Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + BOUTONNIÈRE DEFORMITY Download Section PDF Listen Tiffany M. Barber, DPT, Eric Shamus, PhD, DPT, PT, CSCS, Jesse Solotoff, DPT, Linda M. Martin, PhD, OTR/L, FAOTA ++ +++ 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 ++ PATIENT PRESENTATION The patient is a 42-year-old man who owns a landscaping business. He reports he was injured approximately 2 months ago while trying to clear grass from around a lawnmower blade, resulting in the loss of skin on the top of his middle finger. On examination in the emergency room, he was found to have full thickness skin loss of about 2.5 cm in diameter from the dorsum of the proximal interphalangeal (PIP) joint of the R middle finger; damage to the central tendon was also apparent. The surgeon debrided the wound and covered the joint using a pedicle flap from the radial side of the adjacent ring finger, and a partial thickness graft to the donor site. The doctor positioned the finger near full extension; subsequent release of the flap from the adjacent finger was done and healing occurred without complication. Though cautioned against PIP flexion, or use of the hand that involved the finger, the patient reported he had resumed his work out of necessity, though on a limited basis. He presents with a stiff, enlarged PIP joint held in flexion at 40 degrees, and DIP joint at 10 degree hyperextension. He is unable to actively extend his PIP, and passive motion is limited to 10 degree extension from the initial measurement after treatment. Active and passive flexion of the DIP is limited to 5 degrees. ++ FIGURE 169-1 The tendons attaching to the middle phalanx. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 169-2 Boutonnière splint. The finger is splinted with the proximal interphalangeal joint held in extension. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ SIGNS AND SYMPTOMS Pain with grasping Flexion of the PIP joint and extension of the DIP joint Inflammation around the joint Joint redness and pain +++ 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 ++ FIGURE 169-3 Boutonnière deformity caused by loss of active proximal interphalangeal extension secondary to loss of the central slip insertion on the proximal dorsal middle phalanx. (Reproduced, with permission, from Way LW, ed. Current Surgical Diagnosis & Treatment. 10th ed. Appleton & Lange, 1994.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ MEDICAL PROCEDURES ++ Surgery in the case of RA, severed tendon, or minimal improvement with splinting Repair of the extensor tendon ++ REFERRALS/ADMITTANCE For imaging, X-ray For corticosteroid injection For surgical consult For occupational therapist to provide splints and instruct patient in joint protection techniques +++ 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 ++ FIGURE 169-4 Boutonnière deformity. A boutonnière deformity of the fourth digit. Note the flexion of the PIP joint and the extension of the DIP joint. (From Knoop KJ, Knoop K, Stack L, Storrow A, Jason Thurman R. The Atlas of Emergency Medicine. 3rd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Photo contributor: E. Lee Edstrom, MD.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 169-5 Boutonnière deformity. This depiction of a boutonnière deformity illustrates the rupture of the central slip and the resultant subluxation of the lateral bands. The subluxation exerts a pull on the middle phalanx resulting in the deformity. (From Knoop KJ, Knoop K, Stack L, Storrow A, Jason Thurman R. The Atlas of Emergency Medicine. 3rd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 169-6 Boutonnière deformity. (A) The lateral bands of the extensor tendon slip volarly and cause PIP flexion and DIP extension. (B) Clinical photograph. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed: www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ PATIENT RESOURCE AAOS, American Academy of Orthopaedic Surgeons. Boutonnière Deformity. http://orthoinfo.aaos.org/topic.cfm?topic=a00004. Accessed May 7, 2013. +++ REFERENCES +1. +The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. The American Physical Therapy Association. 2003. http://guidetoptpractice.apta.org/content/1/SEC12.extract?sid=ccb92104-9626-443e-ab17-b2a32a7792b7. DOI: 10.2522/ptguide.978-1-931369-64-0. Accessed May 7, 2013. +2. +Dutton M. Finger injuries. In:Dutton M McGraw-Hill’s NPTE (National Physical Therapy Examination). 2nd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/56504934. Accessed May 7, 2013. +3. +Cline S. Chapter 22. Acute injuries of elbow, forearm, wrist, and hand. In:Patel DR, Greydanus DE, Baker RJ Pediatric Practice: Sports Medicine. New York, NY: McGraw-Hill; 2009. http://www.accessphysiotherapy.com/content/6978574. Accessed May 7, 2013. +++ ADDITIONAL REFERENCES + +Burton RI, Eaton RG. Common hand injuries in the athlete. Orthop Clin North Am. 1973;4:809–838. [PubMed: 4783899] + +Churchill M, Citron N. Isolated subluxation of the extensor pollicis longus tendon. A cause of ‘boutonniere’ deformity of the thumb. J Hand Surg Br. 1997;22(6):790–792. [PubMed: 9457590] CrossRef + +Dutton M. Tendon ruptures. In:Dutton M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/56540484. Accessed May 7, 2013.+ +El-Sallakh S, Aly T, Amin O, Hegazi M. Surgical management of chronic boutonniere deformity. Hand Surg. 2012;17(3):359–364. [PubMed: 23061946] CrossRef + +Fox A, Kang N. Reinserting the central slip—a novel method for treating boutonniere deformity in rheumatoid arthritis. J Plast Reconstr Aesthet Surg. 2009;62(5):e91–e92. [PubMed: 19010750] CrossRef + +Haerle M, Lotter O, Mertz I, Buschmeier N. [The traumatic boutonnière deformity]. Orthopade. 2008;37(12):1194–1201. [PubMed: 19050849] CrossRef + +Hooker DN, Prentice WE. Basic principles of electricity and electrical stimulating currents. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed May 7, 2013.+ +ICD9Data.com. http://www.icd9data.com. Accessed May 7, 2013.+ +ICD10Data.com. http://www.icd10data.com. Accessed May 7, 2013.