KIN 428- Midterm 3 Review

KIN 428- midterm 3 review

What are the 2 main functions of the wrist
Final hand placement
Force transmission
What is the function of the distal radial ulnar joint
Pronation and supination
What bones are involved in the radiocarpal joint
Radius, scaphoid, lunate, triquetrium
List the bones involved in the medial complex
Ulna, radius, lunate, scaphoid.
What is the action of Palmaris longus
Flexion
What is the only wrist muscle that ulnar deviates
Extensor carpi ulnaris
What are the components of the carpal tunnel
Hook of the hamate, flexor retinaculum, carpals, trapezium
How many degrees of ROM does the wrist have in flex/ext, & r/u deviation
Radial/ulnar deviation 20-35
Flex/ext 70-75
What limits wrist ROM
Ligaments and bony contact
How is wrist joint articulation controlled
Liamentous stretch
Carpal contact surface
What are the 2 main classes of ligaments in the wrist/hand
Between carpal rows radiocapitate
Within carpal rows interosseous scaphoid lunate (prox.) hamate capitate (distal)
What is the weber column concept
There are 3 columns in the hand,
Ulnar- control (capitate- lunate)
Central- force bearing (scaphoid)
Radial- thumb control
How does ulnar/radial deviation effect force transmission
Changes the axis of rotation and bone alignment, changes the force loading and transmission through the hand
What joint does palmer flexion occur at
Midcarpal joint
What prevents hyper flexion
As the compressive force on the capitate increases the Lunate extends, ligaments don’t
At which joint does extension happen, what prevents hyperextension
Radiocarpal joint
Ligaments at the mid carpal joint
Explain the “wrist as a link mechanism” for flexion and extension
Capitate, lunate, radius all in line
Scaphoid acts as a slider crank to constrain ROM and absorb force
How does the Capitate lunate radius arangment change during flexion and ext
Flexion Lunate and radius stays same as neutral but the capitate angles down
Extension the lunate and capitate stays the same but the radius rotates up around the lunate
What is the navarror and taleisnik column wrist structure theory based on and how does it work
Concept is based on motion
Have 3 columns
Central – flexion and extension
Lateral – mobile
Medial – rotation
In what order are the perilunate ligaments damaged
Scapholunate
Capitolunate
Triquitrolunate
Dorsal radialcarpal
What happens once you reach the last stage of perilunate instability
The lunate is free to rotate when loaded and can sublux or dislocate
How can you predict the type of injury of the wrist
Injury to the greater arc predicts bone injury
Injury to lesser arc indicates ligament damage, perilunate ligs
How does the ring concept work
Within row carpals have rigid posts to increase stabilization
Mobility occurs at the ulnar (triquitrium- hamate) and radial (scaphoid- trapezium)
If this link is disrupted can get volar or distal instability
What is the point of the tendon pulley model
Want to identify the normal force, or transverse loading on the flexor tendons going through the carpal tunnel.
What is the equation for FN and FS
FN = Ft/R
FS= FN μ
How does the coefficient of friction change during carpal tunnel syndrome
Synovial fluid compromised increasing the μ value thus increasing the shear force
Give evidence for how awkward posture and gender can cause CTS
How do the 2 D advanced tendon models work????
