1. PTA 130 Fundamentals of Treatment I
Wrist and Hand

2. 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

3. 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.

4. 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
????

5. 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

6. 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

7. Convex-Concave Arrangement of Carpal Bones

8. 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

9. Common tissue injuries, conditions and surgical interventions

10. 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?

11. 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

12. 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

13. Carpal Tunnel Syndrome

14. Carpal Tunnel Syndrome

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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

23. 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

24. 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 , K&C
I think too much information-kp

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

26. 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.

27. Trigger Finger

28. 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.

29. Dupuytren's Contracture

30. 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.

31. 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.

32. 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

33. Scaphoid Fracture

34. Scaphoid Fracture

35. 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

36. Colles' Fracture

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

39. 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

40. 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.

41. What is the purpose of this activity?

42. What is being stretched?

43. Purpose of this activity?

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

45. 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

46. 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

48. Hook Fist Position

49. Full Fist Position

50. Straight Fist Position

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

52. Extensor Tendon Gliding

53. 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

58. 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

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

60. Hand and Wrist Strengthening Exercises

61. Hand Therapy equipment

62. Orthopedic Special Tests

63. 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.

64. 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

65. 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.

66. 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.

67. QUESTIONS?