Upload
tbf413
View
1.893
Download
3
Tags:
Embed Size (px)
DESCRIPTION
Hand therapy for common hand innjuries
Citation preview
Common Hand Conditions
Dan PurtellHand / Occupational
Therapist
Common Hand ConditionsTrigger finger / thumb
De Quervain’s
Mallet Finger
PIPJ Dislocations
Dupuytren’s disease
Simple #’s
Trigger finger Definition
Not clearly / consistently defined
Triggering of the digital flexor tendons at the fibrooseous tunnel formed by the metacarpal neck and A1 pulley
In thumb the sesamoid bones may also be site of constriction
Generally affects FDS rather than FDP because it lies directly under A1 pulley
Anatomy
Trigger fingerIncidence
Primary trigger finger most commonly found in middle aged women, 2–6 X more than men
Most commonly affects thumb (30-50%)
Then ring, long, index, & little
Trigger fingerCausative Agents
Stenosing tendovaginitis Digital flexors susceptible to
compression and shear at level of wrist and MP joints where they enter fibrooseous tunnels
Blunt trauma or sustained tool use causing direct compression at A1 pulley
Secondary TF in individuals with connective tissue disorders
Pathophysiology Discrepancy between
the size of the A1 finger pulley lumen and tendon volume
Hypertrophy of the pulley
Poor tendon vascularity between A1 and A2 pulley makes tendons more susceptible to degenerative changes
Tendons develop nodules from tenosynovitis
Clinical and diagnostic features Pain over site of tendon disorder
aggravated by movement Symptoms vary from stiffness, to
uneven movement, catching, blocking, or complete locking of tendon
Pain can also be referred to distal joint or proximally up forearm
Local swelling and thickening creating a palpable nodule over distal palmar crease (A1 pulley area)
Local tenderness over A1 Patient may present with acute,
subacute or chronic disorder
Management - ConservativePatients often reluctant
tohave cortico-steroid
injection,even more reluctant to
have surgery
Conservative measures should
be trialled for 4-6 weeks
Thermoplastic hand based splint to limit MCP flexion (stops triggering through A1 pulley)
Splinting works better for fingers than for thumbs
Management - Conservative
Trigger Thumb -Thermoplastic barrel splint, IP joint at 10 degrees flexion
Passive tendon gliding exercises
Soft tissue massage of nodule and tendon.
+/- Ultrasound +/- NSAID gel
Management - Cortico-steroid injection
Cortisone injection for trigger fingers and thumbs relieves symptoms in 47% to 94% of affected digits.
Management - Surgery Most reported success
rates are above 90%. Decompression of pulley
to allow flexor tendon to glide
Turowski, 1997: n=59, 97% complete resolution. No post-op nerve or tendon damage.
Eastwood, 1992: Percutaneous release, n=35, 94% complete resolution. No complications. Not for thumb
Thorpe, 1988: n = 53, 60% complete resolution, success correlated with surgeon skill.
Post operative management
Oedema and wound management Scar management once wound healed Active tendon gliding exercises Stretching long finger flexors Strengthening only if necessary Conclusion Surgery remains the most successful
treatment option Splinting and exercise program good
alternative for those patients reluctant to consider a CSI or surgery
De Quervain’s
de Quervain’s tenosynovitis is the entrapment tendonitis/tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius
De Quervainne’s
Most cases it is a tendinopathy like trigger finger, tennis elbow etc that leads to tenosynovitis.
De Quervain’s
Finklesteins test and clinical Hx confirm diagnosis.
De Quervain’s
10 x more Common in Women than men.
Common in pre-post natal and menopause.
Often caused by repetitive strain or sustained posture of the wrist = strain on EPB and APL.
