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62 Cards in this Set
- Front
- Back
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DJD of the hand :
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• Generally effects 1st metacarpal joint, radiocarpal joint and theinterphalangeal joint. It is 10 times more likely in women 50-60 yearsold than men.
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DJD of the hand : Causes
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- Cartilage degeneration in load bearing areas- Structural joint change- Abnormal function- Secondary to trauma - Secondary to De Quervains
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DJD of the hand : Assessment
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- Insidious intermittent ache with stiffness and swelling
- Increased inflammation and pain - History - Palpatory tenderness, swelling, crepitus, motion changes- Decreased ROM |
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DJD of the hand : Treatment
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- Adjustments/mobilisations (be careful with adjusting. However subluxations are usually found along with degeneration)- STT - Heat, pain control, bracing -ROM and stretching exercise, gentle strengthening exercise(resistance PNF exercise) - Nutrition supplementation (Omega 3) - Decrease aggravating factors
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Rheumatoid arthritis:
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• Usually effect 3 times more females under the age of 40.• It hits distal joints symmetrically, which produces bilateral pain• It starts with joint destruction and tissue change, which in turn leads toinstability, impairment and deformity• Starts distally then moves proximal and finally into the trunk. So maystart in hand and travel to the elbow and shoulders
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Rheumatoid arthritis: Cause
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- Joint change which results in hypermobility and leads toankylosis
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Rheumatoid arthritis: Assessment
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- Insidious, stress - Morning pain, stiffness, swelling - Soft tissue swelling = Rheumatoid - Bony swelling = DJD - Deformities of the wrist and hand
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Rheumatoid arthritis:
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- Palpatory ‘boggy’ nodules - Hypermobility - ROM decreased - Neurological S/S - Digital imaging
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Rheumatoid arthritis: Treatment
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- Acute (soft approach) vs Remission (little bit more aggressive,but be careful) - Adjust/mobilise- STT (gentle NIMMO)- Pain control-Immobilisation and graded exercise (These two need to be balanced out)- Nutritional support (Omega 3)
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Psoriatic arthritis:
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• Males to females are equally effected. It is most commonly found inindividuals between the ages of 20-50 years of age.
• 15% of people who develop the disease occurs within 5 years ofhaving a skin condition • Similarly to Rheumatoid it effects peripheral joints, however it causesdestruction of the transverse cervical ligament leading to instabilitybetween C1 and C2 |
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Psoriatic arthritis: Assessment
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- Asymmetrical and bilateral pain
- Psoriasis on the scalp and fingernails - Swelling and pain the seems no specific and not right - Decreased ROM - Dx imaging |
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Psoriatic arthritis: Treatment
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- Acute (soft) vs Remission (increase workload)
- Aim to decrease pain and inflammation as well as maintain function and prevent exacerbations- Same as Rheumatoid |
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Hypertrophic Arthritis:
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• Develops when people have severe interthoracic problems.
• More likely in males 40-60 years old • This is a severe condition and when you see it get patient out of your office and to a GP ASAP |
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Hypertrophic Arthritis: Assessment
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- Digital clubbing (swelling on the edge of bone)
- Nail contour - Arthritic symmetrical system - Vital signs may have changed - Digital imaging |
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Hypertrophic Arthritis: Treatment
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- Referral
- Aim to decrease pain and inflammation as well as maintainfunction and prevent exacerbations - Same as Rheumatoid |
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De Quervains (Stenosing tenosynovitis):
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•Occurs from inflammation of the synovial sheath around extensorpollicis brevis, abductor pollicis longus and extensor pollicis longus.
