SECTION F: WRIST AND HAND DISORDERS

CONDITION/SYNONYM

• BD

ICD-9-CM CODE

• 736.21 Boutonnière deformity

ICD-10-CM CODES

• M20.02 Boutonnière deformity

• M20.021 Boutonnière deformity of right finger(s)

• M20.022 Boutonnière deformity of left finger(s)

• M20.029 Boutonnière deformity of unspecified finger(s)

PREFERRED PRACTICE PATTERN

• 4E: Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation¹

KEY FEATURES

Description

• Generally from a forceful blow to a flexed finger

• Severed central slip tendon

• Signs and symptoms may develop in acute to subacute phase of injury

• Flexion of the PIP joint and extension of the distal interphalangeal (DIP) joint²

• Injury to the central slip tendon and often damage to the volar plate

• Volar displacement of the lateral bands

• Shortening of the oblique retinacular ligament

Essentials of Diagnosis

• Diagnosis is usually made by clinical examination or x-ray

• Assess finger ROM

• Boutonnière classification

  • I: Mild extension lag, passively correctable

  • II: Moderate extension lag, passively correctable

  • III: Mild flexion contracture

  • IV: Advanced flexion contracture

General Considerations

• Symptoms can occur up to a few weeks after trauma

• Inflammation around the joint

• Can be associated with trauma (forceful blow or cut of the tendon)

• Rheumatoid arthritis

Demographics

• Adults

  • Hit or blow onto the finger, basketball³

CLINICAL FINDINGS

Functional Implications

• Pain with grasping, holding objects

• Inability to fully extend the finger

Possible Contributing Causes

• Trauma

• Rheumatoid arthritis

• Central slip tendon injury

• Joint arthritis/injury

• Nerve damage

• Burns

• Infection

• Osteoarthritis

Differential Diagnosis

• Fracture

• Gout

• Mallet finger

• PIP joint flexion contracture

MEANS OF CONFIRMATION

• Imaging

  • X-ray

FINDINGS AND INTERPRETATION

• X-ray may show a bone spur

  • Location

  • Size

TREATMENT

Medication

• Anti-inflammatory

• Corticosteroid injection

MEDICAL PROCEDURES

• Surgery in the case of RA, severed tendon, or minimal improvement with splinting

• Repair of the extensor tendon

IMPAIRMENTS

• Pain with grasping objects for work and daily activities

TESTS AND MEASURES

• Haines–Zancolli test

• Thenar muscle strength test (lateral pinch dynamometry)

• Manipulative ability test (nine-hole peg test)

INTERVENTION

• Rest, to reduce inflammation

• Bracing/Splinting

• Safety pin splinting is applied for approximately 4 to 6 weeks to help straighten the finger

• Taping techniques

• Address swelling and pain

  • Ice

• Address pain

  • Ice

  • Massage

  • Joint mobilization

  • Electric stimulation

  • Infrared

• Address weakness and joint instability

  • Strengthening of extensors

• Address lack of flexibility

  • Stretching

    • Intrinsic flexor stretching

    • Fluidotherapy

• Address joint mobilization

  • DIP glides and rotation

• Address soft tissue mobilization

FUNCTIONAL GOALS

• Patient will be able to

  • Open hand to place around a jar to open.

  • Fully extend the finger to don/doff gloves.

PROGNOSIS

• Good if early treatment; focus on stretching out the flexors.

• Surgery may be indicated if the flexion becomes severe.

• If associated with fragment fracture, 1 to 6 weeks of immobilization.

REFERENCES

ADDITIONAL REFERENCES

ICD-9-CM CODES

• 715 Osteoarthrosis and allied disorders

• 715.14 Osteoarthrosis localized primary involving hand

• 715.24 Osteoarthrosis localized secondary involving hand

• 715.9 Osteoarthrosis unspecified whether generalized or localized

• 715.94 Osteoarthrosis unspecified whether generalized or localized involving hand

ICD-10-CM CODES

• M18.9 Osteoarthritis of first carpometacarpal joint, unspecified

• M19.049 Primary osteoarthritis, unspecified hand

• M19.249 Secondary osteoarthritis, unspecified hand

PREFERRED PRACTICE PATTERNS

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders

• 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty

• 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery

KEY FEATURES

Description

• Most common form of osteoarthritis (OA)

