Distal Radioulnar Ligament

Palmar Radioulnar Ligament

 Interossesous membrane: this is the strongedst of the three

What is the function of the distal Radioulnar joint?

What is the capsular pattern?

Fucntion: Movement--> pronation and supination

Capsular Pattern: No limitation, pain w/ End of ROM EOR

what joint is considered the wrist joint?

WHat bones make up this joint?

How is it stabilized?

Radiocarpal joint

Between proximal row of carpals and the distal radius

Dorsal radiocarpal ligament: Very strong

Palmar radiocarpal ligament: Very Strong

Radial Collateral Ligament

Function of the radiocarpal joint?

Capsular pattern?

Movement: Flex/Ext Ulnar Dev/Radial dev

Capsular Pattern: Flx/Ext are = limited

What is the prox row of carpals from lateral side to medial and distal?

What is the stability of these bones?

What is the movement that occurs as a part of the intercarpal joint?

Capsular pattern?

Scaphoid, Lunate, Triquetrum, pisiform

trapezium, trapazoid, Capitate, hamate

Stability: Small dorsal, palmar and interosseous ligaments

passive accessory movements not active movements, typically gliding

No capsular pattern

Midcarpal joints:

Where is it located?

Less or more mobile and stable than intercarpel joints

Movements?

Casular pattern?

Located between the distal and prox rowof carpals

More mobile but less stable than the intercarpel joints

Movementas: Flx/Ext, Radial and Ulnar deviation

Capusular pattern: flx/ext are equally limited

Same movements and capsular pattern as radiocarpal

Carpometacarpal:

Stability?

Movement?

Capsular pattern?

Dorsal and palmar ligaments

Movement: Gliding

Capsular Pattern: Equal limitations in all directions

CMC joint of the thumb:

Type of joint?

Bones that make it up?

Stability?

Movements?

Capsular pattern

Saddle joint

trapezium and 1st metacarpal

stability: Dorsal/Palmar and lateral ligaments

Flx/Ext (AKA abd in the plane of the fingers), ABD, ADD, opposition

Capsular Pattern: ABD>Ext

MCP joint 1-5

Stability

Movements

Capsular pattern

Stability: Collateral ligaments

Movements: Flx/Ext/ABD/ADD

Capsular Pattern: Flx>Ext

IP joints:

DIP PIP

Stability?

MOvement

Capsular Pattern?

Stability: Joint capsules, collaterals, palmar ligaments

Movement: Flx/Ext

capsular pattern: Flx>ext

TFCC:

What is the full name?

Where is it located?

How many ligaments attach to it, what are these lig?

What side of the wrist does it reinforce?

What is it's function between the radius and the ulna?

Triangular Fibrocartalige Complex

Between the ulna  and the lunate and trquetrum

4 lig attach to the TFCC, Ulnar collateral, ulnolunate, radioulnar, and ulnotriquetral lig

Reinforces the Ulnar side of the wrist

Fct b/w radius and ulna: binds them togther

20-40% of the load through the wrist

radius bares 60-80%

What is the functional Position of the hand?

Is this considered the rest position of the hand?

Is this the position that that hand is placed in to heal?

Wrist slightly ext and ulnarly deviated, thumb in slight flexion(out from the palm of the hand to the side) and slight ABD (perpendicular to palm) and slight opposition, the rest of the fingers are in slight flexion of the joints

Healing position of the hand

What has to happen at both the radiocarpal and mid-carpal joints for global wrist movement to take place?

Where does more movement need to occur for each of these?

Flx and Ext

Flx: more movement need to occur at the midcarpal joints

Ext: more movement needs to occur at the radiocarpal joints

Scapholunate: torn in scaphoid dislocations, if there is instability there can be degenerative changes in the radius--> OA

Lunotriquetral: Torn in lunate dislocations

Need to know these two bc they are torn in fall often a FOOSH

Wrist Crease indicate what at the joints?

Distal Wrist, middle, prox crease indicates what anatomical structure?

Why do these crease occur?

Movement

Distal Wrist Crease: Border of  Prox flexor retinaculum

Middle Wrist: radiocarpal joint

Proximal: Proximal magrin of flexor tendon sheaths

These crease occur where the skin addhears to the fascia

What anatomical structure does each of the following creases reveal?

Radial longitudinal crease

Prox Transverse Crease

Distal Transverse Crease

RLC: Encircles the thernar eminence

Prox Trans crease: Metacarpal shafts

Distal Transverse crease: metacarpal heads

What is kienbock's disease? What can process this disease?