• Most common in females between the age of 30-50 years (computerwork), and also occurs commonly in people who perform manual jobsand play sports that require them to grip an object. |
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De Quervains (Stenosing tenosynovitis):
Causes |
- Inflammation results in a decrease in synovial sheath, whichimpairs tendon movement and causes tendonitis
- Inflammation may decrease nutrition and affect extensorretinaculum - Overuse repetitive motion - May result in crepitus and trigger finger - Associated with metabolic disorder such as diabetes |
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De Quervains (Stenosing tenosynovitis):
History |
- Sport ,work type and practices
- Pain and swelling over radial styloid - Muscle weakness and crepitus |
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De Quervains (Stenosing tenosynovitis):
Examination |
- Palpatory thickening and tenderness
- Thumb/wrist ROM painful -Grip and pinch decreased in strength - Finkelsteins test (+) |
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De Quervains (Stenosing tenosynovitis):
Treatment |
- Treat pathology as well as overuse component first - Adjust wrist and hand as well as whole kinetic chain - STT to weak muscles (Myofascial release to restore function towhole system) - At home perform ice massage-Splinting- Stretching and strengthening activities- Nutritional supplements (Omega 3)- Ergonomic and sport advice (bring in hammer or racket and teach how to hold)- Relative rest
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Trigger finger
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- Nodular scar tissue which tendon gets caught on- Occurs in the digital flexor retinacular sheath and most commonly effect the ring finger or thumb
- Cycle of overuse leads to a decrease in lubrication, which causes inflammation which causes tendonitis which produces a constriction andnodular formation which causes locking in flexion - In initial stages can unlock, however it progressively gets worsestill its stuck |
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Trigger finger: History
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- Snapping and clicking in 1st, 4th and 5th digits - Final stage locking
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Trigger finger : Examination
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- Palpable nodule and click
- Altered ROM - Decreased extension |
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Trigger finger: Treatment
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Early stages: - Adjust/mobilise- STT muscle/tendons- Electrical modalities- stretching and ROM exercises - More times then not have to refer for surgery
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Dupuytren’s contracture:
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• 5 times more likely in males under 50
• Most common in northern European Caucasians |
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Dupuytren’s contracture: Causes
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- Fibrosis and thickening of palmar fascia and skin
- Finger flexion contracture upon extension - Associated with Gout, diabetes, TB, liver disease, invalids, alcoholics - Most common on ulnar side of hand |
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Dupuytren’s contracture: Assessment
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- Painless thickening- palpatory nodules and fibrosis- Flexion deformities-Immobilisation with increase contracture
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Dupuytren’s contracture: Treatment
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- Trial of conservatory therapy
- Adjust- STT - Tape/brace - Exercise - Referral for surgical release |
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Tendon injuries:
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• This is the most common injury you will see. Very prominent in ballsport injuries
• There are four common tendons in the wrist region which aredamaged. • Tendonitis is found proximal to or at insertion • Mallet is trauma to extensors at the distal interphalangeal joint, and iscommon in ball sports • Boutonniere is trauma to extensors at proximal interphalangeal joint |
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Tendon injuries:
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- Mallet/Boutonniere: Rheumatoid
- Flexor tendonitis (FCU: pain over ulnar, FCR: pain 2nd MC) - Extensor tenosynovitis: overuse - Avulsion fractures |
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Tendon injuries: Hx
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- Trauma or overuse (sport/work/leisure)
- Pathology |
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Tendon injuries: Examination
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- Deformity of finger if there is a grade 3 tear or avulsion
- Change in ROM - Tenderness and swelling - Weakness and pain - Digital imaging for fracture |
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Tendon injuries: Treatment
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- Ensure proper function to area- Grade 3 injury, need to use a splint into an extended position, to approximate tissue and promote scar tissue formation and preventdeformity - STT- Ice massage and electrical modalities- Tape/brace- Relative rest (can be training in a different area, such as doing weights or cardio. Look for alternatives)- ROM and stretching and strengthening exercises (need to get it right, stretch too much could cause more damage to the tendon)- Improve function along kinetic chain- Nutritional support
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Ganglion
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• Circular tissue which is rather superficial and happens at the tendonsheath or the joint.
It is just a benign synovial cyst • Can occur post trauma or spontaneously. Can cause a blockage, painand decreased range of motion |
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Ganglion: Causes
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- Associated with DJD and giant tumors - Occur after trauma, and if you look back into the history a patientmay have started doing something differently with their dailyprocedures which has lead to their development - If it form on lateral pisiform it can cause ulnar neuropathy
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Ganglion: Exam
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- Can be no pain, or there could be pain and impairment- Get patients to contact muscles and see if the ganglion moves with the tendons- May cause a decrease in ROM- MRI or Ultrasound
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Ganglion: Treatment
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- If its not painful then leave it alone- Sudden high force (wack with a bible) or continuous (tape a coin to it)
- Surgical removal - Don’t get injected, it happens, but has a high chance of becominginfected - Reoccurrence is high |
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Raynaud’s phenomenon:
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• Sufferers hands go totally white due to lack of blood to area, then will gothrough a blue phase, then it will go back to bright red, almost purple
• Goes from pallor(white, looks dead, cold and painful)-> cyanosis (blueoxygenated blood state)-> vasodilation • In some patients it’s an emotional/stress trigger, in most though its achanging temperatures and the body responds by shunting blood to thecore expecting it to be cold. •More common in females |
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Raynaud’s phenomenon: Cause
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- Cold induced, shunting of blood from areas
- Stress or emotion - In older patients may be an autoimmune disfunction - Collagenated vascular disease |
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Raynaud’s phenomenon: Hx
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- Patient will report slight provocation - Goes cold -> Numb/painful/tingling -> warm/throbbing. Takes 20-30 minutes to go through the phases - It can present inconsistently, eg. it can be one finger, or wholehand
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Raynaud’s phenomenon: Exam
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- Unless under an attack you won’t notice any abnormalities
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Raynaud’s phenomenon: Treatment
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- Ensure function to area by adjusting kinetic chain- Mobilisation techniques such as wrist scissors, hand scissors. Good for improving circulation short term
- STT to nerve tunnels- Seek warmth during attack - Eliminate nicotine - Stress reduction - Biofeedback (train autonomic ns to reverse attack) |
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Carpal dislocation:
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• Rare, but most common is lunate dislocation after foosh, when thelunate dislocates in relation to capitates in hand. Called a perilunatedislocation.