• Degenerative

• Commonly affects hand and weight-bearing joints

• Can also affect interphalangeal joints and first metatarsophalangeal joint

• Associated with increasing age, obesity, sex, and race/ethnicity

• Associated with abnormal loading of the joints

• Characterized by joint pain

• Arthrosis

• Osteoarthrosis

• Polyarthrosis

• Degenerative joint disease

Essentials of Diagnosis

• Radiography is a standard method for diagnosis

• Kellgren and Lawrence (KL) grade ≥2 (definite radiographic OA)¹

• Osteophytes, joint-space narrowing, sclerosis

• Also cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis

• Erosion of articular cartilage

• Synovial hyperplasia

• Fibrosis

• Inflammatory cell infiltration

• Conventional radiograph is the most commonly used tool in OA

• Diagnosis is made based on a careful history taking, physical examination, imaging studies, laboratory examination, and exclusion of other possible diseases

General Considerations

• Low bone mineral density (BMD)

• Repetitive joint use or loading

• Joint alignment

• Bone or joint morphology

• Calcification (e.g., of the knee meniscus)

• Bone formation, cyst formation

• Thickening of subchondral bone plate, osteosclerosis

• Overall joint dysfunction

• Joint swelling and inflammation (in certain cases, severe cases)

• Joint pain

• Morning stiffness

• Long-term disease

  • Secondary problems

    • Muscle atrophy and weakness

    • Bony protrusion/prominence

    • Joint deformity

    • Grasping difficulty

    • Difficulty with activities of daily living (ADLs)

Demographics

• Increase in age (middle to older age)

• Women are more affected than men

• Affects African Americans and Caucasians

• May affect about 12% of the population (United States and other developed countries)²

CLINICAL FINDINGS

Functional Implications

• Limited mobility

• Household- and work-related activity limitation/restriction

• Decreased overall activity and participation

Possible Contributing Causes

• Chronic factors affecting the joint

  • Obesity

  • BMD

  • Leg length discrepancy (LLD)

• Aging

• Chronic and vigorous joint loading

• Previous chronic joint injury (e.g., accident, trauma), hence secondary OA

Differential Diagnosis

• Carpal tunnel syndrome

• Cervical radiculopathy

• Fibromyalgia syndrome

• Gout

• Rheumatoid arthritis

• Spondyloarthropathy

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Not required: Synovial fluid examination

• Other laboratory tests can be performed to rule out other conditions

Imaging

• Conventional radiograph of the joint

• MRI of the joint

• Diagnostic ultrasound of the joint and synovium

FINDINGS AND INTERPRETATION

• OA is a clinical diagnosis that can be based on:

  • Persistent usage-related pain in the joint(s)

  • Age ≥ 45 years²

  • Morning stiffness equal or less than 30 minutes²

  • Imaging studies (e.g., radiograph)

    • Osteophytes, joint-space narrowing, sclerosis

    • Also cartilage lesions, bone marrow lesions, synovitis, effusion, and subchondral bone attrition/sclerosis

  • Erosion of articular cartilage

TREATMENT

Medication

• NSAIDs (including topical NSAIDs, capsaicin)

• Acetaminophen

• Opioids

• Glucosamine and chondroitin sulfate

• Glucocorticoids or corticosteroids

• Intra-articular injections (corticosteroids, hyaluronic acid)

• Emerging drugs such as anti-TNF, calcitonin, growth factors, and nerve growth factor antibodies

MEDICAL PROCEDURE

• Surgery: Total joint replacement, joint lavage and debridement

IMPAIRMENTS

• Mobility

• Self-care

• Role at home and in the community

• School and work

• Recreation, leisure, and sports

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Resisted isometric testing

• Finkelstein test

INTERVENTION

• Exercises (resistance, endurance, and flexibility)

• Training on ADLs

• Use of assistive or adaptive devices

• Heat therapy

• Rest

• Orthoses, splints

• Ice

• Acupuncture

• Pain management

• Energy conservation techniques

• Joint protection

• Ultrasound

• Electric stimulation

• Patient education

FUNCTIONAL GOALS

• Patient will be able to

  • Improve joint mobility and stability to improve grasping.

  • Improve muscle and general (aerobic) endurance.

  • Improve activity and participation related to role at home, at work, and in the community.

  • Return to pain-free ADL, sweeping, mopping.

  • Turn a key or door knob, pain free.

  • Lift baby crib without pain and maintain a neutral wrist posture.

PROGNOSIS

• No definite cure for OA.

• Treatment is for symptoms, but emerging drugs may modify OA disease mechanism.

• Joint damage is irreversible.

• Recovery or relief from symptoms may depend on disease duration and timely intervention.

• OA is a chronic disease and may mean long-term burden.

• May affect prognosis: Demographics, severity and natural history of the disease, medical comorbidities, and behavioral comorbidities such as fear avoidance, catastrophization, and central sensitization.

• Competent general endurance, good muscle strength, and mobile joints are good prognosticating factors.