What are the 3 primary degenerative conditions at the wrist
SLAC wrist (50%)
Triscaphhe arthritis (20%)
Both of them (10%)
Describe the SLAC wrist
Cartilage degradation of the radius allows the scaphoid to rotate increasing the stress contact points (doesn’t fit like spoons together)
What are the progression steps in the SLAC wrist
Distal then proximal radioscaphoid
Capitolunate lunate
What is the treatment of SLAC wrist
Depends on the integrity of radiolunate joint
1st- fustion of capitate and lunate (help with force transmission)
2nd- implant a silicone scaphoid which can deform
What would happen if you replaced the scaphoid bone with a hard plastic implant
Radial deviation would occur because it couldn’t deform
What are the symptoms and cause of triscaphe arthritis
Caused by osteoarthritis
S&S aching at base of thumb, weakness, swelling at dorsal joint
What is the treatment of triscaphe arthritis
Fustion of the scaphoid, trapezium and trapezoid to make one big bone
How do you treat a crush injury to the carpus – what carpals are normally affected
Capitate-hamate joint , pisotriquetral when carpal arch is flattened
ORIF
How common are distal radius fractures and how do they occur
Very common, 75% of all bone injuries in the wrist, most broken bone in the arm
FOOSH or auto accident (holding onto the steering wheel)
Explain the distal radius classification method
Based on the direction the fracture occurred
Flexion colles
Extension smiths
Intrarticular  bartons
List distal radius fractures in most to least stable
Colles, smiths
Bartons
What age groups are at risk for distal radius fracture
Children
Elderly
What are childrens fractures called and why
Green stick fractures because their bones are so soft when broken it doesn’t fracture completely through the bone
What are the 2 categories of distal radius fractures, what is the type based on
articular and extra articular
I, II, III, ect based on displacement and rotation
how many parts does the distal radius normally fracture into
4
What are the steps to managing an unstable fracture
Accurate reduction
Restore radial length
Stabilize reduction
Restore medial complex to prevent degenerative distal radial articulation
What is the highest fractured carpal
Scaphoid (70% of all carpal fractures)
When would you used closed reduction techniques
For extra-articular fractures
When do you use open reduction
For commuted or articular fractures
What are the treatment options for distal radius fractures
Conservative closed reduction (casting)
Surgical internal fixation (kwires, plates)
External fixation
What is the timeline for conservative treatments
2 weeks wearing a 3 point case
2 weeks wearing a short cast
Protective wrist brace for 1 month
What is the purpose of wearing a 3 point cast
Creates tension on the back of the hand and compression of the front of the hand to regain radial length and ensure proper bone orientation
Why do you change to the short cast with the conservative treatment
Gives metacarpal movement
Describe the 2 surgical methods to treat colles fractures
Kwires for stable fractures, placed at 45 degrees to prevent recurrent dorsal tilting, cast for 3 weeks, remove k wires after 6 weeks
External fixation used for stable fractures, adhered through the skin with 4 pins (2 radial and 2 metacarpal). Produces traction continually to increase radial length
Volar fixed angle plates for unstable/comminuted fractures, put on volar side to reduce the disturbance on blood supply and more space,
What is the best fixation technique for surgical treatments
Kapandji
What is the problem with external fixation
Can cause a loss of grip strength and ROM
Can lead to infection
What is the main goal and timeline of rehab after distal radial fracture
Need mobility without compromising stability, causing non-malunion
After 8 months should return to function
Why is restoring radial length so important

List 3 types of classification systems for scaphoid fractures
Mayo, ruse, Herbert
What are the 4 types of Herbert fractures
Type A stable acute
Type b unstable acute
Type C delayed union after 6 weeks of casting
Type D nonunion
What are some risk factors for getting a scaphoid fracture
Football/skating
MVA
What gender/age gets scaphoid fracture
Men 20-30
How is the scaphoid divided and how does this change the injury mechanisms
Anatomical sections: distal pole, waist, prox pole
Waist fracture is caused by hyper dorsiflexion and FOOSH
Prox fracture is caused by hyper extension and ulnar deviation
What are the conservative treatments for scaphoid fractures and when are they used
