PTA 130 Fundamentals of Treatment I Wrist and Hand

Lesson Objectives Identify key anatomical muscles and structures in the wrist and hand Identify common tissue injuries, conditions and surgical interventions Analyze restorative interventions for common injuries, conditions, and surgical procedures Identify soft tissue specific mobilizations Identify flexibility, strengthening, functional, and stabilization exercises

Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. We are able to manipulate our environment through the use of our hands Finger and hand injuries can be among the most devastating if not well cared for because we use our hands for hundreds of daily activities.

Bones of the Wrist and Hand Bones of the wrist include: Distal radius, scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate How do you remember the carpal bones? 5 metacarpals 14 phalanges ????

Wrist Joints Made up of two compound joints Radiocarpal and Midcarpal Stability is provided by numerous ligaments Allows for the following motions: Flexion Extension Abduction: Radial deviation Adduction: Ulnar deviation

Hand Joints Intercarpal joints: Carpometacarpal joints: Stability provided by ligaments Carpometacarpal joints: Permit flexion, extension, abduction, adduction of metacarpals (MC) Metacarpophalangeal joints (MCP) Interphalangeal joints, Proximal and Distal (PIP, DIP) Convex proximal segment, concave distal segment Allows flexion and extension

Convex-Concave Arrangement of Carpal Bones

Fascia of the Hand Palmar fascia Dorsal fascia Superficial - extension of transverse carpal ligament and palmaris longus tendon; goes to fingers Deep - floor from thenar to hypothenar; serves to cushion and protect hand and maintain hand’s concavity Dorsal fascia Two layers but less dense

Common tissue injuries, conditions and surgical interventions

Referred Pain C6, C7, C8 nerve roots terminate in the hand Injury or entrapment of these nerves may occur anywhere along their course Median Nerve- compression at the carpal tunnel Ulnar nerve- compression in the ulnar tunnel Where will the patient experience symptoms?

Carpal Tunnel Syndrome Irritation of the synovial membranes around the tendons in the carpal tunnel This inflammation results in in pressure on the median nerve The median nerve travels from the forearm into the hand through a 'tunnel' in your wrist The bottom and sides of this tunnel are formed by wrist bones and the top of the tunnel is covered by a strong band of connective tissue or ligament

Carpal Tunnel Syndrome This tunnel also contains nine tendons that connect muscles to bones and bend your fingers and thumb These tendons are covered with a lubricating membrane called synovium which may enlarge and swell under some circumstances If the swelling is sufficient it may cause the median nerve to be pressed up against this strong ligament which may result in numbness, tingling in your hand, clumsiness or pain, all classic signs of carpal tunnel syndrome Treatment: Splinting, ROM/Stretches, modalities, isometrics exercises

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Joint Hypomobility Common causes: Rheumatoid arthritis Degenerative joint disease Swan-neck deformity Boutonniere deformity

Joint Hypomobility Protection Phase Control Pain and Protect Joints Patient Education Pain Management Splinting Activity modification Maintain Joint and Tendon Mobility and Muscle Integrity PROM, AAROM or active AROM Tendon-gliding exercises Multi-angle muscle setting exercises (isometrics)

Joint Hypomobility Controlled Motion and Return to Function Phases Increase Joint Play and Accessory Motions Joint mobilization techniques Improve joint tracking and pain-free motion Improve mobility, strength, and function Return to functional activities Conditioning exercises

Tendon-Gliding Designed to maintain or develop free gliding between tendons and bones in the wrist, hand, and fingers Adhesions between various structures can become restrictive or incapacitating The most common tendon-gliding exercises are: Flexor Tendon-Gliding Exercises Extensor Tendon-Gliding Exercises

Rheumatoid Arthritis (RA) The joint’s synovium becomes inflamed and swollen Swollen tissues stretch supporting structures of the joints such as ligaments and tendons.   As the support structures stretch out, the joints become deformed and unstable. Treatment: Splinting, ROM, stabilization and modalities

Swan-Neck Deformity Laxity of the PIP joint Hyperextension of the PIP and flexion of the DIP joints Treatment: Splinting/ ROM/Stretch, strengthening and modalities

Boutonnière Deformity An injury to the tendons in the fingers that usually prevents the finger from fully extending The result is that the PIP of the injured finger is in a flexed position, while the DIP remains in a hyperextended position This is the characteristic shape of a boutonnière deformity Treatment: Splinting/ ROM/Stretch, strengthening and modalities

Joint Surgery and Postoperative Management Goals of surgery: Relief of pain Restoration of normal or sufficient function of the wrist and hand Correction of instability or deformity Restoration of ROM Improved strength of the wrist and fingers Necessary for grasping and pinching

Joint Surgery and Postoperative Management Common surgical interventions: Wrist arthroplasty Metacarpophalangeal implant arthroplasty Proximal interphalangeal implant arthroplasty Carpometacarpal arthroplasty of the thumb Tendon rupture associated with RA: Surgical and postoperative management Pgs 600-615, K&C I think too much information-kp

K&C Fig 19.11 Dynamic extension splint following MCP Arthroplasty- permits active MCP flexion but maintains MCP joint in extension and sometimes slight radial deviation

Trigger Finger Can occur in one or more fingers, and can occur at different times in different locations. Trigger finger results from a discrepancy between the size of the tendon and the entrance to the tendon sheath. This discrepancy can be the result of localized inflammation or a nodular swelling on the tendon itself. When the size discrepancy between the tendon and the tendon sheath reaches a critical point, the tendon will experience resistance from the tendon sheath. This is experienced as a snapping of the trigger finger when relaxing a fist. Treatment: ROM/Stretches, Isometrics and modalities.