• Motivation and compliance with PT intervention (e.g., home exercise program) and family and environmental support could also improve PT treatment outcomes.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Colles’ fracture

ICD-9-CM CODES

• 813.41 Colles fracture closed

• 813.51 Colles fracture open

ICD-10-CM CODES

• S52.539A Colles fracture of unspecified, radius, initial encounter for closed fracture

• S52.539B Colles fracture of unspecified radius, initial encounter for open fracture type I or II

• S52.539C Colles fracture of unspecified radius, initial encounter for open fracture type IIIA, IIIB, or IIIC

PREFERRED PRACTICE PATTERN

• 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture¹

KEY FEATURES

Description

• Fracture³

• Any defect in continuity of the distal radius

• Displaced (distal radius is moved on either side of the fracture) or nondisplaced (distal radius has not moved)

• Closed (skin intact) or open (skin breached)

Essentials of Diagnosis

• Diagnosis usually made by clinical examination

• May not be fracture, but distal radioulnar subluxation/dislocation, wrist sprain

General Considerations

• Radius is the most commonly broken bone in the arm

• Most common fracture site in children (35.8%–45% of all pediatric fractures)

Demographics

• In pediatric population, higher frequency among boys than girls

CLINICAL FINDINGS

Functional Implications

• Pain with weight bearing on involved forearm and hand

• Pain with vertical positioning of arm at side

• Pain with all movements (passive, active)

Possible Contributing Causes

• Osteoporosis

• Mechanisms of injury

  • Fall on outstretched hand with the wrist in extension

  • Direct impact

Differential Diagnosis

• Distal radioulnar subluxation or dislocation

• Wrist sprain

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray for fracture, often limited view⁴

• CT for detailed imaging⁴

• MRI

• Ultrasonography may be used in pediatric population

FINDINGS AND INTERPRETATION

• Pain and crepitus with passive or active ROM in the wrist and forearm

• Visible wrist deformity

• Upper extremity held in protective position to avoid gravitational distraction of the joint

• Muscle guarding with all movements

• Inability to actively perform wrist movements or forearm pronation/supination secondary to pain

• If vascular structures involved, affected hand will appear cool, pale, diminished palpable pulse

• If neurologic structures involved, individual will report numbness, decreased ability to move the affected hand

IMPAIRMENTS

• Inability to

  • Perform ADLs with involved upper extremity

  • Bear weight on involved forearm and hand

  • Write with involved hand (especially if dominant hand affected)

  • Grab a cup secondary to pain and muscle weakness

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Joint mobility

• Strength assessment

• Sensory testing

• Reflex testing

• Vascular assessment

INTERVENTION

• Address swelling

  • Ice/cryotherapy⁵

  • Compression

  • Elevation

  • Electrical stimulation⁶

• Address pain

  • Ice/cryotherapy⁵

  • Massage

  • Electrical stimulation⁶

• Address lack of flexibility via stretching

  • Wrist flexors

  • Wrist extensors

  • Elbow flexors

• Address mobilization upon healing of fracture site (after 6 weeks postoperative)

  • Distal radioulnar joint dorsal glide for supination

  • Distal radioulnar joint volar glide for pronation

  • Radiocarpal joint distraction for pain management

  • Radiocarpal joint dorsal glide for wrist flexion

  • Radiocarpal joint volar glide for wrist extension

  • Radiocarpal joint radial glide for wrist ulnar deviation

  • Radiocarpal joint ulnar glide for wrist radial deviation

• Address weakness via strengthening activities

  • Closed chain weight-bearing activities

  • Isometric exercises (submaximal initially)

  • Open chain with free weights and resistance bands

  • Grip strengthening

• Address scar mobility

  • Scar tissue mobilization progressing from parallel to perpendicular upon wound closure

FUNCTIONAL GOALS

• Patient will have increased

  • Grip strength to 30 kg in order to open jars.

  • Forearm supination to 55 degrees in order to facilitate eating with fork.

  • Wrist-flexor strength to 4 out of 5 muscle strength score to carry a briefcase.

  • Distal radioulnar joint mobility to 3 in order to open doors.

PROGNOSIS

• Good, though recovery takes approximately 1 year.

• Some residual stiffness and ache expected for up to 2 years or permanently; more common among the following populations.

  • High-energy impact trauma (e.g., motorcycle accident).

  • Individuals aged 50 years or older.

  • Individuals with osteoarthritis (OA).