What pop is it likely to occur in?

S/S

Cause?

Avascular necrosis of the lunate

Causes: Trauma, repetitive stress, short ulna cuasing excess pressure on the lunate bc more pressure is being placed through the radius bc ulna is not articulating

Young adults

S/S: Aching, stiffness with wrist flexion, tender over lunate, decreased grip, degeneration on radiograph

Cause is unknown

what are the stages of Kienbocks disease?

See slides for a good picture

Stage I: Acute stage--> aching or stiffness (Sx similar to wrist sprain). Ischiema of the lunate, no radiographic changes

Stage II: Density changes--> Trabecular necrosis. Reactive cortical bone growth (sclerosis). Trabecular bone begins to be built up

Stage III: Collapse of the lunate. Pathologic fracture. Deformity( prox migration of capitate), scaphoid rotation

Stage IV: Pan Carpal arthrosis (joint disease of the carpals, mechanical disruption of the radiocarpal joint, degenerative changes and instability at the wrist(altered biomechanics))

Conservatively at first: Immobilzation 1-3 months decreasing stress on the lunate. If revascularization occurs deformity stops, if not have to preform surgery

Surgical Management: If there is a normal shaped lunate will do a radial ostetomy tilting the meidal edge of the radius away from lunate

Radial shortening: create anatomicl cavity to decrease pressure on lunate

Surgical Management if the lunate is deformed: Excision of the prox row of carpals. Can lead to an unstabel wrist--> OA

Lunate arthroplasty: Put in a new lunate

Kienbock's disease

decreased fucntion of the scaphoid, trapezoid, trapezium bc of lunate gone now these do not function in the correct way therefore they fuse teh scapho lunate traizium trapazoid together. Take pressure as a group and lunate is relieved of that pressure

What can cuase Carpal instability?

S/S?

Causes: Fx, trauma (recent or distal past), RA joint errosin causes instability

S/S: Wrist pain, stiffness, tenderness over lunate/Scaphoid(where wrist articulates), clicking/snapping, decrease grip strength

Anatomic

Instability Complex

Region

Scapholunate dissociation (instability)KNOW bc falls: Most common, gap between scaphoid and lunate >3mm

Clinical Signs:  Increased PA and AP movement between 2 bones

Triquetrolunate dissociation(2nd most comon): Triquetrum rotates. Decreases stability between triquestrum and lunate

Ulnar translocation of carpals: Prox row migrates toward the ulna, hand deviates to radial side, common in RA as distal radius erodes

Radiocarpal subluxation: Carpals sublux on radius (dorsal or volar). Occurs when wrist is completelty unstable (advanced RA). Uncommon

Instability Complex Classification:

Dorsal intercalated segmental instability (DISI) what does this mean

DOrsal instability between scaphoid and lunate

Occurs in scaphoid lunate disassociation

DISI: Dorsal tilt of lunate volar tilt of scaphoid with reguard to the concave surface of the lunate

Instability Complex

What is a VISI

what carpal bone disassociation does VISI often occur with

Volar tilt of lunat dorsal tilt of scaphoid with regaurd to the concave surface of the lunate

Occurs with triquetrolunate dissociation KNOW THIS

Lateral Carpal Instability:Instability of radial wrist, scapholunate dissociation (involves DISI), Scaphocapitate disruption(RARE), Scaphotrapezial disruption (RARE)

Medial Carpal Instability: Instabilitty of ulnar wrist, triquetrilunate dissociation (involves VISI)

Proximal Carpal Instability: Instability at the radiocarpal joint, ulnar translocation of carpals(radial deviation of wrist)

Lateral Carpal instability:instability of radial wrist

Meidal Carpal Instability: instability of ulnar wrist (triquetrolunat dissociation)

Proximal Carpal Instabilty: instability at radiocarpal joint

Acute Instability: Closed or open reduction. fix what is moved out of place. Ligament Repair if indicated. Immobilization: cast or kirshcner wires (K-wires, Ext fixation through soft tissues and bones, inserted between lunate and scaphoid), Progressive ROM and strengthening

Chronic Instability: Ligamentous repair no longer possible. anage pain and inflammation(RICE, Modalities, brace). PRogressive ROM.

Arthrodesis(fusion): intercarpal, radiocarpal or radiocarpal/metacarpal. Provided wrist stability. Movement may remain at midcarpal joint

Arthroplasty: carpal and distal radius implants( these components fail fairly rapidly)

What is a Colles' Fx?

