wrist and hand pathology 2.ppt · identify signs and symptoms of musculoskeletal issues ... ––...

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Wrist and HandWrist and Hand

Pathology 2Pathology 2

ObjectivesObjectivesIdentify signs and symptoms of musculoskeletal issues that can be Identify signs and symptoms of musculoskeletal issues that can be addressed by PT including:addressed by PT including:

–– Carpal tunnel releaseCarpal tunnel release–– Trigger fingerTrigger fingerTrigger fingerTrigger finger–– DeQuervainsDeQuervains DiseaseDisease–– Tendonitis/Tendonitis/TenosynovitisTenosynovitis–– Neurological conditionsNeurological conditions

Peripheral nerve entrapmentsPeripheral nerve entrapments–– Miscellaneous pathologyMiscellaneous pathology

DupuytrensDupuytrens contracturecontractureGanglion cystsGanglion cysts

Identify signs and symptoms of issues that require immediate referral Identify signs and symptoms of issues that require immediate referral including:including:

–– Gout/Gout/PseudogoutPseudogout–– Rheumatoid ArthritisRheumatoid Arthritis–– InfectionInfection–– Kienbock’sKienbock’s diseasedisease–– Peripheral nerve entrapmentPeripheral nerve entrapment–– Raynaud’sRaynaud’s PhenomenonPhenomenon–– ViscerogenicViscerogenic Referred painReferred pain–– SclerodermaScleroderma

Musculoskeletal Impairments IIIMusculoskeletal Impairments III

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Repetitive Trauma Repetitive Trauma Repetitive Trauma Repetitive Trauma Syndromes/Overuse SyndromesSyndromes/Overuse Syndromes

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

PathologyPathology

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Repetitive Trauma Syndromes/Overuse Repetitive Trauma Syndromes/Overuse SyndromesSyndromes

Carpal tunnel syndromeCarpal tunnel syndrome–– Characterized by numbness and pain in the Characterized by numbness and pain in the

palmarpalmar aspect of fingers 1aspect of fingers 1--4 1/24 1/2–– Typically a gradual progression Typically a gradual progression –– Exacerbated by repetitive overuse of the Exacerbated by repetitive overuse of the

extrinsic wrist flexors extrinsic wrist flexors –– TenosynovitisTenosynovitis and crowding of the structures and crowding of the structures

in the carpal tunnel causing entrapment of the in the carpal tunnel causing entrapment of the median nervemedian nerve

–– Patient presentation:Patient presentation:May c/o dropping items from sensory lossMay c/o dropping items from sensory lossMay have pain travel proximally into the May have pain travel proximally into the forearm and shoulder in severe, chronic forearm and shoulder in severe, chronic casescasesWomen who are postWomen who are post--menopausal are menopausal are most susceptible and thought to be a most susceptible and thought to be a

b li ib li imetabolic issuemetabolic issue–– Examination:Examination:

PhalensPhalens and/or reverse and/or reverse phalensphalens are +are +Differential diagnosis of Differential diagnosis of pronatorpronator teresteressyndrome and C7 nerve root entrapment syndrome and C7 nerve root entrapment in the cervical regionin the cervical regionAlso assess for Also assess for lunatelunate volarvolar subluxationsubluxation


Repetitive Trauma Repetitive Trauma Syndromes/Overuse SyndromesSyndromes/Overuse Syndromes

Carpal Tunnel SyndromeCarpal Tunnel Syndrome–– Impairments?Impairments?

