Evaluation of Orthopedic and Athletic Injuries

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					Evaluation of Orthopedic and Athletic Injuries
ATP 305
Wrist and Hand Injuries


  I. Wrist Pathologies
          a. Sprain
                  i. MOI
                       1. Wrist being stretched past its available range of motion
                 ii. S&S

                 iii. Special Tests
                         1. Wrist glides

           b. TFC Injury
                 i. MOI

                  ii. S&S
                        1.   Pain on ulnar side of wrist that does not go away
                        2.   No appreciable swelling
                        3.   Limited AROM, PROM - especially extension and ulnar deviation
                        4.   Painful RROM

                iii. Treatment
                        1. refer to physician
           c. Neurological Conditions
                  i. Carpal Tunnel Syndrome
                        1. MOI
                               a. Repetitive trauma to flexor tendons, causing tenosynovitis,
                                   resulting in fibrosis of the synovium and closing off of the carpal
                               b. degeneration of the carpal bones that border the canal
                               c. acute smack
       2. S&S

       3. Special Tests

       4. Treatment
              a. Stop irritating activity
              b. NSAID’s
              c. Possible splinting at night
              d. Strengthening
              e. Surgery for nonresponsive cases
ii. Claw Fingers
       1. MOI

        2. S&S
              a.   Hyperextension of MCP
              b.   Flexion of PIP and DIP
              c.   Loss of normal cupping in hand
              d.   Loss of transverse and longitudinal arches
iii. Ape Hand
        1. MOI

       2. S&S
              a. Wasting of thenar eminence
              b. Thumb falls in line w/ other fingers (extensors pull thumb back to
              c. Unable to oppose or flex the thumb
iv. Drop Wrist
       1. MOI

       2. S&S
            a. Extensor muscles of wrist are paralyzed
            b. Can not extend wrist or fingers
                v. Bishop’s Deformity
                      1. MOI

                      2. S&S
                            a. Wasting of the hypothenar eminence, interossei, and two medial
                                lumbrical muscles
                            b. Flexion of the fourth and fifth fingers occurs
               vi. Volkmann’s Ischemic Contracture
                      1. MOI

                       2. S&S
                            a.    Reduced distal pulse
                            b.    Swollen arm/wrist/hand w/ complaints of pressure
                            c.    Cold
                            d.    Decrease sensory
                            e.    Flexed wrist and fingers
         d. Fractures
                 i. Colles’ Fracture
                ii. Smith fracture (Reverse Colles’)
               iii. MOI

               iv. S&S
                      1. Heard a “snap”
                      2. Immediate pain
                      3. Possible deformity
                      4. Loss of function and range of motion
                v. Treatment
                      1. Splint and send to ER
                      2. Check distal pulses – rule out vascular compromise
                      3. Capillary refill
                      4. Watch for shock
II. Hand Pathologies
        a. Fractures
                i. Scaphoid
                      1. MOI

                       2. S&S
                            a. Pain and ache in the anatomical snuff box
                            b. Painful to palpation
                            c. AROM PROM painful in end rangeflexion, extension and radial
                            d. Decreased grip strength
                            e. First ray compression = painful
              3. Special Tests
                      a. X-ray – with a 2 week follow up
                      b. Bone scan
                      c. MRI
                      d. CAT scan
              4. Treatment
                      a. Stabilize wrist and thumb with short arm cast
                      b. Surgery if a non-union occurs
       ii. Hammate
              1. MOI
                      a. Fall on an outstretched hand
              2. S&S
                      a. Palpable pain in hypothenar eminence
                      b. Decreased grip strength
              3. Note
                      a. Ulnar nerve and artery are very close – take care to check ulnar
                          nerve dermatomes and distal pulse (cap refill)
                      b. Often causes a non union fracture due to pull of muscles
                      c. Racquet and bat sports – may take a few months before equipment
                          is comfy in hand.
      iii. Metacarpal fractures
              1. MOI
                      a. Axial compression of the shaft of the bone (i.e. punching a wall)
              2. S&S
                      a. Heard a “snap” or “pop”
                      b. Immediate and local pain
                      c. Gross deformity possible
                      d. Tenderness with palpation
                      e. Swelling on dorsum of hand
                      f. Crepitis
                      g. Limited ROM from pain
                      h. PATIENT UNABLE TO MAKE A FIST
              3. Type
                      a. Boxer’s fracture – fx of the 5th met. shaft
              4. Special Tests
                      a. Long bone compression test
              5. Treatment
                      a. If finger isn’t rotated – casting for 4-6 weeks
                      b. Rotated finger – open fixation – casting 4-6 weeks
b. Perilunate and lunate dislocation
        i. MOI

       ii. S&S
             1. Pain along radial side of hand
             2. Possible visible deformity
                   a. Lunate dislocation
                                 b. Perilunate dislocation