What population is it most common in?

Which way is the distal segement displaced?

Trasnverse Fx of the distal radius

Most common in elderly women those with OP and high probability of a fall

Posteriorly(Dorsally)

Shattering of the distal radius

Fx of the ulnar styloid process

Injury of the radiocarpal or distal radioulnar joints

What is the MOI for a Colles Fx?

S/S?

Management?

MOI: FOOSH

S/S: Silver fork deformity, pain with wrist/hand movements/local tenderness

Management: Closed reduction and immobilization. ORIF and External fixation if unstable or complex(often will do this bc hard to get the distal segement back where it belongs). Progressive ROM and strengthening

Adhesive capsilitis

Tell them to move the shoudler and the elbow

Compartment syndrome: due to decreased circulation 2dary edema within cast, blanch test of nail beds, neural screen

Complex Regional Pain Syndrome (CRPS): hypersensitivity, edema, sweaty hand, trophic changes, shinny skin, loose hair, blantched looking

Malunion. Delayed union of the ulnar styloid process fx (painful). Rupture of EPL tendon (crossed distal radius). Disuse osteoprosis. Adhesive capsulitis

What is a Smith's Fx?

MOI?

Managment?

Volarly displaces Transverse Fx of the distal radius. Opposite direction of a Colles Fx(dorsal displacement)

MOI: Fall onto a flexed wrist

Management: Closed Reduction, ORIF, External Fixation, beaware of Adhesive capsulitis move elbow and shoulders, gradual ROM and strengthening

Radial Styoid Fracture:

MOI

Management

MOI: FOOSH w/ forced radial deviation (R. styloid process displaced laterally)

Management: Closed reduction, immobilization in UD (Fixation with K wires if necessary). Progressive ROM and strengthening

What is the most common carpal fx?

MOI

S/S

What other injury may be included with this

Scaphoid Fx

Fall on a fully extended wrist

S/S: pain w/ extension weak/painful grip, pain w/ compression through 1st MC. Tender anatomical snuff box.

What is the classic sign of a scaphoid fx?

How is a scaphoid fx managed?

Tender in the anatomical snuff box

Management: Immobilization including thumb. Possible ORIF (usually not nessary). Progressive ROM and Strengthening.

Boxers Fx?

Does the distal Fragment move Volarly or Dorsally?

MOI?

Management?

Transverse Fracture of Neck of MC 2-5?

5th most common fx

Volar angulation of the distal fragement

MOI: Compressiveforce through metacarpals

S/S: Flattening of knuckle, pain, swelling

Management: Reduction, immobilization, k wire if unstable

Bennett's Fractures:

What is this?

How does the finger affect appear and why?

MOI?

S/S?

Management?

Management?

Oblique fracture of the base of the 1st MC (extends into CMC joint creating instability can cause dislocation of the CMC joint.

The thumb appears shorter dislocated towards the radius.

MOI: Punching/Martial arts

S/S: Edema, short appearing thumb

Magement? ORIF, immobilization, progressive ROM and strengthening

Phalangeal Fx:

What type of fx is common in the prox and middle and distal?

MOI of Prox, middle, and Distal?

Management?

Transverse fx in PRox and Middle. Complex in Distal.

MOI (Prox and Middle): Bending, Twisting(transvers fx)

MOI Distal: Closing in door or hammer

Management: Undisplaced (splint, buddy taping). Displaced: Closed reduction, immobilization (k wire if unstable). Prgressive ROM and strengthening.

Phalangeal Fracture/Dislocation:

Do these often occur together?

MOI?

S/S?

Management?

Phalangeal Fx and dislocation often occur together

MOI: Forced bending usually with twisting or compression or both

S/S: Deformity, pain, swelling

Management: Closed reduction and splinting

Drop Wrist deformity

Intrinsic Minus Hand

Nerva Palsy issue. Claw hand claw fingers

Combined median and ulnar verve palsy: congenital or brachial plexus injury. Imbalance of intrinsic and extrinsic muscles

S/S: MCP hyperextension, DIP and PIP flexion. Loss of arches. Atrophy of intrinsics.

Management: Tendon transplants for function

Drop Wrist Deformity:

Issue with what nerve?

S/S?

Management?

Radial Nerve Palsy: Fx of humerus or radius/ulna, compression of nerve.

S/S: Paralysis of wrist and finger extensors

Management: Repair/Decompress Radial nerve if able. plinting in functional hand position

Ganglion cyst:

What is it?

WHat population is it common in?

S/S?