Pain with repetitive usePain with repetitive useProgressive weakness and atrophy in Progressive weakness and atrophy in thenarthenar and 1and 1stst two two lumbricleslumbriclesTightness in adductor Tightness in adductor pollicispollicis and extrinsic extensors of and extrinsic extensors of thumb/2thumb/2ndnd and 3and 3rdrd digitdigitIrritability/sensory loss in median nerve distributionIrritability/sensory loss in median nerve distributionDecreased joint mobility in wrist/MCP joints of thumb and Decreased joint mobility in wrist/MCP joints of thumb and 22ndnd and 3and 3rdrd digitdigitSympathetic changesSympathetic changes

–– Functional Limitations/DisabilitiesFunctional Limitations/DisabilitiesDecreased Decreased prehensionprehension activities requiring thumb oppositionactivities requiring thumb oppositionDecreased use of hand in area of altered sensationDecreased use of hand in area of altered sensationInability to perform sustained or repetitive wrist motionInability to perform sustained or repetitive wrist motion


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Trigger FingerTrigger Finger

PathologyPathology


Trigger fingerTrigger finger–– Finger that is locked in flexionFinger that is locked in flexion

Flexor tendons are not able to Flexor tendons are not able to –– Flexor tendons are not able to Flexor tendons are not able to glide through the A1 pulley to glide through the A1 pulley to allow for finger extension allow for finger extension resulting in the finger remaining resulting in the finger remaining flexedflexed

–– Occurs from:Occurs from:Inflammation of the synovial Inflammation of the synovial tissue of the flexor sheathtissue of the flexor sheathThickening/fibrosis of the A1 Thickening/fibrosis of the A1 pulleypulleyNodule present on the flexor Nodule present on the flexor tendontendon

–– Fibrotic tendon sheath Fibrotic tendon sheath and presence of a nodule and presence of a nodule occur together in 70% of occur together in 70% of casescases

Repetitive overuse is Repetitive overuse is attributed to the onsetattributed to the onset


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Trigger finger (Trigger finger (Con’tCon’t))–– Patient presentation:Patient presentation:

Gradual onsetGradual onsetGradual onsetGradual onset–– First signs:First signs:

Stiffness in flexing and extending the involved finger Stiffness in flexing and extending the involved finger Pain to direct palpationPain to direct palpation

–– As the condition progresses:As the condition progresses:MCP joint flexion or extension produces a snapping MCP joint flexion or extension produces a snapping feeling or sound produced when the tendon passes feeling or sound produced when the tendon passes in/out of the A1 pulleyin/out of the A1 pulley

Involved finger remains flexed while the remaining fingers Involved finger remains flexed while the remaining fingers t d t th MCP j i t i th h dt d t th MCP j i t i th h dextend at the MCP joints upon opening the handextend at the MCP joints upon opening the hand

Most commonly affected?Most commonly affected?–– Thumb (50Thumb (50--70%)70%)–– Third and fourth finger (10Third and fourth finger (10--20%)20%)–– Fifth finger (5%)Fifth finger (5%)–– Second finger (2%)Second finger (2%)


De De Quervain’sQuervain’s DiseaseDisease

PathologyPathology

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de de Quervain’sQuervain’s diseasedisease–– Inflammation of the tendons and Inflammation of the tendons and synoviumsynovium affecting the affecting the

ABD ABD lli illi i ll d t d t lli illi i b ib iABD ABD pollicispollicis longuslongus and extensor and extensor pollicispollicis brevisbrevisAka Aka stenosingstenosing tensosynovitistensosynovitis of 1of 1stst dorsal compartmentdorsal compartment

–– Occurs from?Occurs from?Repetitive overuse especially with thumb extension/ABD, Repetitive overuse especially with thumb extension/ABD, radial deviation or wrist extension with radial deviationradial deviation or wrist extension with radial deviation

–– May have crystals form in the May have crystals form in the tendinoustendinous sheaths sheaths contributing to the progressive nature of the diseasecontributing to the progressive nature of the disease

–– Patient presentation:Patient presentation:Localized pain to the APL and EPB tendons that increases with Localized pain to the APL and EPB tendons that increases with Localized pain to the APL and EPB tendons that increases with Localized pain to the APL and EPB tendons that increases with ulnarulnar deviation or thumb ABD/Extensiondeviation or thumb ABD/Extension

–– Examination:Examination:Finkelstein’s test is +Finkelstein’s test is +Differential diagnosis with Differential diagnosis with Wartenburg’sWartenburg’s syndrome and OA of syndrome and OA of the 1the 1stst CMC joint or CMC joint or radioscaphoidradioscaphoid jointjoint


Tendonitis/ Tendonitis/ TenosynovitisTenosynovitis

Pathology and ManagementPathology and Management

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Tendonitis/Tendonitis/tenosynovitistenosynovitis–– Inflammation resulting from:Inflammation resulting from:

Repetitive use of involved muscleRepetitive use of involved muscleRARAStress overload to contracting muscleStress overload to contracting muscleRoughening of surface of tendon or sheathRoughening of surface of tendon or sheath



TenosynovitisTenosynovitis/Tendinitis/Tendinitis–– Impairments?Impairments?