Used for distal and medial scaphoid fractures
Short arm thumb spica cast
How does the SATSC work, how effective is it
Strictly immobilizes tumb movement for 3 weeks to promote proper union
90-100% union in 2 months
What is a surgical method of treatment for scaphoid fractures and when is it used
Finger cot or arc wrist traction tower
Can be used for all types of scaphoid fractures
What are some advantages to the surgical method for treating scaphoid fract
Preserves dorsal blood supply of scaphoid
What is percutaneous & arthroscopic guided fixation
What is a secondary pathology with carpal dislocations
Ligamentous damage which stabilizes carpals
What is the treatment goal of carpal dislocations
Reduction and return to normal function
What dislocation is called the sprained wrist, give symptoms
Scapholunate dislocation
pain on dorsal wrist with extension, minimal swelling
What is damaged in perilunate dislocations and what are the signs
Radiocapitate and radiotriquitrial ligs torn
Lots of volar swelling, dorsal deformity
What is the treatment for perilunate dislocations
Closed reduction (finger trap) or open reduction
Describe the 4 stages of perilunate dislocation
Scapholunate dislocation  60% of the time scaphoid will fracture
Capitolunate dislocation dorsal dislocation of capitate (lesser arc injury) radiocapitate ligament tear
Triquetrolunate dislocation lunotriquetral lig dislocation
Radiolunate dislocation radiocarpal lig damage, lunate is now without lig attachment
What direction does the lunate dislocate
Volarly
How do you test for the different stages of the lunate dislocation
Scapholunate ballotment push up with one hand and down with the other between the scaphoid and lunate
Lunotriquetral ballotment same as above
Scaphoid shift test ulnar/radial deviate while pressing on the joint
Shuck test flex wrist while pressing on the lunate
What diagnostic tools can be used to evaluate lunate dislocation
Video fluoroscopy sequential xrays
Arthrography/arthroscopy
MRI
CT scan (analyses bone displacement)
What are the treatment options for perilunate dislocations
Closed reduction finger trap
ORIF
How does a scaphoid perilunate dissociation symptoms and treatment differ from just perilunate dislocation
Scaphoid is broken so you have to treat it at the same time you are treating the dislocation
This happens frequently
Treatment requires reduction of perilunate dislocation and open repair of scaphoid fracture
What is Kienbock’s disease
Lack of blood supply to lunate leads to necrosis
Who gets Kienbock’s disease
20-40 year old males
What are the symptoms of kienbock’s
Dorsal lunate tenderness
Decreased grip strength and ROM
What are the stages of kienbocks
Transverse fracture
Multiple facture and necrosis
Compression on lunate
Scaphoid rotation and almost no lunate
What are the treatments to each of the stages
Stage 1 immobilization
Stage 2 revascularization and ulnar lengthening
Stage 3 bone fusion or silicon replacement
Stage 4 salvage/joint removal
What types of joints in the hand have synovial joints
MCP,PIP,DIP
What ligaments are on the fingers
Collateral, volar, transverse metacarpal
What are the intrinsic muscles in the hand and how do they differ from extrinsic muscles
Hypo/Thenar muscles are smaller than extrinsic muscles with limited function
They are often useful during diagnosis
How does the thumb ROM differ from the digit ROM
Less flexion and extension range BUT it is capable of ab/adduction 70°
Describe Dequervain’s disease
Radial swelling of tendons of the thumb
What are the symptoms with Dequervains
Pain on radial side especially with forceful grip
Numbness of thumb and index finger
Who gets dequervains
Women between 30-50 because it can be triggered from hormone fluctuations
List the causes of DQV
Repeated wrist and thumb motions
Arthritis
Post trauma
What is the diagnostic test for DQV
Finklesteins where the thumb is tucked behind the digits and you radially and ulnarly deviate to put extra stress on the tendon
If there is pain after doing it for a short amount of time= positive test
What is the problem with Finklesteins test
Lots of false positives
describe are the treatment options for DQV
conservative cortisone, thumb splint, remove exacerbating activity
surgical increase tunnel room,
what is the risk for the surgical treatment of DQV
may result in short or long term loss of function of wrist/thumb
how did gamekeepers thumb get its name
strangling rabbits necks requires high valgus force to the thumb resulting in the failure of the UCL
what other activities increase the risk of gamekeeper thumb
