radius in DRUJ).Articular incongruity 2 mm or more of the sigmoid notch (articular surface of distal radius in DRUJ).

A comminuted fracture of the distal radius with marked dorsal displacem ent and rotation. 40 year old female, sustained during high impact RTC

Post k-wire fixation and immobilis- ation

there is a markedly foreshortened distal radius fracture, the articular element has been displaced and is over- riding the metaphysis on the dorsal aspect. 66 year old female, sustained from slip in garden

Following 7/52 POP surgery deemed “not essential” so decision left up to patient.

Wrist fracture management Oedema mangementOedema mangement Scar management (where necessary)Scar management (where necessary) StiffnessStiffness FunctionFunction StrengthStrength

Thank you