P i ith l t ti lidi f t d ith i t d P i ith l t ti lidi f t d ith i t d Pain with muscle contraction or gliding of tendon with associated Pain with muscle contraction or gliding of tendon with associated joint movementjoint movementTenderness to palpation, warmthTenderness to palpation, warmthImbalance in muscle strength, endurance, and lengthImbalance in muscle strength, endurance, and length

–– Functional Limitations/Disabilities?Functional Limitations/Disabilities?Pain that worsens with activityPain that worsens with activity

–– Management:Management:Acute phase:Acute phase:

–– SplintingSplinting–– CrossCross--friction massage in elongated positionfriction massage in elongated positionCrossCross friction massage in elongated positionfriction massage in elongated position–– MultipleMultiple--angle muscleangle muscle--setting in painsetting in pain--free positionsfree positions–– PainPain--free ROMfree ROM–– TendonTendon--gliding exercisesgliding exercises

SubacuteSubacute/chronic phase:/chronic phase:–– Progress previous Progress previous rxrx–– Assess accessory joints for proper biomechanicsAssess accessory joints for proper biomechanics


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Tests and MeasuresTests and MeasuresSpecial TestsSpecial Tests

NeurologicalNeurological–– TinelsTinels signsignTinelsTinels signsign–– Phalen’sPhalen’s testtest–– Reverse Reverse phalen’sphalen’s–– *Carpal compression test*Carpal compression test–– *Flick test*Flick test

Muscle PathologyMuscle Pathology–– FinklesteinFinklestein Test Test

VascularVascular–– Allen testAllen test

Musculoskeletal Musculoskeletal Impairments IIIImpairments III

Neurological ConditionsNeurological Conditions

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Neurological ConditionsNeurological ConditionsSuperficial Radial NerveSuperficial Radial Nerve–– Includes Includes WartenburgsWartenburgs diseasediseasegg–– Where?Where?

Entrapment of superficial radial nerve between the tendons Entrapment of superficial radial nerve between the tendons of of brachioradialisbrachioradialis and ECRLand ECRL

–– Patient presentation:Patient presentation:Pain and numbness over the dorsum of the hand and most Pain and numbness over the dorsum of the hand and most prominent just proximal to the anatomical snuff boxprominent just proximal to the anatomical snuff box

–– Examination:Examination:PronationPronation and and ulnarulnar deviation exacerbate symptomsdeviation exacerbate symptomsPronationPronation and and ulnarulnar deviation exacerbate symptomsdeviation exacerbate symptoms

–– Can be misdiagnosed as Can be misdiagnosed as deQuervainsdeQuervains diseasedisease–– Blunt force trauma can also produce a palsy of this nerveBlunt force trauma can also produce a palsy of this nerve


Neurological ConditionsNeurological ConditionsUlnarUlnar NerveNerve–– Occurs in Occurs in GuyonsGuyonsyy

tunnel which is found tunnel which is found under the hook of under the hook of hamatehamate

Floor is formed by Floor is formed by the the pisohamatepisohamateligamentligamentRoof is formed by Roof is formed by fascia and fascia and palmarispalmarisppbrevisbrevis

–– Direct compression over Direct compression over the tunnel can produce the tunnel can produce entrapment of the entrapment of the ulnarulnarnervenerve


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Neurological ConditionsNeurological ConditionsUlnarUlnar Nerve (Nerve (Con’tCon’t))–– Primary symptoms Primary symptoms y y py y p

include include ParesthesiasParesthesias in the in the 5th and half of the 5th and half of the 4th fingers4th fingersWeakness in the Weakness in the intrinsic hand intrinsic hand muscles muscles