• Dislocation is posterior for most carpals, but the lunate is anterior • Due to median nerve being compromised need to refer •May be involved after dislocation in rehabilitation as it is a grade 3 tearof ligaments and structures surrounding it |
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Carpal dislocation: Hx
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- Foosh injury
- Deformity |
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Carpal dislocation: Assessment
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- Post trauma stability decreased - ROM decrease - Neurological exam - Digital imaging, xray MRI
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Carpal dislocation: Treatment
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- Post trauma care. Goal is stability and alignment, restore normal ROM and strength- Ensure proper function. Find what needs adjusting, but he careful of dislocation- STT - Brace- Nutrition- Exercise- Brace, temporary, don’t allow patients to become dependent upon it- Relative rest
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Dislocations of fingers and thumb:
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• 1st metacarpal phalangeal joint is quite common as well as 5thinterphalangeal joint
• Cause grade three tears to ligaments and supporting structures • Need to be aware of fractures • Persistent instability of the joint can lead to medical subluxations • Need to be aware of neurovascular damage |
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Dislocations of fingers and thumb: Exam
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- Observation (length) - Orthopaedic test - Motion palp - Neurological/vascular changes - Diagnostic imaging
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Dislocations of fingers and thumb:
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- Reduction (sometimes get the patient to do it themselves)
- Relocate by basically tractioning the joint- Immobilise, tend to put more into a flexion splint and buddy tape so its hooked up with another finger- Motion exercises as it is healing- Nutrition, anti-inflammatory- If sore for a long period after incident then need to go in and do mobilisation. Use finger rotation and side bend under a traction load.Take thorough ROM - Cross friction on co-lateral tissue where pain is present. Do untilpain disappears, be persistent and keep doing - If its unstable need to refer for surgery |
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Wrist fractures:
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• Common in 50+ due to osteoporosis• Most common is after a FOOSH injury. After any foosh refer for Xray• Several combinations; Colles (fracture distal radius), Smith(oppositeof colles on radius, fall on flexed wrist), Monteggia(fracture of theproximal 2/3 of ulnar with dislocation of radial head), Galeaszzi (breakin distal radius and ulnar dislocation)• Sometimes with the fracture the dislocation is not looked at andmissed• With fractures going to have associated neurovascular complicationsand carpal tunnel
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Wrist fractures: Treatment
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- Referral for immobilisation - Once in cast try to get them to do finger ROM and upperextremity ROM to limit the immobilisation and maintain function inthese joints cast - Nutrition- Spinal adjustments- Adjust kinetic chain as its under abnormal stress- Rehabilitation program to maintain stability and strength whilst in - STT , maintain muscle balance- Progressive exercise
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Carpal Fracture:
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• Most common is scaphoid, and then hamate(common in golfers)
• Occur after FOOSH injury•Fracture can effect blood supply to proximal pole • If there is scaphiod fracture then also look for forearm fracture |
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Carpal Fracture: Examination
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- Swelling over radial aspect, particularly anatomical snuff box - Pain in the area - Compression test (radial deviation and flexion compress scaphiod, ulnar deviation and extension compresses triquetrum andTFCC) - Diagnostic imaging, if you feel it is a fracture and doesn’toriginally show up then wait 10 days for calcification to form and xrayagain
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Carpal Fracture: Treatment
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- Immobilisation- Healing treatment (ultrasound, nutrition)- Rehabilitation- Co-management with orthopaedic surgeon
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Finger and thumb fracture:
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• Lead to functional loss and rotation deformities• Adjacent injury of dislocation
• Types; Metacarpal (bennet, mc shaft, boxers, bar room), Phalangeal(distal>proximal>middle) |
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Finger and thumb fracture: Exam
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- Observation, swelling, pain
- Passive wrist flexion and rotation - Diagnostic imaging |
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Finger and thumb fracture: Treatment
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- Immobilisation with early ROM- Surgery- Rehabilitation
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Kienbock’s disease:
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• Avascular necrosis of the lunate
• Males 9x more likely, most common between 20-40 years • Vascular vulnerability |
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Kienbock’s disease: Causes
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Abnormal stress on joint
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Kienbock’s disease: Hx
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- Acute/chronic trauma
- Occupation - Weakness and pain in grip |
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Kienbock’s disease: Exam
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-Pain and dysfunction- Limited ROM- Palpatory pain- Weakness and pain in grip- Finkelsterers sign- Diagnostic imaging
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Kienbock’s disease: Treatment
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- Referral
- Immobilisation |