Management?

Cystic degeneration of capsule, tendon sheath or bursa ( degeneration of the sheath allow fluid to leak out and then forms a pouch)

Common in young adults

S/S: painless soft lump, usually on dorsal wrist. Medial wrist, dorsal foot dorsal hand.

Management: None. can aspirate/excise (recurrence common)

deQuervain's disease:

What is it?

What population is commonly occuring?

MOI?

S/S?

Management?

tenosynovitis: Inflammation of extensor/ ABD tendon sheaths( extensor pollicis brevis and abductor pollicis longus). Even though the sheaths are inflammed the tendon itself can remain normal

POP: Middle aged Women

MOI: Unusual or unaccustomed use of the hand

S/S: pain and swelling at radial wrist. Palpable thickening of tendon sheath. + Finkelstein's test.

Management: NSIADS, injection, immobilization w/ a spika cast. Ionto, modification of activity, progressive exercise. Surgical release of the extensor retinaculum

Tenosynovitis:

Where can it occur?

S/S

Management

Can occur in any tendon sheath( all flxor tendons can get it). Most commonly extensor pollicis brevis and ABD pollicis longus. Finger flexors are vulnerable

S/S: Marked edema. Increased temperature. Pain.

Management: Rest, NSAIDS

Dupuytren's Contracture:

What is it?

Pop?

Causes?

S/S?

Management?

dupuytren's Contracture: hypertrophy and contracture of palmar fascia (usually 4th or 5th finger)

POP: Middle Aged males

Causes: Genetic component. metabolic changes (AIDS, diabetes, drugs (dilantin))

S/S: nodular thickening in palm (extends distally. Pulls PIP and MCP into flexion as the fascia begins to contract and unable to extend against contracture). Often occurs bilaterally.

Management: Conservative tx (can slow progression but not stop it. Stretching, friction massage, modalities)

Surgical Excision of thickened fascia (often reoccurs)

Swan Neck deformity:

What is it?

Causes?

S/S? Management?

Flx of DIP, hyperext of PIP,MCP Flexion

Causes: Contracture of intrinsic muscles, tearing of volar plate of PIP

S/S: Flexion of MCP and DIP, hyperextension of PIP

ManagementL stretching may help if contracted (not if volar plate is torn)

Boutonniere Deformity:

What is it?

When is it seen?

S/S?

Management?

Rupture of extensor hood (seen in RA and trauma)

S/S: extension of MCP and DIP, flexion of PIP bc the ext hd slides down past the AOR of the PIP

Management: Surgical repair if it interferes with function

Boutineir: MCP ext, PIP Flx, DIP ext

Swan: MCP Flx, PIP Ext, DIP flx

Mallet Fingers:

What is it?

MOI?

S/S?

Management?

Rupture/avulsion of extensor tendon at the insertion at base of distal phalanx

MOI: Forced flexion during active extension (Stubbing injury)

S/S: Inability to extend distal phalanx

Management: Acute (splint) Chronic (none, not functioning limiting)

trigger finger/thumb:

What is it?

Cause?

S/S?

Management?

Stenosing tenosynovitis: nodule or swelling in the tendon. Prevents gliding through sheath

Cause: Unclear, associated w/ RA, DM, gout

S/S: Discomfort at base of digit=>locking of finger/thumb

Management: NSAID, injection, splint. Surgical splittingof sheath

Management: Total tear surigcial repair imbolization

Imcomplete: immbolization but frq gentle ROM

Gradual return to activity

Carpal Coaliton:

was is it?

which is most common?

Common, congenital condition. Imcoplete separation of bones.

Lunotriquetral coalition most common: Often asymptomatic. OFten asociated with widened scapholunate space.

osteoarthritis:

Common at what joints of the wrist?

S/S?

Management?

Common at the 1st CMC and at scaphoid/trapezium/trapezoid joints but it can occur at any joint of the hand.

S/S: stiffness with rest. Pain with movemet

Management: Joint mobilization, ROM exercises, deep heating modalities. Arthrodesis (fusing of bones)

What is the most common cause of hand pain?

What structures are involved in this issue?

Causes and contributing Factors?

Carpal Tunnel Syndrome

flexor retinaculum (AKA transverse carpal ligament) compresses down on the median nerve in the carpal tunnel

Anatomical/ physiological, diseases and prediposing factors, chronic stress, individual and environmental factors

F/M 8:1

middle age

can happen during pregancy retention of fluid

Diabetes, OA, RA, Thyroid disorders, Colles Fx

Pregnancy, Chronic physical stress ( static positions: wrist flexed most stressfull, Ulnar deviation, supination). Dynamic stress: Repetition, sustained grip or pinch. Poor genereal physical conditon, cold , vibration, emoitinal stress

What are the S/S of carpal tunnel syndrome?