Trigger Finger

Dupuytren's Contracture An abnormal thickening of tough tissue (fibrous layer) underneath the skin of the palm and fingers May cause the fingers to flex Dupuytren's contracture is more common in men than in women Treatment: Splinting/ ROM/Stretch, strengthening and modalities.

Dupuytren's Contracture

Fractures Immobilized so ligaments of the joints are placed on stretch to reduce risk of contracture. Open reduction and internal fixation (ORIF) may be used with unstable fractures. Immobilization is used for only as many joints as necessary to stabilize fracture. Wrist fractures most commonly affect the hamate or pisiform.

Scaphoid Fracture A fall on an outstretched arm often results in a fracture of the scaphoid bone in the wrist. This small bone is one of 8 carpal bones in the wrist. The scaphoid sits below the thumb, and is shaped like a kidney bean. This complex bone has a unique and limited blood supply that can be easily disrupted by a fracture.

Scaphoid Fracture Due to poor blood supply, a fracture in the center of the bone can actually sever blood flow to the proximal portion of the bone. For this reason, scaphoid fractures need immediate diagnosis and treatment. Scaphoid fractures may heal very slowly or may not heal at all. Treatment: Splinting, Isometrics and modalities

Scaphoid Fracture

Scaphoid Fracture

Colles' Fracture A break at the distal aspect of the radius The radius is the most commonly broken bone in the arm A Colles' fracture typically occurs when the individual lands on an outstretched hand Treatment: Pain management, immobilization, stretching, ROM activities, isometrics and modalities

Colles' Fracture

Repetitive Trauma Syndromes/Overuse Syndromes Tenosynovitis Tendinitis Traumatic Lesions in the wrist and hand Sprains Lacerated flexor tendons Lacerated extensor tendons

Common Interventions for the Wrist and Hand Techniques for Musculotendinous Mobility Tendon-gliding and tendon-blocking exercises Scar tissue mobilization for tendon adhesions Palmar fascia release

Flexibility and Stretching Guidelines Apply joint mobilization before stretching Apply force precisely and in sequence from most distal to most proximal joint. When only one joint is stretched, others must be stabilized. Stretch one finger at a time. Wrist stretches begin with fingers and move to wrist.

What is the purpose of this activity?

What is being stretched?

Purpose of this activity?

Wrist and Hand Wrist and Hand Stretches- What is being stretched?

Tendon-Gliding Exercises Uses active muscle contraction and specific motions of the digits and wrist to maintain or develop mobility between connective tissue structures in the wrist and hand These are particularly important following immobilization when scar adhesions may have developed Tendon-gliding exercises may also help develop coordinated movement

Flexor Tendon-Glide Exercises Designed to maintain or develop free gliding between tendons and bones in the wrist, hand, and fingers Five positions: Straight hand Hook fist Full fist Table top Straight fist

Hook Fist Position

Full Fist Position

Straight Fist Position

Extensor Tendon-Glide Exercises Extensor tendons are more susceptible to adhesions than flexor tendons Similar movement patterns when compared with flexor tendon-gliding exercises

Extensor Tendon Gliding

Exercises to Develop and Improve Muscle Performance Techniques used during the controlled motion phase and return to function phase Used to strengthen muscles of the wrist and hand Examples of isometric exercises? Examples of isotonic exercises? Safe return to functional activities

Plyometric & Activity-Specific Ex. Plyometric exercises for the wrist and hand are similar to those used for shoulder and elbow Activity-specific exercises are determined by the demands of the patient’s sport and position or occupation Progress to specific patterns needed for ADL, job activities, hobbies, or recreational function Exercises should be adapted to meet the goals

Fine Motor Control Cones Blocks Begs Writing and typing Dealing cards Buttoning shirts and pants

Hand and Wrist Strengthening Exercises

Hand Therapy equipment

Orthopedic Special Tests

Tests for Tendons Finkelstein Test Used to determine the presence of DeQuervain’s or Hoffman’s disease, a tenosynovitis of the thumb A positive test is indicated by pain over the abductor pollicis longus and extensor pollicis brevis tendons. The patient makes a fist with the thumb inside the fingers. The examiner stabilizes the forearm and deviates the wrist toward the ulnar side.

Tests for Neurological Dysfunction Tinel’s Sign Testing for Carpal Tunnel symptoms at the wrist A positive tests causes tingling or paresthesia into the thumb, index finger and middle and lateral half of ring finger. The examiner taps over the carpal tunnel

Tests for Neurological Dysfunction Phalen’s Test A positive test is indicated by tingling in the thumb, index finger and middle and lateral half of ring finger Indicative of Carpal Tunnel Syndrome The examiner flexes the patient's wrists maximally and holds this position for 1 minute by pushing the patient's wrists together.

Tests for Neurological Dysfunction Reverse Phalen’s Test A positive test is indicated by tingling in the thumb, index finger and middle and lateral half of ring finger Indicative of Carpal Tunnel Syndrome The examiner extends the patient's wrists maximally and holds this position for 1 minute by pushing the patient‘s wrists together.

QUESTIONS?