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Washerwoman’s sprain

• Radial styloid tenosynovitis

• de Quervain tenosynovitis

• de Quervain disease

• de Quervain stenosing tenosynovitis

• Mother’s wrist

• Mommy thumb

ICD-9-CM CODE

• 727.04 Radial styloid tenosynovitis

ICD-10-CM CODE

• M65.4 Radial styloid tenosynovitis [de Quervain]

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation¹

KEY FEATURES

Description

• Inflammation and thickening of the abductor pollicis longus and extensor pollicis brevis synovial tendon sheaths and extensor retinaculum²

• Named after Swiss surgeon, Fritz de Quervain

• Chronic tendinosis

Essentials of Diagnosis

• Tenderness with palpation

• Positive resisted isometric test in thumb abduction and extension

• Finkelstein test is best for diagnosis³

General Considerations

• Entrapment tendonitis, tendon friction

• Often a direct result of repetitive stress or chronic overuse of extensor and abductor muscles causing excessive friction to tendon sheath

• Patients likely to develop adhesions and irritation between tendons and their sheaths

Demographics

• Mostly found in women aged 30 to 50 years, possibly due to great angle of the styloid process

• Common among individuals who perform any activity requiring repetitive hand and wrist movement

• At-risk populations include

  • Massage therapists

  • Musicians

  • Milliners

  • Gardeners

  • Office workers

  • Pregnant and postpartum women

CLINICAL FINDINGS

Functional Implications

• Pain with pinching, grasping, squeezing, holding heavy objects, wringing

• Pain with movements of the hand and wrist

• Loss of strength

• Tendon rupture

Possible Contributing Causes

• Occupations that require repetitive use of hands for excessive periods of time

• A direct trauma to the tendon or wrist

• Inflammatory arthritis, such as rheumatoid arthritis

Differential Diagnosis

• Rheumatoid arthritis

• Carpal tunnel

• Osteoarthritis

• Intersection syndrome: Pain 2 to 3 inches proximal to the wrist

• Infection

• Dorsal wrist ganglion (tumor)

• Trigger finger

• Scaphoid fracture (history of trauma, tenderness over snuffbox)

• Wartenberg syndrome: Radial nerve entrapment at the forearm

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray to rule out arthritis at the thumb CMC joint

• MRI

FINDINGS AND INTERPRETATION

• MRI will often show acute inflammation or chronic tendinosis

TREATMENT

Medication

• NSAIDs⁴

• Cortisone injection

IMPAIRMENTS

• Hand weakness with grasping, squeezing, pinching

• Restricted ROM in thumb abduction and extension

TESTS AND MEASURES

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Resisted isometric testing

• Finkelstein test²

INTERVENTION

• Acute stage

  • Rest

  • Cold laser⁶

  • Ultrasound⁷

  • Ice to reduce inflammation and swelling⁸

  • Wrist/thumb splint 3 to 4 weeks, early splint compliance essential

• Subacute stage

  • Stretching exercises

  • Eccentric exercises

• Chronic stage

  • Surgery only after conservative treatment has been exhausted

• Address weakness

  • Stretching and strengthening program

  • Hand coordination exercises, such as gripping and pinching

  • Ensure patient knowledge regarding home exercise program

  • Educate patient in postural awareness and proper body mechanics

  • Hand/wrist-joint protection strategies

FUNCTIONAL GOALS

• Patient will be able to

  • Grasp a gallon of milk pain-free with both hands.

  • Resume pain-free ADLs, sweeping, mopping.

  • Turn a key or door knob pain-free.

  • Lift baby from crib without pain, maintaining neutral wrist posture.

PROGNOSIS

• Most cases last between 4 and 8 months.

• Prognosis is very good.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Morbus Dupuytren

• Dupuytren disease

• Palmar fasciitis

• Palmar fibromatosis

ICD-9-CM CODE

• 728.6 Contracture of palmar fascia

ICD-10-CM CODE

• M72.0 Palmar fascial fibromatosis [Dupuytren]

PREFERRED PRACTICE PATTERN

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction¹

KEY FEATURES

Description

• Usually painless thickening of the fascia, contraction of palmar fascia (aponeurosis)

• Nodules develop along longitudinal tension lines

• Characterized by development of nodules in the palmar and digital fascia

• Can be associated with other fascial contractures

  • Feet (Ledderhose disease), callus under foot with curling of toes

  • Penis (Peyronie disease), curvature

  • Garrod knuckles, pads on back of finger knuckles

• Named after Baron Guillaume Dupuytren

• Viking disease

Essentials of Diagnosis

• Classified into three biologic stages:

  • First stage (proliferative stage): Intense proliferation of myofibroblasts (cells believed to generate the contractile forces responsible for tissue contraction) and formation of nodules

  • Second stage (involutional stage): Represented by alignment of the myofibroblasts along lines of tension

  • Third stage (residual stage): Tissue becomes mostly acellular and devoid of myofibroblasts, only thick bands of collagen remain

General Considerations

• Not usually associated with trauma, but can develop

• after surgery

• Unknown etiology, possibly autoimmune

• Usually bilateral with one side more severely affected

• Early stages based on palpable nodule, characteristic skin changes, changes in fascia, progressive joint contracture