+ +Izadpanah A, Izadpanah A, Sinno H, Williams B. Pediatric boutonniere deformity after blunt closed traumatic injury. Pediatr Emerg Care. 2011;27(11):1069–1071. [PubMed: 22068071] CrossRef + +Massengill JB. The boutonniere deformity. Hand Clin. 1992;8(4):787–801. [PubMed: 1460075] + +Prentice WE. Cryotherapy and thermotherapy. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137995#8137995. Accessed May 7, 2013.+ +Silva PG, Lombardi I Jr, Breitschwerdt C, Poli Araújo PM, Natour J. Functional thumb orthosis for type I and II boutonniere deformity on the dominant hand in patients with rheumatoid arthritis: a randomized controlled study. Clin Rehabil. 2008;22(8):684–689. [PubMed: 18678568] CrossRef + +Simon RR, Sherman SC. Closed tendon injuries. In:Simon RR, Sherman SC Emergency Orthopedics. 6th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/7703566. Accessed May 7, 2013.+ +Yoshino N, Watanabe N, Fujita N et al.. Boutonniere deformity of the second toe after planter dislocation of proximal interphalangeal joint: a case report. Arch Orthop Trauma Surg. 2009; 129(11):1527–1529. [PubMed: 19169694] CrossRef + +Zhang X, Yang L, Shao X et al.. Treatment of bony boutonniere deformity with a loop wire. J Hand Surg Am. 2011;36(6):1080–1085. [PubMed: 21636024] CrossRef + THUMB CARPOMETACARPAL JOINT OSTEOARTHRITIS Download Section PDF Listen Eric Shamus, PhD, DPT, PT, CSCS, Reuben Escorpizo, DPT, MSc, PT ++ +++ 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 ++ PATIENT PRESENTATION The patient is a 67-year-old woman who presents with pain at the base of the right thumb with decreased ability to knit. It is affecting her grip and ability to manipulate small objects. She complains of a constant pain, but feels better in warm water when she washes the dishes. The patient has an X-ray that showed an osteophyte with degenerative changes at the carpometacarpal joint. The opposite side is starting to bother her. There is visual enlargement of the joint. +++ 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 ++ FIGURE 170-1 Radiograph of thumb basilar osteoarthritis. There is irregular loss of the joint space between the proximal thumb metacarpal and the trapezium bone, together with bony sclerosis and bony cysts. There is also proximal and radial subluxation of the thumb metacarpal, indicative of carpometacarpal joint ligament laxity, caused by the progressive arthritis. (From Imboden J, Hellmann DB, Stone JH. Current Diagnosis & Treatment in Rheumatology. 2nd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ SIGNS AND SYMPTOMS Aching joint Activity limitation Bony enlargement Crepitus Heberden nodes Joint deformity in severe cases Joint line tenderness Joint pain Joint stiffness Limited joint range of motion Muscle atrophy Muscle weakness +++ 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 ++ FIGURE 170-2 Thumb spica splint. (From Tintinalli JE, Stephan Stapczynski J, John Ma O, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 170-3 (A) Extensor expansion. (B) Movements of the lumbrical and interossei muscles. (C) Ligaments and joints of the hand. (From Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ REFERRALS/ADMITTANCE Rheumatologist to assess underlying complications Internal medicine specialist Orthopedic specialist Surgical consult Dietician/nutritionist +++ 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 ++ FIGURE 170-4 Thumb spica splint: a slab of plaster is applied over adequate padding and secured with a loose elastic bandage. (From Stone CK, Humphries RL. Current Diagnosis & Treatment: Emergency Medicine. 7th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ PATIENT RESOURCE Osteoarthritis Research Society International. OARSI Primer. http://primer.oarsi.org. Accessed March 3, 2013. +++ REFERENCES +1. +Kellgren JH, Lawrence JS The Epidemiology of Chronic Rheumatism: Atlas of Standard Radiographs of Arthritis. Oxford, UK: Blackwell Scientific; 1963. +2. +National Collaborating Centre for Chronic Conditions at the Royal College of Physicians. Osteoarthritis: National Clinical Guideline for Care and Management in Adults. London, UK: Royal College of Physicians of London; 2008. +++ ADDITIONAL REFERENCES + +American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001. Revised 2003. + +Dutton M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/612. Accessed March 13, 2013. + +Dutton M. Chapter 18. Adjunctive interventions. In:Dutton M McGraw-Hill’s NPTE (National Physical Therapy Examination). 2nd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/5405918. Accessed March 13, 2013. + +ICD9Data.com. http://www.icd9data.com. Accessed March 3, 2013. + +ICD10Data.com. http://www.icd10data.com/ICD10CM/Codes. Accessed March 3, 2013. + +McKinnis LN. Fundamentals of Musculoskeletal Imaging. 2nd ed. Philadelphia, PA: F.A. Davis Company; 2005. + +Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/675. Accessed March 13, 2013. + COLLES FRACTURE Download Section PDF Listen Jennifer Cabrera, DPT, GCS, Eric Shamus, PhD, DPT, PT, CSCS ++ +++ 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 ++ PATIENT PRESENTATION A 65-year-old woman tripped on a rug in her home and fell on her outstretched hand with her wrist dorsiflexed (extended). She felt immediate pain in her wrist and has difficulty moving her wrist or hand. She has been postmenopausal for 15 years and has never taken hormone replacement therapy or bisphosphonates. She presented with pain and swelling in her wrist. Her arm had a “dinner fork” deformity. Radiographs showed a distal radius fracture (Colles fracture). There was dorsal angulation seen on the lateral view.2 +++ 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 ++ SIGNS AND SYMPTOMS Pain Point tenderness Edema Ecchymosis Visual wrist deformity Loss of general function Loss of active mobility Muscle guarding with passive movement Crepitus +++ 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 ++ FIGURE 171-1 Colles fracture. The classic dinner-fork deformity is demonstrated in this photograph. The distal forearm is displaced dorsally. (From Knoop KJ, Stack L, Storrow A, Jason Thurman R. The Atlas of Emergency Medicine. 