Can occur post direct trauma to the area (rare)
De Quervain’s
Treatment: Steroid (won’t fix
tendinopathy)
Splint and rest
Kinesio tape
Surgery (last resort)
De Quervain’s
Surgery
Mallet Finger Definition
Any injury that causes a mallet deformity of the distal phalangeal joint
Diagnosis
Disruption of the terminal extensor tendon as it inserts into distal phalanx +/- fracture
Anatomy
Causative agents
MECHANISM OF INJURY
Flexion force on extended DIP joint
Direct crush Ball to tip of
finger Often occurs in ball sports.
Clinical and diagnostic features
Signs & Symptoms
Inability to extend distal phalanx actively
Can still passively extend within pain limits
Swelling Bruising Redness
Similar PresentationsVolar plate laxity =
swan neck deformity
Management
depends on size of fragment and position of jointIf complete tendon rupture without
fractureIf # is less than 30% joint surface→ Conservative management - splinting
If # greater than 30% joint surface or joint is significantly displaced needs surgical intervention
Conservative management
Mallet splint reduces the fragment
Conservative management Splinting
Splint DIP in hyperextension 6 – 8/52 Splint strictly 24/24 Clear instructions and demonstration re
changing and wearing routine Advice re skin care PIP flexion exercises May return to sport with splinting
Mallet Splinting
Off the shelf stack splint often fit poorly
Patient may end up with a lag at DIP joint
Conservative Management Wean splint slowly
after 6-8 weeks Keep on at night and
for work a further 2 weeks
Initially active flexion exercises to gain full flexion
Start off 30 degrees flexion first week and increase slowly ie 20 degrees per week
May take 4 – 6 weeks to regain full flexion
If lag reoccurs → RESPLINT
Passive flexion only added if needed
Mallet Finger
Large Fragment Fixed with K-wire or 2
Middle Phalanx #’sCentral Slip avulsion
Middle Phalanx #’s
- Conservative approach only if small fragment with no joint subluxation. - Splint for 6/52 in barrel splint DIPJ can be free.- Larger fragments with joint subluxation can be ORIF’d.
= Boutonniere Deformity= FFD of PIPJ
= Very hard to fix
PIPJ DISLOCATIONS/VOLAR PLATE DISRUPTION
PIPJ dislocation Mechanism of Injury – hyperextension of
the PIP joint with or without dislocation often initial injury seems trivial
X-ray
Dislocation of the PIPJ
Avulsion # of middle phalanx
Disruption of volar plate over the PIP joint
PIPJ dislocation Signs &
Symptoms
• Swelling• Bruising• Pain volar aspect
of PIP joint• Instability or pain
on stress of volar plate
• Decreased range of motion particularly flexion
PIPJ dislocation
If dislocation without # OR If # fragment less than 30%
joint surface
→ reduce then manage conservatively in dorsal
blocking splint (DBS)
Dorsal blocking splint
• PIPJ in 30 degrees flexion
• volar structures off stretch
• slowly increase out to neutral
Not this please !
Because!
Treatment splint 4 - 6/52 weekly adjustments PIPJ from 30
flexion → full extension as stability increases
• Coban for swelling • Flexion exercises within splint• Isolated FDP & FDS flexion
important to prevent adherance to volar plate
• Early mobilisation also assists oedema
PIPJ DISLOCATION
• If collaterals involved need to buddy strap when out of splint• Tape/splint for work for 6 -8/52• Watch for FFC PIPJ in late stages → may need to include extension splinting
Volar Plate Injury / surgery If volar plate repaired post
surgical management same but progress slower
Occasionally flexion exercises are delayed if stability is a concern
#’s
5th Metacarpal Assess ROM and digit
Rotation Usually managed
conservatively
#’s
4th Metacarpal Spiral # Assess ROM and digit
Rotation Tendency to rotate Impacted #’s result in
extension lag = poor function.
UCL Avulsion #
Treat conservatively in splint unless joint subluxation occurring
Skier’s thumb
Treat conservatively in splint unless joint subluxation or stenners lesion is present.
- Usually characterised by lots of oedema, nil end point of stability.- Very difficult to assess with certainty- U/s scan to confirm