• Skin changes caused by a retraction of skin, creating dimples or pits

Demographics

• Caucasian with Scandinavian/Northern European decent

• Usually associated with family history

• Rare with children

• Men 7 to 15 times more likely than women to require surgery

• Females develop less severe cases

• Incidence increases with age >40 years

• Higher incidence among people with alcoholism, diabetes, epilepsy

CLINICAL FINDINGS

Functional Implications

• Limitation in opening hand, extending fingers fully

• Can limit ability to shake hands

Possible Contributing Causes

• Smoking may decrease vascular changes in the hands

• Alcoholism³

• Epilepsy⁴

• Pulmonary tuberculosis⁵

• Diabetes

• Liver disease or cirrhosis

  • Heredity: heterogeneous

  • Higher expression levels of the fibroblast growth factor 9 gene

• Effect androgen receptors in males

• Genetic association with chromosomes^6,11,16

Differential Diagnosis

• Dupuytren contracture; a fixed-flexion contracture of the hand

MEANS OF CONFIRMATION OR DIAGNOSIS

Diagnostic Procedures

• Imaging not usually necessary

FINDINGS AND INTERPRETATION

• Cord-like thickening of the skin around the fourth and fifth fingers

TREATMENT

Surgery

• Surgery to skin graft and remove contracture

  • Return of fibrosis is common

Medication

• Enzyme injection

  • Triamcinolone

  • Collagenase clostridium

• Histolyticum (Xiaflex) to soften and break down taut bands

IMPAIRMENTS

• Restricted movement of the hand and fingers

• Hand deformity

• Difficulty wearing gloves or placing hand in pockets due to the inability to straighten fingers

TESTS AND MEASURES

• Visual and palpation for thickened scar tissue (fibrosis)

• Tabletop test; negative if able to lay hand flat on a table, palm down

• Skin pliability

INTERVENTION

• Scar management

• Stretching, massage, heat, paraffin

• Splinting

• Breaking apart the cords

  • Dry needling/acupuncture

  • Surgery⁶

FUNCTIONAL GOALS

• Patient will be able to

  • Open fingers and hand so as to put on gloves.

  • Lay hand flat on a table, palm down.

PROGNOSIS

• Can remain functional with treatment.

• Does not progress at any specific rate.

• Develops slowly over decades.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Thumb ulnar collateral ligament (UCL) tear

• Thumb UCL sprain

• Skier’s thumb

• Breakdancer’s thumb

ICD-9-CM CODE¹

• 842.12 Sprains and strains of metacarpophalangeal (joint) of hand

ICD-10-CM CODES²

• S63.649A Sprain of metacarpophalangeal joint of unspecified thumb, initial encounter

• S63.659A Sprain of metacarpophalangeal joint of unspecified finger, initial encounter

PREFERRED PRACTICE PATTERN³

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Connective Tissue Dysfunction

KEY FEATURES

Description

• Injury involving the UCL of the MCP joint in the first ray (thumb)

• Acute or repeated forceful abduction (valgus force) to the proximal phalanx results in ligamentous disruption

• Instability of the MCP joint

• Forced extension or abduction of the proximal phalanx of the thumb

Essentials of Diagnosis

• Gamekeeper’s thumb is ligamentous disruption of the UCL of the first MCP joint due to acute or repeated valgus stress to the thumb.

• Presents as instability and/or pain with valgus forces to the thumb or pain and weakness with opposition or pinching.

• Tenderness or swelling may be present at medial aspect of the thumb.

• Valgus stress to the UCL of the first MCP joint will result in asymmetric laxity compared to uninvolved side or lack of an end point.

General Considerations

• Injury can be either acute or chronic and is common in athletics (especially skiing and football).

• Injury involves valgus force to the proximal phalanx of the thumb.

• Injury can also involve an avulsion fracture of the base of the proximal phalanx, which is termed “gamekeeper’s fracture.”

• Plain-film radiographs are beneficial to rule out fracture.

• Manage surgically or nonsurgically depending upon severity of signs and symptoms and orthopedic physician recommendations.