3rd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Photo contributor: Cathleen M. Vossler, MD.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 171-2 Testing the radial nerve. (A) Sensory distribution. The radial nerve supplies the dorsolateral surface of the upper arm, forearm, wrist, and hand; the dorsal surface of the thumb; the dorsal surface of the index and middle fingers above the distal interphalangeal joints; and the lateral half of the dorsal surface of the ring finger above the distal interphalangeal joint. (B) Extensor pollicis longus. The thumb is extended at the interphalangeal joint against resistance. (C) Extensor pollicis brevis. The thumb is extended at the metacarpophalangeal joint against resistance. (D) Extensor digitorum. The fingers are extended at the metacarpophalangeal joints against resistance. (E) Abductor pollicis longus. The thumb is abducted (elevated in a plane at 90 degrees to the palm) at the carpometacarpal joint against resistance. (F) Extensor carpi radialis longus. The wrist is extended toward the radial (thumb) side against resistance. (From Greenberg DA, Aminoff MJ, Simon RP. Clinical Neurology. 8th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 171-3 Lateral view of left wrist shows the dorsal angulation that gives the arm the “dinner fork” deformity. (From Simon RR, Sherman SC, Koenigsknecht SJ. Emergency Orthopedics, the Extremities. 5th ed. p. 204, Fig. 8-30 [right side], Copyright 2007, McGraw-Hill.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ REFERRALS/ADMITTANCE To hospital for imaging: X-ray or CT4 To physician for medication: NSAIDs or opioid for pain management To orthopedist for immediate consult if Nondisplaced fractures or displaced fractures that may be reduced are treated nonoperatively Immobilization splint, casting Severely displaced fractures treated operatively via Open reduction internal fixation External fixation +++ 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 ++ FIGURE 171-4 Anterior–posterior view demonstrating a transverse distal radius fracture (Colles fracture). (From Simon RR, Sherman SC, Koenigsknecht SJ. Emergency Orthopedics, the Extremities. 5th ed. p. 204, Fig. 8-30 [left side], Copyright 2007, McGraw-Hill.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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). ++ PATIENT RESOURCE American Academy of Orthopaedic Surgeons. Distal Radius Fracture. OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=A00412. Accessed June 10, 2013. +++ REFERENCES +1. +The American Physical Therapy Association. Pattern 4G: Impaired joint mobility, muscle performance, and range of motion associated with fracture. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_7. Accessed June 10, 2013. +2. +Chumley H. Chapter 97. Distal Radial Fracture. In:Usatine RP, Smith MA, Chumley H, Mayeaux E Jr, Tysinger J The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009. http://www.accessmedicine.com/content.aspx?aID=8204067. Accessed June 10, 2013. +3. +Hall SJ. Chapter 4. The biomechanics of human bone growth and development. In:Hall SJ Basic Biomechanics. 5th ed. New York, NY: McGraw-Hill; 2007. http://accessphysiotherapy.mhmedical.com/content.aspx?bookid=445&Sectionid=41288112. Accessed May 27, 2014. +4. +Malone TR, Hazle C, Grey ML. Imaging in Rehabilitation. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/613. Accessed June 10, 2013. +5. +Prentice WE. Chapter 9. Cryotherapy and thermotherapy. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137995#8137995. Accessed June 10, 2013. +6. +Hooker DN, Prentice WE. Chapter 5. Basic principles of electricity and electrical stimulating currents. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed June 10, 2013. +++ ADDITIONAL REFERENCES + +Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, PA: Saunders; 2003. + +ICD9DATA web site. http://www.icd9data.com. Accessed June 10, 2013. + +ICD10DATA web site. http://www.icd10data.com. Accessed June 10, 2013. + +Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007. + +Magee DJ. Orthopedic Physical Assessment. 5th ed. Louis, MO: Saunders Elsevier. St; 2008. + +Riego de Dios R. Distal Radial Fracture Imaging. Medscape Reference. http://emedicine.medscape.com/article/398406-overview#showall. Accessed June 10, 2013. + DE QUERVAIN TENOSYNOVITIS Download Section PDF Listen Abby Lopez, LMT, CT, NCTMB, Eric Shamus, PhD, DPT, PT, CSCS, Mae L. Yahara, MS, PT, ATC ++ +++ 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 ++ PATIENT PRESENTATION The patient is a 48-year-old woman who started a new job 6 months ago as a bookkeeper. She has been experiencing pain in the right wrist for approximately 1 month. The pain and tenderness are in the region of the styloid process of the radius. She states that the pain radiates into the forearm and thumb as her day progresses. She states that the pain began as a dull ache at the end of the day, but has progressed to the point of inability to complete her morning activities because of the discomfort. Her daily routine includes counting bills and receipts in the morning using her right hand with a repetitive pronation to supination movement. In the afternoon, her work is primarily done utilizing a keyboard. She has no hobbies, but does routine housework and cooking for herself and her spouse. +++ 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 ++ FIGURE 172-1 Finkelstein test. The patient places the thumb in the palm and makes a loose fist. The examiner then ulnarly deviates the patient’s wrist (as indicated by the arrow). Pain at the first dorsal compartment with this maneuver is a positive response. (From Brunicardi FC, Andersen D, Billiar T, et al., eds. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ SIGNS AND SYMPTOMS Forearm pain Crepitus of tendons within the extensor sheath Unilateral palmer pain and swelling Tendon friction rub Upper-extremity pain4 Weak thumb abduction Decreased grip strength Wrist pain and swelling Decreased abduction ROM of the carpometacarpal (CMC) joint, thumb Pain with thumb activity, worsens when combined with wrist radial or ulnar deviation +++ 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 ++ REFERRALS/ADMITTANCE To primary or secondary healthcare provider for corticosteroid injection to sheath To orthopedist for wrist/thumb splint allowing movement at the thumb interphalangeal (IP) joint only5 +++ IMPAIRMENTS ++ Hand weakness with grasping, squeezing, pinching Restricted ROM in thumb abduction and extension ++ FIGURE 172-2 Finkelstein test. (From Dutton D. Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. http://accessphysiotherapy.mhmedical.com/ViewLarge.aspx?figid=40799084. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 172-3 Motions of the fingers and thumb. (From LeBlond RF, DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ PATIENT RESOURCES American Academy of Orthopeadic Surgeons. de Quervain’s Contracture. http://orthoinfo.aaos.org/topic.cfm?topic=A00008 Accessed March 13, 2013. Mayo Clinic. De Quervain’s Tenosynovitis. http://www.mayoclinic.com/health/de-quervains-tenosynovitis/DS00692/DSECTION=causes. Online April 3, 2010. Accessed March 13, 2013. Wesley Hand Centre. Fact Sheet: De Quervain’s Tenosynovitis. http://www.wesleyhandcentre.com.au/pdf/de-quervains-tenosynovitis.pdf. Accessed March 13, 2013. +++ REFERENCES +1. +The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_5. Accessed March 1, 2013. +2. +Patel DR, Lyne ED. Chapter 23. Overuse injuries of elbow, forearm, wrist, and hand. In:Patel DR, Greydanus DE, Baker RJ Pediatric Practice: Sports Medicine. New York, NY: McGraw-Hill; 2009. http://www.accessphysiotherapy.com/abstract/6979237#6979237. Accessed March 13, 2013. +3. +Dutton M. Dutton’s Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/resource/685. Accessed March 13, 2013. +4. +Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/612. Accessed March 13, 2013. +5. +Anatomy and Physiology Revealed. McGraw-Hill; 2007. http://anatomy.mcgraw-hill.com/apt.html?login=1318935388357&system=Muscular§ion=Dissection&topic=Forearm%20and%20hand&topicAbbr=For&view=Posterior&viewAbbr=Pos&catAbbr=Oth&grpAbbr=San&structure=Surface%20projection%20of%20interphalangeal%20joint%20of%25. Accessed March 13, 2013. +6. +Houghton PE. Chapter 3. The role of therapeutic modalities in wound healing. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/8135453#8135453. Accessed March 13, 2013. +7. +Draper DO, Prentice WE. Chapter 10. Therapeutic ultrasound. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/abstract/8138751. Accessed March 13, 2013. +8. +Prentice WE. Chapter 9. Cryotherapy and thermotherapy. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137995#8137995. Accessed March 13, 2013. +++ ADDITIONAL REFERENCES + +Brulhart L, Gabay C. The differential diagnosis of tenosynovitis. Rev Med Suisse. 2011;7(286):587–588, 590, 592–593. [PubMed: 21510342] + +Car-Blanchard M. Dequervain’s Tenosynovitis—Wrist Tendonitis. 2011. http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/Default.aspx?ContentPubID=219. Accessed March 13, 2013.+ +Disease comparison results for de Quervain’s tendonitis and gout. Retrieved from http://en.diagnosispro.com/disease_comparison-for/dequervain-s-tendonitis-thumb-versus-gout/12970-14414.html. Accessed March 13, 2013.+ +Drexel University. Drummin’ Doc. http://www.pages.drexel.edu/~ak57/healthcare.html#intro. Accessed March 13, 2013.+ +ICD9DATA web site. http://www.icd9data.com. Accessed March 6, 2013.+ +ICD10DATA web site. http://www.icd10data.com. Accessed March 6, 2013.+ +Lowe W. Functional Assessment in Massage Therapy. 3rd ed. Sisters, OR: Orthopedic Massage Education and Research Institute (OMERI); 1997.+ +Pho C, Godges J. Hand muscle power deficits. Loma Linda University. http://xnet.kp.org/socal_rehabspecialists/ptr_library/04WristandHand%20Region/06Hand-MusclePowerDeficits.pdf. Accessed March 13, 2013.+ +Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain’s tendinitis. J Hand Surg Am. 1998;23(1):89–96. [PubMed: 9523961] CrossRef + DUPUYTREN CONTRACTURE Download Section PDF Listen Eric Shamus, PhD, DPT, PT, CSCS, George Hanbury, PhD ++ +++ 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 ++ PATIENT PRESENTATION A 53-year-old man presents with stiffness in his hands. He says his hand began to feel stiff several years ago, and now he finds that he cannot straighten many of his fingers. He delayed seeing a physician because he did not feel any pain in his hands. He recently began having difficulty holding his woodworking tools and wants to regain the function he has lost in his hands.2 +++ 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 ++ SIGNS AND SYMPTOMS Thickening and shortening of fascia of the hand Contractures form at metacarpophalangeal (MCP), proximal interphalangeal (PIP), and occasionally distal interphalangeal (DIP) joints Fifth finger involved in 70% of cases +++ 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 chromosomes6,11,16 ++ FIGURE 173-1 Dupuytren disease. (A) This patient has cords affecting the thumb, middle, ring, and small fingers. (B) The resected specimens are shown. (C) Postoperatively, the patient went on to heal all his incisions and, with the aid of weeks of hand therapy, recovered full motion. (From Brunicardi FC, Andersen DK, Billiar TR, et al., eds. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 173-2 Deformities of the hand. (A) Clubhand. This is a congenital lesion in which the hand development is rudimentary; the stub may be surmounted by rudimentary or normal digits. (B) Ulnar deviation. Also called ulnar drift. (C) Position of anatomic rest. (D) Clawhand. (E) Ape hand. (F) Carpal spasm. (G) Benediction hand. (H) Wrist-drop. (I) Dupuytren contracture. (J) Athetoid hand. (K) Heberden nodes. (L) Haygarth nodes. The spindle-shaped enlargements of the middle interphalangeal joints occur in RA. (From LeBlond RF, DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ REFERRALS/ADMITTANCE Hospital for surgery to release fascia Acupuncture Physician for enzyme injection of the collagen-eroding enzyme, collagenase Physician for radiotherapy, radiation therapy (low-energy X-rays) +++ 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. ++ PATIENT RESOURCES ASSH, American Society for Surgery of the Hand. Dupuytren’s Disease. http://www.assh.org/Public/HandConditions/Pages/DupuytrensDisease.aspx. Accessed June 20, 2013. International Dupuytren Society. Dupuytren’s Disease. http://www.dupuytren-online.info/dupuytrens_contracture.html. Accessed June 20, 2013. +++ REFERENCES +1. +The American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. Interactive Guide to Physical Therapist Practice. 