Miscellaneous PathologyMiscellaneous Pathology

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Miscellaneous PathologyMiscellaneous PathologyDupuytren’sDupuytren’s ContractureContracture–– A disease characterized by:A disease characterized by:

Development of new fibrous Development of new fibrous tissue forming nodules and tissue forming nodules and andand cords in the cords in the palmarpalmar and and digital sheaths of the handdigital sheaths of the hand

–– Leads to formation of flexion Leads to formation of flexion contractures of the fingerscontractures of the fingers

–– Primarily involves MCP and Primarily involves MCP and PIP jointsPIP joints

–– More common in?More common in?People with diabetes, liver People with diabetes, liver disease, alcoholism, and disease, alcoholism, and smokers smokers Caucasians, advancing ageCaucasians, advancing age

–– Most common gender?Most common gender?Men occurring at a 9:1 ratio Men occurring at a 9:1 ratio to womento women


Miscellaneous PathologyMiscellaneous PathologyDupuytren’sDupuytren’s ContractureContracture–– Classified into 3 biologic Classified into 3 biologic gg

stages:stages:First stage First stage

–– Proliferative stageProliferative stage–– MyoblastMyoblast proliferation proliferation

and formation of nodulesand formation of nodulesSecond stageSecond stage

–– Alignment of Alignment of myofibroblastsmyofibroblasts along lines along lines of tensionof tensionof tensionof tension

Third stageThird stage–– Tissue becomes Tissue becomes acellularacellular

and devoid of and devoid of myofibroblastsmyofibroblasts

–– Primarily thick bands of Primarily thick bands of collagencollagen


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Miscellaneous PathologyMiscellaneous PathologyDupuytren’sDupuytren’s ContractureContracture–– Usually bilateral with one Usually bilateral with one

h d th thh d th thhand worse than otherhand worse than other–– May have 1,2, or 3 rays May have 1,2, or 3 rays

involvedinvolved–– Most commonly involves 5Most commonly involves 5thth

digit (little finger)digit (little finger)70% of patients70% of patients

–– Surgical intervention when Surgical intervention when MCP joint contracts to 30MCP joint contracts to 30oo

PostPost operative success (50%) operative success (50%) –– PostPost--operative success (50%) operative success (50%) dependent on effective dependent on effective splinting and exercisesplinting and exercise

–– Splinted in 10Splinted in 10--2020oo MCP MCP flexion with PIP extensionflexion with PIP extension


Miscellaneous PathologyMiscellaneous PathologyGanglion cystsGanglion cysts–– MucusMucus--filled cysts found filled cysts found MucusMucus filled cysts found filled cysts found

in the wristin the wrist–– No known cause No known cause –– Typically found people Typically found people

with repetitive wrist ROMwith repetitive wrist ROM–– More common in women More common in women

than menthan men–– Ganglions are most Ganglions are most –– Ganglions are most Ganglions are most

commonly found?commonly found?70% in the dorsal aspect70% in the dorsal aspect20% in the 20% in the palmarpalmar aspectaspect10% in the tendon 10% in the tendon sheathssheaths


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Miscellaneous PathologyMiscellaneous Pathology

Ganglion cysts (Ganglion cysts (con’tcon’t))–– May interfere with ROM May interfere with ROM –– May interfere with ROM May interfere with ROM –– Patient presentation:Patient presentation:

Appearance of the cyst Appearance of the cyst during wrist flexionduring wrist flexionSoft, squishy, and tender Soft, squishy, and tender to palpationto palpation

–– May require surgical May require surgical excisionexcision


Differential DiagnosisDifferential Diagnosis

Wrist and HandWrist and Hand

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Differential DiagnosisDifferential DiagnosisGout/Gout/PseudogoutPseudogout–– Metabolic joint diseases with deposition of sodium Metabolic joint diseases with deposition of sodium urateurate or or

calcium calcium pyrophhosphatepyrophhosphate crystals in the jointscrystals in the joints–– Wrist 2Wrist 2ndnd most common after kneesmost common after knees–– Moderate night pain that increases with no positional reliefModerate night pain that increases with no positional relief