Demographics

• Common in athletes, typically involving a fall (football), impact from a ball (basketball), or repeated stress (skiing)

• Seen in fowl hunters

CLINICAL FINDINGS

Functional Limitations

• Difficulty and/or pain when

  • Grasping dishes, utensils, or drinking cups due to pain and weakness

  • Grasping and turning steering wheel

  • Turning doorknob

Possible Contributing Causes

• Participation in activities or sporting events that involve repeated valgus stress to the proximal phalanx in the thumb

• Participation in contact sports

• Generalized ligamentous laxity

Differential Diagnosis

• Gamekeeper’s fracture

• Fracture of the base of the first metacarpal bone (Bennett fracture)

• Distal metacarpal fracture

• Proximal phalanx fracture

• Extensor tendon rupture (boutonnière deformity)

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Radiographs to rule out fracture

• MRI

FINDINGS AND INTERPRETATION

• MRI may show increased fluid/edema at the medial MCP joint and can assess integrity of the UCL

TREATMENT

Medication

• NSAIDs

• Corticosteroid injection

MEDICAL PROCEDURES

• Recommended for grade II tears and avulsion fractures

• Involves open reduction internal fixation if displaced fracture present

• Involves repairing UCL or allograft replacement

IMPAIRMENTS

• Decreased strength and pain for grasping activities (e.g., dressing and eating)

• Decreased strength, pain, and/or instability of the MCP joint with pinching activities (e.g., turning a key)

TESTS AND MEASURES

• Upper limb tension test (ULTT)

• Valgus stress to the UCL of the first MCP joint

  • Valgus stress test to the proximal phalanx at 0 degrees of extension and 30 degrees of flexion to test the accessory collateral ligament and UCL, respectively

• Self-reported symptoms on the Katz hand diagram⁵

• Sensory loss may include diminished two-point discrimination, decreased vibration sense, increased threshold in Semmes-Weinstein monofilament test

• Flick sign

• Thenar muscle strength test (lateral pinch dynamometry)

• Manipulative ability test (nine-hole peg test)

INTERVENTION

• Acute phase

  • PRICE: Protection, Rest, Ice Compression, Elevation

  • Splinting (thumb spica)

  • Ice massage

  • Pulsed ultrasound

  • Avoiding activities that provide valgus stress to the thumb

• Chronic phase

  • Gradually increase workload as pain and discomfort diminish

  • Continue taping or splinting when patient returns to sport participation

  • Addressing pain

    • Ice

    • High-voltage pulsed stimulation

    • Iontophoresis

    • Ultrasound

    • Extracorporeal shockwave therapy

  • Addressing swelling

    • Ice

    • Elevation

  • Addressing Weakness, joint instability

    • As symptoms improve, gradually resume activities, with thumb spica taping for sports activities

    • Establish full, pain-free thumb ROM

    • Taping/splinting for sports participation thereafter until valgus stress is pain-free and stable

    • Incorporate stretching and progressive strengthening exercises as warranted to restore full mobility and strength.

FUNCTIONAL GOALS

• Patient will be able to

  • Turn doorknob and key without weakness, instability, or pain.

  • Use all kitchen and dining utensils without weakness, instability, or pain.

  • Lift a gallon milk carton from refrigerator at shoulder level, pain free.

  • Turn the key in her car and front door, pain free.

  • Use garden tools, pain free.

PROGNOSIS

• Good. Healing can be prolonged if rest/immobilization period is inadequate due to sports participation.

• Time periods of immobilization may vary depending upon degree of UCL injury.

• Immobilization period common, typically 3 weeks.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/SYNONYMS

• Baseball finger

• Dropped finger

ICD-9-CM CODE

• 736.1 Mallet finger

ICD-10-CM CODE

• M20.019 Mallet finger of unspecified finger(s)

PREFERRED PRACTICE PATTERN

• 4E: Impaired joint mobility, motor function, muscle performance, and ROM associated with localized inflammation¹

KEY FEATURES

Description

• Distal joint of the finger is bent into a claw-like position

• Usually due to trauma from impact on tip of the finger²

• Flexor muscles, fascia, tendons shorten

• Disruption of the extensor tendon, 15 to 20 degree loss of DIP finger extension

• Flexion of the DIP joint

Essentials of Diagnosis

• Diagnosis is usually made by clinical examination or x-ray

• Finger extension strength, often extensor digitorum communis injury

General Considerations

• Swelling

• Inflammation around the joint

• Can be associated with fracture, children type IV epiphyseal fracture³

• Altered joint position

Demographics

• Adults

  • Hit or blow onto the finger tip from sports, i.e., basketball³

CLINICAL FINDINGS

Functional Implications

• Pain with grasping, holding objects

• Inability to extend the finger

• At risk of injury in factories as finger not in alignment with the others and can get caught or injured

Possible Contributing Causes

• Muscle imbalance

• Extensor digitorum communis injury

• Trauma

• Joint arthritis/injury

• Muscle atrophy

• Nerve damage

• Osteoarthritis

• Rheumatoid arthritis

Differential Diagnosis

• Gout

• Boutonnière deformity

• Stress fracture

MEANS OF CONFIRMATION

• Imaging

  • X-ray

FINDINGS AND INTERPRETATION

• Bone spur, location and size

TREATMENT

Medication

• Anti-inflammatory

• Surgery to straighten out the finger and lengthen ligaments/tendons

IMPAIRMENTS

• Pain with grasping objects for work and daily activities

TESTS AND MEASURES

• Thenar muscle strength test (lateral pinch dynamometry)