2003. DOI: 10.2522/ptguide.3.1_4. Accessed June 20, 2013. +2. +Chumley H. Chapter 101. Dupuytren’s disease. In:Usatine RP, Smith MA, Chumley H, Mayeaux E Jr, Tysinger J The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009. http://www.accessmedicine.com/content.aspx?aID=8204224. Accessed June 20, 2013. +3. +US National Library of Medicine. Alcoholism and alcohol abuse. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001940/. Online March 3, 2011. Accessed June 20, 2013. +4. +US National Library of Medicine. Epilepsy. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001714/. Online March 28, 2011. Accessed June 20, 2013. +5. +US National Library of Medicine. Pulmonary tuberculosis. PubMed Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001141/. Online December 6, 2011. Accessed June 20, 2013. +6. +Dutton M. Common orthopedic conditions. In:Dutton M McGraw-Hill’s NPTE (National Physical Therapy Examination). 2nd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/5398559. Accessed June 20, 2013. +++ ADDITIONAL REFERENCES + +Al-Qattan MM. Factors in the pathogenesis of Dupuytren’s contracture. J Hand Surg Am. 2006;31:1527–1534. doi: 10.1016/j.jhsa.2006.08.012. [PubMed: 17095386] CrossRef + +Dutton M. Observation. In:Dutton M Dutton’s Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8653105. Accessed June 20, 2013.+ +Dutton M. Practice Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In:Dutton M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/content/55578994. Accessed June 20, 2013.+ +ICD9DATA web site. http://www.icd9data.com. Accessed June 20, 2013.+ +ICD10DATA web site. http://www.icd10data.com. Accessed June 20, 2013.+ +Michou L, Lermusiaux JL, Teyssedou JP, Bardin T, Beaudreuil J, Petit-Teixeira E. Genetics of Dupytren. Joint Bone Spine. January 2012;79(1):7–12.CrossRef + GAMEKEEPER’S THUMB Download Section PDF Listen Patrick S. Pabian, DPT, PT, SCS, OCS, CSCS, Linda M. Martin, PhD, OTR/L, FAOTA, Eric Shamus, PhD, DPT, PT, CSCS ++ +++ 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 ++ PATIENT PRESENTATION The patient is a 22-year-old competitive downhill skier who injured herself during a fall on the slopes. She reports that her thumb was forced outward by the ski pole as she fell. She was taken to the emergency complaining of pain and inability to use the thumb. It was determined that a partial rupture of the UCL of her L thumb at its proximal insertion had occurred, and that conservative treatment was indicated. She was provided with a cast to the hand which held the thumb midway between radial and palmar abduction, and in approximately 5 degrees MP flexion, with the IP joint free. She presents to the clinic 3 weeks later. The patient has focal swelling and tenderness at the medial aspect of the first metacarpophalangeal (MCP) joint. She is having difficulty with grasping kitchen utensils and drinking cups and difficulty turning doorknobs due to pain and weakness of the thumb. The patient presents with grade II laxity during a valgus stress test at 30 degrees of the first MCP joint. +++ 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 ++ FIGURE 174-1 Gamekeeper’s thumb. Laxity of 30 to 40 degrees more than the uninjured thumb measured in neutral and 30 degrees of flexion are strongly suggestive of a complete ulnar collateral ligament tear. There is no “endpoint” to the radial deviation of the phalanx. (Used with permission from Brunicardi FC, Anderson DK, Billar TR, et al. Schwartz’s Principles of Surgery, 8th ed. © 2005 McGraw-Hill, New York, NY.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ SIGNS AND SYMPTOMS Pain over medial MCP joint Palpable tenderness and possible swelling over the medial MCP joint line/UCL of the thumb Instability and/or pain with valgus stress to the MCP joint of the thumb Weakness with pinching or opposition Repeat subluxation of the MCP joint resulting in medial angulation of the proximal phalanx with valgus stress or force +++ 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 ++ REFERRALS/ADMITTANCE To radiologist for imaging, X-ray To orthopedist for surgical consult To occupational therapist to provide splints and instruct patient in joint protection techniques ++ FIGURE 174-2 Gamekeeper’s thumb. Stress x-ray of a thumb with a complete ulnar collateral ligament tear demonstrates marked instability of the ulnar side of the MP joint and radial deviation of the proximal phalanx. (Used with permission from Brunicardi FC, Anderson DK, Billar TR, et al. Schwartz’s Principles of Surgery. 8th ed. © 2005 McGraw-Hill, New York, NY.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 174-3 Stress examination of the thumb metacarpophalangeal collateral ligament. The ulnar side is injured more frequently. Test both sides in extension and 30 degrees of flexion. Compare the injured digit with the uninjured thumb. Feel for a firm end point and absence of excessive laxity. (From Stone CK, Humphries RL. Current Diagnosis & Treatment: Emergency Medicine. 7th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 174-4 Mechanism of sprain of the ulnar collateral ligament of the thumb metacarpophalangeal joint. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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) ++ FIGURE 174-5 Stress test for ulnar collateral ligament of the MCP joint of the thumb. With thumb held in extension, the metacarpal is stabilized with one hand and a gentle stress is applied on the ulnar side of the proximal phalanx. Pain or increased laxity at the metacarpophalangeal joint will be elicited with ulnar collateral ligament sprain. