PTA 130Fundamentals of

Treatment IWrist and Hand

Lesson ObjectivesIdentify key anatomical muscles and structures in the wrist and handIdentify common tissue injuries, conditions and surgical interventionsAnalyze restorative interventions for common injuries, conditions, and surgical proceduresIdentify 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 handsFinger 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 metacarpals14 phalanges

Wrist JointsMade up of two compound joints

Radiocarpal and MidcarpalStability is provided by numerous ligamentsAllows for the following motions:

Flexion Extension Abduction: Radial deviation Adduction: Ulnar deviation

Hand JointsIntercarpal joints:

Stability provided by ligamentsCarpometacarpal 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 HandPalmar 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 PainC6, 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 nerveThe median nerve travels from the forearm into the hand through a 'tunnel' in your wristThe 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 thumbThese tendons are covered with a lubricating membrane called synovium which may enlarge and swell under some circumstancesIf 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 HypomobilityCommon causes:

Rheumatoid arthritis Degenerative joint disease Swan-neck deformity Boutonniere deformity

Joint HypomobilityProtection 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 HypomobilityControlled 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-GlidingDesigned to maintain or develop free gliding between tendons and bones in the wrist, hand, and fingersAdhesions between various structures can become restrictive or incapacitatingThe most common tendon-gliding exercises are:

Flexor Tendon-Gliding Exercises Extensor Tendon-Gliding Exercises

Rheumatoid Arthritis (RA)

The joint’s synovium becomes inflamed and swollenSwollen 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 DeformityLaxity of the PIP joint

Hyperextension of the PIP and flexion of the DIP joints

Treatment: Splinting/ ROM/Stretch, strengthening and

modalities

Boutonnière DeformityAn injury to the tendons in the fingers that usually prevents the finger from fully extendingThe result is that the PIP of the injured finger is in a flexed position, while the DIP remains in a hyperextended positionThis 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

Trigger FingerCan 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 fingersMay 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

FracturesImmobilized 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 FractureA 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 FractureDue 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' FractureA break at the distal aspect of the radiusThe radius is the most commonly broken bone in the armA 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

TenosynovitisTendinitisTraumatic Lesions in the wrist and handSprainsLacerated flexor tendonsLacerated 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 stretchingApply 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 HandWrist 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 handThese are particularly important following immobilization when scar adhesions may have developedTendon-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 fingersFive 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 tendonsSimilar 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 phaseUsed 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 elbowActivity-specific exercises are determined by the demands of the patient’s sport and position or occupationProgress to specific patterns needed for ADL, job activities, hobbies, or recreational functionExercises should be adapted to meet the goals

Fine Motor ControlCones Blocks BegsWriting and typing Dealing cards Buttoning shirts and pants

Hand and Wrist Strengthening Exercises

Hand Therapy equipment

Orthopedic Special Tests

Tests for TendonsFinkelstein 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.

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.

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

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

QUESTIONS?