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Wrist/Hand Sx - Coggle Diagram
Wrist/Hand Sx
Radial sided Sx
Musculotendinous
deQuairvain's Tenosynovitis
MOI: repetitive injury (involving APL & EPB)
Presentation:
pain
swelling at radial wrist
radiation of sx into thumb
objective findings:
pain with fxnl tasks involving thumb FLX, ADD (stretch or eccentric pattern)
pain with ROM in stretch pattern of thumb and wrist
pain with MMT
(+) Finkelsteins
Tx:
reduce inflammation (oral medication, injection, modalities)
splinting early on to reduce use/friction
modification of form/activities to prevent recurrence
address faulty form/biomechanics that may have lead to sx
intersection syndrome
MOI: repetition injury
friction btwn 1st extensor compartment (APL & EPB) over the 2nd extensor compartment (ECRL & ECRB) via repetitive wrist EXT (i.e. weight lifting, raking, rowing)
Presentation:
pain
swelling
crepitus/"squeaking" 4-6 cm prox to Lister's tubercle
Objective Findings:
pain with MMT of mms involved
ROM limitation with stretch pattern of mm involved
TTP over intersection
Neurogenic
median neuropathies (carpal tunnel)
radial neuropathies
Intraarticular/bony
1st CMC
degeneration
arthritis
MOI: repetitive loading
Presentation:
OA pattern
crepitus
problems with gripping and pinching
Objective Findings:
Lmtd CMS FLX/EXT/ABD/ADD
(+) basilar grind test
ROM: opposition -- pain/limitation
grip/pinch(key/tripod) affected
Tx:
activity modification/correction
splinting
NSAIDs
Surgery
Gamekeeper's thumbs
MOI: HyperEXT + Valgus injury to 1st MCP
--> If UCL retracts = displaced
Presentation:
Objective Findings:
Possible swelling
laxity with valgus testing
valgus with accessory mobility testing
Tx:
Non-Displaced:
splinting
-casting 6x weeks
Displaced: surgery
Acute:
pain
swelling
bruising & tenderness ulnar side of 1st MCP
Chronic:
instability
pain with pinching
scapholunate
instability
dissociation
MOI: trauma -- loading through wrist in EXT + UDEV position
FOOSH
MVA
Presentation:
Pain over DORSAL/DORSORADIAL wrist
(+) click
swelling
limited ROM
limited/painful grip
Objective Findings:
AROM/PROM limitation
TTP snuffbox
(+) Watson's
Tx:
closed reduction with casting
splinting
surgical intervention
Fracture
Scaphoid
MOI:
FOOSH
direct trauma (MVA)
Presentation:
Pain
pain with gripping/pinching
swelling
tenderness over radial wrist (snuff box)
Objective Findings:
swelling
acute TTP in anatomic snuff box
pain with WB in wrist EXT
pain with FLX/EXT
deviations at wrist
gripping
Tx:
Non-displace:
casting/splinting 10-12 weeks total
displaced/non-union: Surgery
distal radius
Presentation:
after immobilization/surgery:
global stiffness
weakness
possible hypersensitivity
Acute:
pain
swelling
possible deformity,
ROM limitations
objective Findings:
acute:
swelling
limited ROM
healed
COLLES FX = dorsal displacement:
lmtd PRON
SMITHS FX = ventral displacement:
lmtd SUP
Tx:
splinting
surgery
SMITHS FX: distal fragment volarly/ventrally tilted/displaced
COLLES FX: distal fragment dorsally tilted/displaced
Considerations:
Nerve injury
(+) Ulnar variance
concomitant carpal instability/fx
Ulnar Sided Sx
musculotendinous
ECU tendinopathy
MOI:
repetitive loading with gripping and ROT (i.e. racket/bat/club sports)
Presentation:
Pain
swelling @ ulnar sided wrist
"snapping"/"popping" with SUP/EXT
Objectieve findings
pain with palpation
pain and weakness with MMT ECU
PROM RDEV + FLX bias painful/limited (stretch bias)
FCU tendinopathy
MOI:
repetitive loading through sport (racquet) or work (laborers)
Presentation: @ ulnar side of wrist
pain
swelling
Objective Findings:
pain with palpation
Pain and weakness with MMT FCU
PROM RDEV + EXT bias painful/limited (stretch bias)
Tx:
reduce inflammation (oral meds, injection, modalities)
immobilization early on to reduce use/inflammation
modification of form/activities to prevent recurrence
address faulty form/biomech that lead to sx
Surgical intervention if non-responsive
Neurogenic
Ulnar neuropathy
intraarticular/bony
fracture
pisiform
hamate
MOI:
FOOSH
direct trauma (stick sports)
RARE (< 1% of carpal fxs)
Presentation:
pain
swelling
tenderness over ulnar wrist (Volar side)
Pain/weakness c gripping
Objective Findings:
Swelling
acute TTP over hamate/pisiform
Tx:
non-displaced: immobilization 6-8 weeks
displaced/non-union: surgical excision
ulno-carpal abutment
MOI:
(+) ulnar variance
excessive impact between distal ulna and carpals (lunate usually)
Presentation:
ulnar sided pain @ distal radioulnar joint (DRUJ)
pain with WB
possible Hx c injury!