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ FIGURE 174-6 MCP dislocation of the thumb. (A) Clinical photograph. (B) Radiograph. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 174-7 Examining for disruption of the ulnar collateral ligament of the thumb at the MCP joint. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ PATIENT RESOURCE Game Keeper’s Thumb. Wheeless’ Textbook of Orthopeadics. http://www.wheelessonline.com/ortho/gamekeepers_thumb. Accessed March 3, 2013. +++ REFERENCES +1. +ICD9Data.com. http://www.icd9data.com. Accessed March 3, 2013. +2. +ICD10Data.com. http://www.icd10data.com/ICD10CM/Codes. Accessed March 3, 2013. +3. +American Physical Therapy Association. Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001. Revised 2003. +++ ADDITIONAL REFERENCES + +Dutton M. The Forearm, Wrist, and Hand. In: Dutton M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012. New York, NY: McGraw-Hill; 2008:735–838.+ +Garnham A, Ashe M, Gropper P. Wrist, Hand, and Finger Injuries. In: Clinical Sports Medicine. 3rd ed. Australia: McGraw-Hill Book Company; 2009:308–339.+ +Michaud EJ, Flinn S, Seitz WH Jr. Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint. J Hand Ther. 2010;23(1):77–82. [PubMed: 20142008] CrossRef + +Prentice WE. The Forearm, Wrist, Hand, and Fingers. In:Prentice WE Arnheim’s Principles of Athletic Training: A Competency-Based Approach. 13th ed. New York, NY: McGraw-Hill; 2011:722–723.+ +Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. 2010;20(2):106–112. [PubMed: 20215892] CrossRef + MALLET FINGER Download Section PDF Listen Eric Shamus, PhD, DPT, PT, CSCS, Linda M. Martin, PhD, OTR/L, FAOTA ++ +++ 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 ++ PATIENT PRESENTATION The patient is a 46-year-old man who injured his middle finger while playing a casual game of basketball with friends. He reports that he attempted to catch a rebound, and the ball struck his outstretched finger, forcibly bending it. Examination revealed a characteristically flexed distal interphalangeal (DIP) joint and patient’s inability to actively extend the DIP joint; X-ray revealed no bony disruption; mild swelling was present. +++ 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 ++ FIGURE 175-1 Mallet splint. The finger is splinted with distal interphalangeal joint held in extension. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ Demographics ++ Adults Hit or blow onto the finger tip from sports, i.e., basketball3 +++ CLINICAL FINDINGS ++ SIGNS AND SYMPTOMS Pain with grasping Decreased extension of the finger, extensor lag Joint redness and pain +++ 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 ++ FIGURE 175-2 Mechanism of mallet finger injury. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ REFERRALS/ADMITTANCE For imaging, X-ray For corticosteroid injection For surgical consult For occupational therapist to provide splints and instruct patient in joint protection techniques +++ 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 ++ FIGURE 175-3 Three ways the extensor tendon can be disrupted. (A) A stretch of the tendon without division of the tendon. (B) When the tendon is ruptured from its insertion on the distal phalanx, there is a 40-degree flexion deformity present, and the patient cannot actively extend the tendon at the DIP joint. (C) A fragment of the distal phalanx can be avulsed with the tendon. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ FIGURE 175-4 Flexion deformity the DIP of a mallet finger. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 175-5 Mallet finger with fracture. (From Knoop KJ, Stack L, Storrow A, Jason Thurman R. The Atlas of Emergency Medicine. 3rd ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Photo contributor: Matthew Kopp, MD.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ PATIENT RESOURCE American Academy of Orthopaedic Surgeons. Mallet Finger (Baseball Finger). http://orthoinfo.aaos.org/topic.cfm?topic=A00018. Accessed July 6, 2013. ++ FIGURE 175-6 Mallet finger without fracture. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ REFERENCES +1. +The American Physical Therapy Association. Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation. interactive guide to physical therapist practice. The American Physical Therapy Association. 2003. http://guidetoptpractice.apta.org/content/1/SEC12.extract?sid=ccb92104-9626-443e-ab17-b2a32a7792b7. DOI: 10.2522/ptguide.978-1-931369-64-0. Accessed July 6, 2013. +2. +Dutton M. Finger injuries. In:Dutton M McGraw-Hill’s NPTE (National Physical Therapy Examination). 2nd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/56504934. Accessed July 6, 2013. +3. +Cline S. Chapter 22. Acute Injuries of Elbow, Forearm, Wrist, and Hand. In:Patel DR, Greydanus DE, Baker RJ Pediatric Practice: Sports Medicine. New York, NY: McGraw-Hill; 2009. http://www.accessphysiotherapy.com/content/6978574. Accessed July 6, 2013. +++ ADDITIONAL REFERENCES + +Burton RI, Eaton RG. Common hand injuries in the athlete. Orthop Clin North Am. 1973;4:809–838. [PubMed: 4783899] + +Dutton M. Tendon ruptures. In:Dutton M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012. http://www.accessphysiotherapy.com/content/56540484. Accessed July 6, 2013.+ +Hamilton N, Weimar W, Luttgens K. Kinesiology: Scientific Basis of Human Motion. 11th ed. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/resource/618. Accessed July 6, 2013.+ +Hooker DN, Prentice WE. Basic principles of electricity and electrical stimulating currents. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136367#8136367. Accessed July 6, 2013.+ +ICD9Data.com. http://www.icd9data.com. Accessed July 6, 2013.+ +ICD10Data.com. http://www.icd10data.com. Accessed July 6, 2013.+ +Malone TR, Hazle C, Grey ML. The ankle and foot. In:Malone TR, Hazle C, Grey ML Imaging in Rehabilitation. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/content/5940160. Accessed July 6, 2013.+ +Prentice WE. Cryotherapy and thermotherapy. In:Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137995#8137995. Accessed July 6, 2013.+ +Simon RR, Sherman SC. Closed tendon injuries. In:Simon RR, Sherman SC Emergency Orthopedics. 6th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/7703566. Accessed July 6, 2013. + SCAPHOID FRACTURE Download Section PDF Listen Jennifer Cabrera, DPT, GCS, Eric Shamus, PhD, DPT, PT, CSCS ++ +++ 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 ++ PATIENT PRESENTATION A 25-year-old woman tripped while exiting her tub and fell onto her outstretched hand with her wrist extended. She felt immediate pain, but waited until the next day to seek medical attention. She presented with difficulty moving her wrist in all directions and difficulty gripping objects secondary to worsening pain. She demonstrated mild edema in the wrist and hand. Radiographs showed were negative for a distal scaphoid fracture. Patient was placed in a wrist immobilizer for 3 weeks secondary to pain with a tuning fork and as a precaution. Upon re-examination after 3 weeks patient continued with point tenderness in the snuff box and was sent for a follow-up X-ray. Follow-up X-ray demonstrated a healing fracture line of the scaphoid. ++ FIGURE 176-1 Scaphoid fracture in the middle third or waist (arrow). (From Tintinalli JE, Stapczynski JS, John Ma O, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 176-2 Gilula’s arcs are seen shown in this normal patient (A) and in a patient with a scaphoid fracture and perilunate dislocation (B). (From Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 176-3 A. Preoperative images demonstrate a nonunion of a scaphoid fracture sustained 4 years earlier. B. Postoperatively, cross-sectional imaging with a computed tomography scan in the coronal plan demonstrates bone crossing the previous fracture line. This can be difficult to discern on plain x-rays due to overlap of bone fragments. (From Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ SIGNS AND SYMPTOMS Pain at the base of the thumb Point tenderness within the snuff box Edema Loss of general function Loss of active wrist and/or thumb mobility Muscle guarding with passive movement ++ FIGURE 176-4 Scaphoid fracture. Fracture of the waist, or middle third, of the scaphoid. These injuries can be associated with delayed healing and avascular necrosis. (From Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Photo contributor: Alan B. Storrow, MD.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ REFERRALS/ADMITTANCE For imaging, x-ray or CT For medication: NSAIDs or opioid for pain management For immediate orthopedic consult Distal scaphoid pole fractures are treated nonoperatively Immobilization casting of hand and may or may not include thumb Waist or proximal scaphoid pole fractures may be treated: Nonoperatively, immobilization cast of hand and thumb Operatively, open reduction internal fixation +++ 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 ++ FIGURE 176-5 Scaphoid fracture. (A) Scaphoid fracture nonunion. (B) Open reduction and internal fixation of scaphoid nonunion. (From Doherty GM. Current Diagnosis & Treatment in Surgery. 13th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 176-6 Line diagram showing scaphoid fracture sites. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. http://www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 176-7 Watson test of scapholunate instability. Pain or a click or clunk in the wrist is felt when stabilizing the scaphoid with one hand and moving wrist from a position of radial deviation (A) to ulnar deviation (B) as pressure is applied on the scaphoid with the thumb of the other hand. (From Patel DR, Greydanus DE, Baker RJ. Pediatric Practice: Sports Medicine. http://www.accesspediatrics.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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. ++ PATIENT RESOURCES American Academy of Orthopaedic Surgeons. Scaphoid Fracture of the Wrist. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00012. Accessed July 2, 2013. Boles CA. Scaphoid Fracture Imaging. Medscape Reference. Available at: http://emedicine.medscape.com/article/397230-overview#showall. Accessed July 2, 2013. +++ REFERENCES +1. +ICD9Data.com. http://www.icd9data.com. Accessed July 3, 2013. +2. +ICD10Data.com. http://www.icd10data.com/ICD10CM/Codes. Accessed July 3, 2013. +3. +Pattern 4G: Impaired joint mobility, muscle performance, and range of motion associated with fracture. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001. Revised 2003. +++ ADDITIONAL REFERENCES + +Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia, PA: Saunders; 2003. + +Kisner C, Colby LA. Therapeutic Exercise. 5th ed. Philadelphia, PA: F.A. Davis Company; 2007. + +Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Saunders Elsevier; 2008. + +Malone TR, Hazle C, Grey ML Imaging in Rehabilitation. New York, NY: McGraw-Hill; 2008. http://www.accessphysiotherapy.com/content/5940000. Accessed July 8, 2013. + +Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8137872. Accessed July 8, 2013. + SWAN-NECK DEFORMITY Download Section PDF Listen Eric Shamus, PhD, DPT, PT, CSCS, Jesse Solotoff, DPT, Tiffany M. Barber, DPT, Linda M. Martin, PhD, OTR/L, FAOTA ++ +++ 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 ++ PATIENT PRESENTATION Patient is a 32-year-old woman diagnosed with rheumatoid arthritis 3 years ago. She experienced an exacerbation of symptoms, with increased pain and inflammation in both hands 2 months ago, and was seen by her rheumatologist for medical management. Although pain and inflammation have subsided, she now reports difficulty in her job as a music teacher at the local high school. Her chief complaint is that she is unable to demonstrate playing instruments because her “fingers won’t cooperate.” When trying to straighten the fingers, “the middle joint bends backwards and gets in the way.” When asked to extend her fingers, the patient moved the index, long, and ring fingers of her right hand into a position involving proximal interphalangeal (PIP) joint hyperextension and distal interphalangeal (DIP) joint flexion; the small finger moved normally into extension. After demonstrating this, the patient then had mild difficulty returning to a flexed position (unintended slight hesitation). The MP joints were slightly swollen, but appeared to be in good alignment and functioning properly. Wrist motion was within normal limits (WNL). +++ 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 ++ FIGURE 177-1 Boutonnière (A) and swan-neck (B) deformities. (From Toy EC, Patlan JT. Case Files: Internal Medicine. 