skiing
what is the scientific name for trigger finger and what is it
stenosing tenosynovitis is the swelling of the sheath surrounding the tendon making the tendon get stuck
why is trigger finger called trigger finger
when the digit finally unlocks it extends rapidly like releasing the trigger from a gun
how prevalent is trigger finger
pretty rare less than 3% a year, women and kids most likely to get it
list some risk factors for developing trigger finger
vibrating hand tools
repetitive hand mvmt
sustained grip
rheumatoid arthritis
gout
diabetes
explain the stages of trigger finger
1 pain and discomfort on palmer side of hand
2 snapping during flex/ext
3 digit may be locked in position because tendon sheath swelling is so bad
what are the treatment options for trigger finger
conservative remove exacerbating factors like vibration, corticosteroid injections, splint
surgical increase the space in the tunnel
where does boutonnier disease affect
extensor tendons at the DIP and PIP joints
what is the cause of boutonnier disease
trauma cut, dislocation, avulsion
injury of central slip portion of the extensor tendon
list the symptoms of boutonniers disease
pain swelling joint deformity
what are the conservative and surgical treatments of boutonniers disease
conservative treatment is used on an avulsion injury and it consists of splinting the DIP joint only
Surgical treatments of BD normally repair the tendon or soft tissue or as a last resort fuse the phalanx
What is mallet finger and what is the other name for it
Damage to extensor tendon only at DIP
Baseball finger
List the symptoms of mallet finger
Swelling, pain, loss of joint extension, finger nail detachment, swan neck deformity
What causes mallet finger
Hyper flexion of DIP
How does rate of injury affect the type of MF
Rapid loading indicates extensor tendon tear (this is most common)
A slow rate of loading is often indicative of an avulsion (where a piece of the bone comes off too)
What are the conservative and surgical treatments for MF
ConservativeMUST Immobilize the DIP joint to eliminate flexion. don’t over extend though or skin dies
Surgical pins placed in finger to hold tendon in tact
When is the surgical method chosen for MF
If the conservative method couldn’t adequately reduce it
List the complications to the surgical method of treating MF
Stiffness, infection, healing probs
What are the 4 steps to MF rehab
Passive ROM (straighten injured joint with other hand)
Finger lift ( palm on table lift fingers)
Make fist
Pick up small objects
Describe bowlers thumb
Lesion on the digital nerve of the thumb, occurs to the side of the thumb where theres less padding
What is intersection syndrome
Inflam of tendons before entering the wrist, caused by stressful activities for wrist extensors
Who gets carpal tunnel syndrome and what is it
Women (5 times more likely) between 30-60
Compression of the median nerve going through the carpal tunnel which is made of the carpal bones, flexor retinaculum ,
List some of the causes of carpal tunnel syndrome
Pressure increase pregnancy, diabetes
Work factors repetition, vibration, awkward posture, force ect
Lifestyle smoking, obesity, caffeine
What are the symptoms of CTS
Numbness in radial side of hand
Pain in wrist neck and shoulder
Thenar wasting
Difficulty grasping/holding objects
If untreated what can CTS cause
Ischemia, nerve dysfunction
Describe some of the tests that can diagnose CTS
Phalens test upside down prayer
Tinel’s sign tap over median nerve, pain indicates positive test
Pressure measurment/nerve conduction
Describe the conservative treatments of CTS
Anti inflam / cortisone
Wrist brace
Remove stressor
PT
What are surgical options for treatment of CTS
Open Release palmer fascia and FR to increase space in carpal tunnel through scar tissue covering
Endoscopic 2 incisions that cut FR, dicey
What is the rehab protocol for CTS
No gipping and pinching for 6 weeks
Gradual strengthening and increase ROM
What are the components of ulnar tunnel syndrome
Pisiform, hook of hamate
What is the difference between bennets and rolando thumb fractures
Bennets is intra-articular fracture/dislocation and rolando is intra-articular commuted
What type of IP joint dislocates more often and in what direction
PIP and dorsally
What is the cause and treatment of PIP dislocations
Trauma involving hyper flexion and extension, or atrauma from lax ligs
Treatment is traction with hyper extension and splint for 2-3 weeks, buddy tape for 3-6 weeks
Define contracture
abnormal shortening of muscle, tendon ect.