• Manipulative ability test (nine-hole peg test)

INTERVENTION

• Rest, to reduce inflammation

• Bracing/splinting for 6 weeks until extensor lag at the PIP joint is resolved

• Taping techniques

• Address swelling and pain

  • Ice

• Address pain

  • Ice

  • Massage

  • Joint mobilization

  • Electric stimulation

  • Iontophoresis

  • Infrared

• Address weakness and joint instability

  • Strengthening of extensors

• Address lack of flexibility

  • Stretching

    • Intrinsic flexor stretching

    • Fluidotherapy

• Address joint mobilization

  • DIP glides and rotation

• Address soft-tissue mobilization

FUNCTIONAL GOALS

• Patient will be able to

  • Unclench hand to place around a jar to open.

  • Fully extend the finger to don/doff gloves.

PROGNOSIS

• Good; focus on stretching out the flexors.

• Surgery may be indicated if the flexion becomes severe

• If associated with fragment fracture, 1 to 6 weeks of immobilization.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Navicular fracture of the hand

ICD-9-CM CODES¹

• 814.01 Closed fracture of navicular (scaphoid) bone of wrist

• 814.11 Open fracture of navicular (scaphoid) bone of wrist

ICD-10-CM CODES²

• S62.009A Unspecified fracture of navicular (scaphoid) bone of unspecified wrist, initial encounter for closed fracture

• S62.009B Unspecified fracture of navicular (scaphoid) bone of unspecified wrist, initial encounter for open fracture

PREFERRED PRACTICE PATTERN³

• 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture

KEY FEATURES

Description

• Any defect in continuity of the scaphoid (carpal bone)

• Displaced (scaphoid is moved on either side of the fracture) or nondisplaced (scaphoid has not moved)

• Closed (skin is intact) or open (skin is breached)

Essentials of Diagnosis

• Diagnosis is usually made by clinical examination

• May not be a fracture but a wrist sprain, Colles fracture, distal radioulnar subluxation/dislocation, or fracture of any other carpal bone

General Considerations

• Most frequently fractured carpal bone (71% of all carpal bone fractures)

Demographics

• Occurs in young and middle-aged adults 15 to 60 years of age

• Men aged 20 to 30 years are most likely to suffer from a scaphoid fracture

CLINICAL FINDINGS

Functional Implications

• Pain with weight-bearing activities on involved hand

• Pain with wrist and thumb movements (passive or active)

• Pain when gripping something

Possible Contributing Causes

• Mechanism of injury

  • Fall on outstretched hand

  • Direct impact (i.e., athletic activity, motor vehicle accident)

Differential Diagnosis

• Colles fracture

• Distal radioulnar subluxation/dislocation

• Wrist sprain

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray for fracture, often limited view

• Computed tomography (CT) scan for detailed imaging

• MRI

FINDINGS AND INTERPRETATION

• Pain with passive/active ROM of the wrist and thumb

• Wrist will often be held in radial deviation

• Muscle guarding with all movements

• Inability to actively perform wrist or thumb movements secondary to pain

• Pain with gripping activities

IMPAIRMENTS

• Inability to perform activities of daily living with involved hand

• Inability to bear weight on involved hand

• Inability to use involved hand to write (especially if it is patient’s dominant hand)

• Inability to grab a cup or open a door secondary to pain and muscle weakness

TESTS AND MEASURES

• Grip strength

• Flick sign

• Thenar muscle strength test (lateral pinch dynamometry)

• Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function

• Manipulative ability test (nine-hole peg test)

• Watson test

INTERVENTION

• Address swelling

  • Ice/Cryotherapy

  • Compression

  • Elevation

  • Electrical stimulation

• Address pain

  • Ice/cryotherapy

  • Massage

  • Electrical stimulation

  • Address lack of flexibility via stretching

  • Wrist flexors

  • Wrist extensors

  • Thumb carpometacarpal extensors

  • Thumb metacarpophalangeal joint extensors

• Address mobilization upon healing of fracture site (6 weeks postoperative)

  • Radiocarpal joint distraction for pain management

  • Radiocarpal joint dorsal glide for wrist flexion

  • Radiocarpal joint volar glide for wrist extension

  • Radiocarpal joint radial glide for wrist ulnar deviation

  • Radiocarpal joint ulnar glide for wrist radial deviation

  • Carpal gliding

• Address weakness via strengthening activities

  • Closed chain weight-bearing activities

  • Isometric exercises (initially submaximal)

  • Open chain via use of free weights and resistance bands

  • Grip-strengthening activities

• Address scar mobility

  • Scar tissue mobilization progressing from parallel to perpendicular upon wound closure

• Address functional use of hand

  • Finger opposition

  • Finger dexterity

  • Gripping cups/doorknobs/jars

FUNCTIONAL GOALS

• Patient will

  • Increase grip strength to 30 kg in order to facilitate bringing a glass to the mouth.