                       3. Paresthesia in the middle finger
               iii. Special Tests

              iv. Treatment
                      1. If not treated – Kienbock’s disease
                             a. S&S
                                       i. loss of ulnar deviation
                                      ii. tenderness
                                     iii. pain
                                     iv. swelling over thelunate
                                      v. decreased grip strength
                                     vi. weak wrist extension
                      2. Closed reduction is usually attempted, if the lunate fails to relocate, then
                         the lunate is pericutaneously pinned, then casted for 4-6 weeks.
         c. Dupuytren’s Contracture
               i. MOI

               ii. S&S
                     1. fixed flexion contracture of the MCP and PIP joints.
                     2. Usually seen in the 4th and 5th digits where the skin is adhere to the fascia.
         d. Ganglion
                i. MOI

                ii. S&S
                      1. Can be located on either the dorsum or palmar surface of the wrist.
                      2. Painless and does not limit range of motion
                      3. Jelly-like colorless fluid that is freely moveable and palpable

III. Finger Pathologies
          a. Dislocations
                  i. Types
                        1. MCP

                        2. PIP

                       3. DIP
                ii. Treatment
                       1. Acute – splint and send for x-rays and reduction by a physician
                       2. long term: PIP – splint 30 degrees flexion, DIP – neutral = 3 weeks
b. Collateral ligament injuries
       i. MOI
               1. varus/valgus
               2. compressive
      ii. S&S
               1. pain and swelling around joint
               2. limited ROM due to pain
               3. possible laxity with varus/valgus stress testing
               4. ecchymosis on palmar surface
               5. deformity with dislocations
     iii. Special Tests

     iv. Treatment
             1. x-ray for possible fx.
             2. Splint in slight flexion
             3. Gentle ROM and strengthening as pain decreases
c. Boutonniere Deformity
      i. Mechanical damage

       ii. MOI
             1. Rapid forceful flexion of the PIP
      iii. S&S
             1. Flexed PIP, extended DIP and MCP
             2. inability to actively extend PIP
             3. pain along dorsal surface of the PIP
      iv. Treatment
             1. PIP splinted in extension for 6-8 weeks w/ the DIP left free to move
d. Pseudo-Boutonniere Deformity
        i. Mechanical damage

       ii. MOI
             1. Hyperextension of the finger causes the volar plate to split along the
                finger’s long axis and slide dorsally past the joint’s axis.
      iii. S&S

e. Swan Neck Deformity
      i. MOI

       ii. S&S
             1. Flexion of the MCP and DIP
             2. Extension of the PIP
f. Trigger Finger
       i. MOI

       ii. S&S
              1. athlete attempts to flex finger – finger sticks – then let’s go w/ a snap
              2. tendon thickens and can possibly form a nodule that will not allow the
                   tendon to slide w/i the annular ligaments
              3. finger can become locked in flexion, must passively extend
              4. seen most commonly in 3-4th fingers of middle aged women
      iii. Treatment
              1. cortisone injections
              2. ultrasound
              3. friction massage
              4. NSAID’s
              5. surgery to cut annular ligaments proximal to palpable nodule
g. Finger fractures
        i. Distal phalanx most commonly fx, especially the middle finger and thumb
       ii. Most common type of fracture is an avulsion fx of the extensor or flexor tendons
      iii. MOI

      iv. S&S
             1. an audible “snap”
             2. pain at fx. Site
             3. gross deformity
             4. edema and ecchymosis
             5. lack of AROM
             6. painful palpation
       v. Treatment
             1. same as metatarsal fractures
      vi. Types
             1. Avulsion fractures
                    a. Mallet finger
                              i. Inability to extend DIP
                             ii. Painful with palpation
                            iii. Active flexion present, active extension is lost
                            iv. Finger rests in 20-30 degrees of flexion
                    b. Jersey finger

                              i. Finger appears normal with a little pain – very little
                                 swelling or disfiguration is noted
                             ii. Active fl/ex may be present – flexion is painful
                            iii. W/ PIP in extension, DIP is unable to flex
IV. Thumb Injuries
        a. DeQuervain’s Syndrome
                i. Mechanical

               ii. MOI
                     1. Repetitive stress with radial deviation causing inflammation of the fibrous
                         tendon sheath
                     2. Thickening and narrowing of tendon sheath
              iii. S&S
                     1. Pain at the radial styloid process and dorsum of the thumb, radiates into
                     2. Swelling over syloid process and thenar eminence
                     3. Painful ulnar and radial deviation
              iv. Special Tests

              v. Treatment
                    1. Rest, ice, NSAIDS, splinting, iontophoresis
        b. Thumb Sprains “skier’s thumb”, “gamekeeper’s thumb”

               i. MOI

               ii. S&S
                      1. Pain along UCL
                      2. Extensive swelling of thenar eminence and adductor compartment
                      3. Decreased grip strength
                      4. Inability to pinch or oppose fingers
                      5. Ecchymosis of thenar eminence
                      6. Positive Valgus testing
              iii. Treatment
                      1. incomplete tears with a firm endpoint and less than 30 degrees of opening
                         is treated with a thumb spica for 4-6 weeks
                      2. complete tears – surgical intervention within 3 weeks, after three weeks,
                         surgical graft
c. MCP Joint Dislocation
     i. Mechanical Damage

      ii. MOI

     iii. S&S
              1. obvious deformity
              2. very limited AROM
              3. extensive pain
     iv. Treatment
              1. splint and send
d. Bennett fracture
       i. Mechanical damage

      ii. MOI

     iii. S&S
            1. audible “snap”
            2. immediate pain
            3. loss of AROM
     iv. Treatment
            1. splint and send

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