S/S: N/T meidal nerve distribution which increase at night bc of hand position in prolonged wrist flx. Median nerve distribution: Palmar surface of the hand up through the half of the ring finger. Dorsal surface from PIP to tip of index middle and then half of ring

At night burning pain upoon wakening, ahdn wknes, and incoordination, Positive tinels or phalens

Management of Carpal Tunnel Sx?

ConservativeL activity modification, rest (work restriction, task specific worksite modification, splints at night). Nerve mobilization: NTT exercises, neurodynamic stretching. Anti-inflammatory modalities

Work modification is huge here. If they have to do the positionof aggravation at work stop every little bit and do exercises

what are the two types of surgical intervention in carpal tunnel syndrome?

Post operative management?

Gross decompression : divide flexor retinaculum

Specific decompression: Endoscopic debridement of hypertrophied tissue

PO: immobilization, edema control, scar tissue mobilization, nerve gliding exercises, progressive ROM and strengthening, work simulation

what type of joint is the Sternoclavicular joint?

Is this joint stable or unstable, what makes it this way?

2 functions of the SC joint?

Does it have an articular disc?

Saddle(sellar), synovial (Has an articular disc)

Stable w/ strong capsular and ligamentus support

2 functions: Fulcrum for shoulder movements. Only boney attachment of the shoulder to axial skeleton

SC dislocations:

Most common direction of dislocation?

MOI?

S/S?

How do you relocate?

Most common is anterior dislocation

MOI: falling on the lateral tip of the shoulder (forces have to be just right)

S/S: Pain, protrusion of medial end of clavical

Relocation apply AP pressure to M clavical with distraction of the shoulder

Posteiro Dislocation of the SC joint:

MOI:

Common/Uncommon?

How serious it this?

How is reduction accomplished?

Direct blow to the SC joint

Uncommon

Serious bc could impindge the subclavian artery or trachea

reduction can be open or closed

SC joint degenerative changes:

Common/Uncommon?

Problematic?

What about the articular disc

S/S?

Fairly common not a problem usually, degeneration of articular disc

S/S crepitus, perhaps some pain

AC joint:

Type of joint

Strongest ligamentus support

What is the important function of thsi joitn?

 Plane, synovial joint

The Coracoclavicular ligaments Trapzoid and conoid. Other ligaments actually do not provide much support

Links the shoudler gridle to the clavical and is tied to all motions of the humerus

MOI of the AC joint?

How do you tell another PT how bad it is?

MOI: fall on the tip of the shoulder or FOOSH

Graded according to degree of liamentous injury: 1-3

Grade 1: mild overstretch of AC lig, normal appearance, nrmal radiograph, pain

Grade II: Tear AC ligament, sprain of CC lig (but intact), slight widening of joint space, pain

Grade III: Complete disruption of both AC and CC ligaments. Seperated shoulder not dislocated.Superior displacement of the clavical(CC no longer holding it down)

What are two ways to classify shoulder instability?

What are the components of these classifications?

Atramuatic: AMBRI: Atraumatic, Multidirectional, Bilateral, Rehabilitation, inferior capsular shift

Truamatic: TUBS: Truamtic, Unilateral, Bankart(name of lesion and name of surgery for lesion), Surgery (usually the approach that will be used to take care of a truamatic surgery)

Vague pain of Acromiohumeral space &/or posteriro shoudler

Complaints of shulder slipping in and out

Excessive excursion with special tests for shoulder stability/apprehension

May be concomitant(occuring together): impindgment, loosse shoulders set people up  for impindgement problems

Rest/avoid agg activities

Modalities as needed

Muscle ofthe rotator cuff especially the IR/ERs, strengthening is key

Neuromuscular coordination training (PNF)

Small % pts may require surgery

imporve the enduracne of Rot Cuff and teach them to contract muscles in area of stabilization

traumatic shoulde instability

MOI

Most common dislocation

Recurrent dislocations common

S/S?

MOI: excessive force into ER while in 90 deg of ABD

Most common: anterior inferior (posterior dislocation occurs with different mechanism)

Recurrent dislocations are common.

S/S: pain apprehension with certian position like ER with ABD same position in whnich dislocation occured, weakness due to pain