Rheumatoid arthritisRheumatoid arthritis–– UlnarUlnar deviation of MCP joints, boutonniere and/or swandeviation of MCP joints, boutonniere and/or swan--neck neck

deformity of digitsdeformity of digitsInfectionInfection–– CellulitisCellulitis

Infection of skin and underlying structuresInfection of skin and underlying structuresPatient presentation:Patient presentation:

–– LoaclizedLoaclized redness, swelling and painredness, swelling and pain–– Fever, chills, nausea and vomitingFever, chills, nausea and vomiting


Differential DiagnosisDifferential DiagnosisKienbock’sKienbock’s DiseaseDisease–– AscepticAsceptic or or avascularavascular necrosis of the necrosis of the lunatelunateAscepticAsceptic or or avascularavascular necrosis of the necrosis of the lunatelunate–– Etiology uncertain but trauma believed to be part of causeEtiology uncertain but trauma believed to be part of cause–– PrevelancePrevelance in males and 20in males and 20--40 40 y.oy.o..–– Patient presentation:Patient presentation:

Pain on the dorsal aspect of wrist, esp. during and after Pain on the dorsal aspect of wrist, esp. during and after activityactivityHand stiffnessHand stiffnessIncreasing se erit of pain and eakness of gripIncreasing se erit of pain and eakness of gripIncreasing severity of pain and weakness of gripIncreasing severity of pain and weakness of gripLoss of wrist motion, esp. wrist extensionLoss of wrist motion, esp. wrist extension

–– Conservative treatment:Conservative treatment:ImmobilizationImmobilizationSurgical optionsSurgical options


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Peripheral nerve entrapmentPeripheral nerve entrapment–– Lateral:Lateral:

C6/C7 C6/C7 radiculopathyradiculopathyThoracic outlet syndromeThoracic outlet syndrome

–– Medial:Medial:C8 C8 radiculopathyradiculopathyBrachial plexus compression @ thoracic Brachial plexus compression @ thoracic outletoutletCubitalCubital tunnel syndrometunnel syndrome



Vascular OcclusionVascular Occlusion–– Raynaud’sRaynaud’s phenomenon:phenomenon:

Affects one hand or bothAffects one hand or bothReversible vasospasm with or without Reversible vasospasm with or without underlying disorderunderlying disorderPatient presentation:Patient presentation:

–– Digital pallor followed by cyanosis and Digital pallor followed by cyanosis and ruborrubor–– Digital pallor followed by cyanosis and Digital pallor followed by cyanosis and ruborruborThrobbing and tingling accompany Throbbing and tingling accompany ruborrubor

ViscerogenicViscerogenic referred painreferred pain–– Heart, apical lung and bronchusHeart, apical lung and bronchus


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Differential DiagnosisDifferential DiagnosisSclerodermaScleroderma–– Two types:Two types:

LocalizedLocalized–– Primarily Primarily cutaneouscutaneous

SystemicSystemic–– Multisystem connective tissue diseaseMultisystem connective tissue disease–– Two types:Two types:

LimitedLimited-- Long history of Long history of Raynaud’sRaynaud’s-- Mildly puffy or swollen fingersMildly puffy or swollen fingers-- Digital ulcer heartburn or SOBDigital ulcer heartburn or SOB-- Digital ulcer, heartburn, or SOBDigital ulcer, heartburn, or SOBDiffuse Diffuse -- Much more acute onsetMuch more acute onset-- ArthralgiaArthralgia, CTS, swollen hands and legs, CTS, swollen hands and legs-- CrepitusCrepitus--like over tendon areas of handslike over tendon areas of hands-- Other systemic issues in GI, pulmonary, CV and renalOther systemic issues in GI, pulmonary, CV and renal


wrist and hand pathology 2.ppt · identify signs and symptoms of musculoskeletal issues ... ––...

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