objective findings:
pain with UDEV ROM
pain with WB
(+) TFCC compression
(+) Push off test
pain/weakness with grip in PRON vs. SUP (due to dynamic variance)
Tx:
Non-operative:
immobilization
NSAIDs
activity modification
Operative:
ulnar osteotomy
resection
fusion
Triangular fibrocartilage complex (TFCC) injuries
MOI:
presentation:
Ulnar sided wrist pain
pain with PRON/SUP
pain with loading through wrist
clicking
Objective Findings:
(+) Fovea sign
pain with UDEV (compression) & RDEV (traction) ROM
(+) push off test
TFCC Compression
Treatment:
Type 1 (all) & Type II (first line):
immobilization
NSAIDs
injection
IF fails or falls under specific classification: surgery
Type II:
degenerative due to (+) ulnar variance or impaction
Type I:
FOOSH + PRON
Ulnar traction injury
Fingers/Digits
Musculotendinous
Trigger finger
MOI:
multifactorial (DM, RA)
related to occupation/overuse (weak evidence)
Presentation:
start = painfree clicking/catching with finger EXT/FLX
progression = painful/catching/locking with finger EXT/FLX
@ MCP or PIP joint
Tx:
immobilization
tendon gliding after immobilization
activity modification
injection
surgery
Mallet Finger
MOI: extensor tendon rupture @ distal phalanx after FORCED FLX while muscle active
Presentation: inability to EXT @ DIP
Objective findings:
loss of DIP EXT AROM
PROM ok
Acute:
swelling may be present
Tx:
immobilization of DIP in EXT 6-8 wks
Neurogenic
Median neuropathy
Radial neuropathy
Ulnar neuropathy
Intraarticular/bony
Collateral ligament injury
MOI:
Trauma @ MCP/IP joints
repeated stress @ MCP/IP joints
"jammed finger"
result of dislocation
Presentation:
pain
instability with pinching
Swelling (if acute)
Objective findings:
swelling at joint
TTP over medial/lateral aspect of involved joint
(+) Varus/Valgus Stress Test (hypermobility into Varus/Valgus)
Tx:
immobilization (buddy taping) 3-6 weeks
Arthritis
Osteoarthritis
MOI:
Presentation: PRIMARY
OA affects DIPs, PIPs, 1st CMC
spared MCPs
stiffness after inactivity
stiffness improves with motion < 30 min
Dominant hand
Objective findings:
Herberden's nodes (enlargement of DIP)
Bouchard nodes (enlargement of PIP)
mobility deficits (PROM/AROM) at affect joint
crepitus
grip weakness
Tx:
mobilization
HEP
joint protection
splinting (CMC)
medication
injections
surgery
Primary:
Degeneration over time
Secondary:
degeneration after trauma
Rheumatoid arthritis
MOI: systemic
Presentation:
swelling
symmetric stiffness in arm
stiffness after immobile lasting >30 mins
fatigue
low grade fever
can have other joints involved
Objective Findings:
bone erosion
synovial inflammation
ligamentous laxity and deformation (swan neck, ulnar drift) if longstanding
Tx:
medication
joint protection
activity modification
bracing may be needed
Deformities
Boutonniere
MOI:
rupture of central slip at the PIP joint due to trauma
laxity due to RA
Presentation:
after trauma:
immediate deformity
progress to deformity within weeks
acute:
swelling @ PIP joint
Objective Findings:
FLX of PIP Joint
HYPEREXT of DIP joint
Tx:
Immobilize PIP in EXT via splint 6-8 wks
activity modification
surgery
Swan Neck
MOI:
TRAUMA: volar plate disruption
ALSO: ligamentous laxity
MOST COMMON: RA (lax volar plate)
Presentation:
locking of finger into: PIP HyperEXT + DIP FLX
"snap" into deformity (FLX --> EXT)
Objective findings:
HyperEXT PIP joint
FLX of DIP joint
hypermobility with dorsal glide @ PIP joint
Tx:
Immobilization via Watson ring/splint
Activity modification
surgery
Midline/Central Sx
Intraarticular/bony
Scapholunate dissociation
MOI:
traumatic loading through wrist EXT + UDEV position (FOOSH, MVA)
Presentation:
pain over DORSAL/DORSORADIAL wrist
(+) click
swelling
lmtd ROM
grip painful/limited
Objective findings:
AROM/PROM limitation
TTP snuffbox
(+) Watson's
Treatment:
closed reduction with immobilization
surgical intervention
Mid Carpal instability
MOI:
traumatic loading
repetitive loading
ligament lesion most common
Presentation:
Pain and instability when loading wrist ("giving way")
Lunate/Triquetrum most affected --> presents Central --> ulnarly
Objective findings:
Acute:
swelling
limited ROM
hypermobility with ballotment testing (carpal accessory mobility testing)
Tx:
immobilization
activity modification
surgical
Neurogenic
carpal tunnel syndrome