  • Increase wrist extension to 45 degrees in order to facilitate turning a doorknob.

  • Increase wrist flexor strength to 4/5 in order to facilitate carrying groceries.

  • Increase scapholunate joint mobility to 3 in order to allow the individual to use the telephone.

PROGNOSIS

• Good; however recovery varies based on length of time for fracture to heal.

• Some individuals report residual wrist stiffness and ache even after the fracture has healed.

• Nonunion is more common in scaphoid fractures secondary to poor blood supply.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Duck-bill deformity

• Recurvatum deformity

• Volar plate injury

ICD-9-CM CODE¹

• 736.22 Swan-neck deformity

ICD-10-CM CODES²

• M20.03 Swan-neck deformity

• M20.031 Swan-neck deformity of right finger(s)

• M20.032 Swan-neck deformity of left finger(s)

• M20.039 Swan-neck deformity of unspecified finger(s)

PREFERRED PRACTICE PATTERN³

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction

KEY FEATURES

Description

• Injury or loosening of the volar plate (ligament connecting proximal and middle phalanx that prevents hyperextension of the PIP)

• Hyperextension of the PIPjoint and flexion of the DIP joint

• Duck-bill deformity is the same issue in the thumb less one joint

Essentials of Diagnosis

• RA most common cause of swan-neck deformity

• Chronic inflammation loosens the volar plate and disrupts ligaments and other connective tissues making PIP susceptible to hyperextension

• Migration of the lateral bands of the extensor hood dorsally, to become extensor forces at the PIP

  • This neutralizes the oblique retinacular ligaments’ ability to influence extension of the DIP, resulting in imbalance between the flexors and extensors which results in flexion of the DIP

• As a result, extensor tendon tightens causing DIP to pull into flexed position

• Swan-neck classification by Nalebuff⁴

  • I: PIP joint flexible in all positions

  • II: PIP motion limited only by tenodesis effect

  • III: Fixed PIP joint contracture, x-ray normal

  • IV: X-ray shows arthritic changes

General Considerations

• Pain and swelling of the PIP

• Can be managed surgically or nonsurgically depending upon signs and symptom severity, response to conservative treatment, and orthopedic physician recommendations

• Disruption of the hood and joint capsules results in a cascade of deformities

  • Ulnar drift can result from the EDC losing its dorsal position over the MP, volar subluxation of the MP (the result of the absence of extensor forces, leaving intrinsics and finger flexors unopposed in flexion)

  • Wrist radial deviation as a result of the patients attempt to bring the ulnarly deviated fingers into axial alignment for function

• Other causes include trauma, nerve injury such as cerebral palsy, Parkinson’s disease, or stroke

Demographics

• Adults

• 50% of population with RA⁴

• Associated in population with neurological disorders (cerebral palsy, Parkinson’s disease, CVA)

CLINICAL FINDINGS

Functional Implications

• For patients with RA, pain is really only a problem in the inflammatory phase; do not report pain otherwise, just dysfunction

• Difficulty and/or pain with opening and closing hand in preparation for grasping or reaching

• Difficulty and/or pain with grasping dishes, utensils, or drinking cups due to pain and weakness

• Difficulty and/or pain with grasping and turning steering wheel

• Difficulty and/or pain with turning doorknob

Possible Contributing Causes

• Cerebral palsy

• Ehlers–Danlos syndrome

• Neurological disorders

• Overuse activity of the hand and fingers

• Parkinson disease

• Rheumatoid arthritis, or other rheumatic or connective tissue disorders

• Trauma

• Untreated mallet finger

Differential Diagnosis

• Ganglion of tendon sheath

• Loose body in the MCP joint

• Subluxation of the extensor digitorum communis

• May occur before swan-neck deformities show up, but usually, concurrent with damage to the extensor hood through inflammation/stretching/disruption of tethers, the same as happens at the PIP

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray to rule out fracture

TREATMENT

Medication

• NSAIDs

• Corticosteroid injection

MEDICAL PROCEDURES

• Surgical options possible after failed conservative care

• Soft tissue repair

• PIP arthroplasty (PIP replaced with metal implant)

• Interphalangeal arthrodesis

FINDINGS AND INTERPRETATION

• Classification III: Fixed PIP joint contracture, X-ray normal⁴

• Classification IV: X-ray shows arthritic changes⁴