3rd ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 177-2 Finger deformities. (From Dutton M. Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. http://accessphysiotherapy.mhmedical.com/ViewLarge.aspx?figid=40799382. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ Demographics ++ Adults 50% of population with RA4 Associated in population with neurological disorders (cerebral palsy, Parkinson’s disease, CVA) +++ CLINICAL FINDINGS ++ SIGNS AND SYMPTOMS Pain and swelling of the PIP joint Laxity of the volar plate Snapping and locking of the fingers Hyperextension of the PIP and flexion of the DIP Signs of 11’s (parallel course of lateral bands on the dorsum of the joint is clearly seen under the skin) ++ FIGURE 177-3 Swan-neck deformity. (From Tintinalli JE, Stapczynski JS, John Ma O, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ FIGURE 177-4 Swan-neck deformity. A swan-neck deformity of the index finger. Note the hyperextension of the PIP joint and the flexion of the DIP joint. (From Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Photo contributor: Cathleen M. Vossler, MD.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 ++ REFERRALS/ADMITTANCE To radiologist for imaging, x-ray to rule out other pathology To primary care to rule out rheumatic causes or other connective tissue disorders To orthopedist for corticosteroid injection or surgical consult To occupational therapist to provide silver ring splints and instruct patient in joint protection techniques +++ IMPAIRMENTS ++ Decreased strength and pain for grasping activities such as dressing and eating Pain with opening hand to reach for objects Decreased ability to open or close hand due to joint stiffness +++ TESTS AND MEASURES ++ Start with a full fist, and then ask patient to open the hand and extend the fingers Lateral pinch dynamometry Disabilities of the Arm, Shoulder, and Hand (DASH) score to assess physical function Manipulative ability test (nine-hole peg test) +++ INTERVENTION ++ Objective of treatment is to restore balance of the extensor tendon and volar plate Instruct in joint protection techniques and modify habits to delay/prevent associated joint deformity and dysfunction in the hands Acute phase PRICE: Protection, rest, ice compression, elevation Immobilization/splint Taping to reduce exacerbating activities Ice massage Pulsed ultrasound Chronic phase Gradually increase workload as pain and discomfort diminish Continue intermittent taping or splinting to reduce repeated motions that may exacerbate symptoms Addressing pain Ice High-voltage pulsed stimulation Ultrasound Addressing swelling Ice Massage Addressing weakness, joint instability As symptoms improve, gradually resume activities Establish full, pain-free finger ROM Incorporate stretching and progressive strengthening exercises as warranted to restore full mobility and strength +++ FUNCTIONAL GOALS ++ Patient will be able to Use all kitchen and dining utensils without pain, or restricted mobility. Lift half gallon of milk with both hands. Reach for kitchen and household items without pain or catching. Use garden tools, pain free. +++ PROGNOSIS ++ Symptoms reduction can be slower if associated with connective tissue disorders, rheumatoid arthritis, or in the presence of patient inability to control exacerbating activities. ++ PATIENT RESOURCE Arthritis: Rheumatoid Arthritis. American Society for Surgery of the Hand. http://www.assh.org/Public/HandConditions/Pages/ArthritisRheumatoidArthritis.aspx. Accessed July 7, 2013. +++ REFERENCES +1. +ICD9Data.com. http://www.icd9data.com. Accessed July 7, 2013.+2. +ICD10Data.com. http://www.icd10data.com. Accessed July 7, 2013.+3. +Pattern 4D: impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001. Revised 2003.+4. +Nalebuff EA. The rheumatoid swan-neck deformity. Hand Clin. 1989;5(2):203–214. [PubMed: 2661576] +++ ADDITIONAL REFERENCES + +de Bruin M, van Vliet DC, Smeulders MJ, Kreulen M. Long-term results of lateral band translocation for the correction of swan neck deformity in cerebral palsy. J Pediatr Orthop. 2010;30(1):67–70. doi: 10.1097/BPO.0b013e3181c6c363. [PubMed: 20032745] CrossRef + +Dutton M. The forearm, wrist, and hand. In:Dutton M Dutton’s Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011:Chapter 7. http://www.accessphysiotherapy.com/content/8653078. Accessed July 7, 2013.+ +Dutton M. The forearm, wrist, and hand. In:Dutton M Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hill; 2008.+ +Ercocen AR, Yenidunya MO, Yilmaz S, Ozbek MR. Dynamic swan neck defomity in a patient with ehlers-danlos syndrome. J Hand Surg Eur. 1997;22(1):128–130. doi: 10.1016/S0266-7681(97)80039-3.CrossRef+ +Garnham A, Ashe M, Gropper P. Wrist, hand, and finger injuries. In: Clinical Sports Medicine. 3rd ed. Australia: McGraw-Hill; 2009:308–339.+ +Nalebuff EA, Feldon PG, Millender LH. Rheumatoid arthritis in the hand and wrist. In:Green DP Green’s Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1988.+ +Prentice WE. The forearm, wrist, hand, and fingers. In:Prentice WE Principles of Athletic Training: A Competency- Based Approach. New York, NY: McGraw-Hill; 2011:702–732.+ +Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136922. Accessed July 7, 2013.+ +Sirotakova M, Figus A, Jarrett P, Mishra A, Elliot D. Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique. J Hand Surg Eur Vol. 2008;33(6):712–716. doi: 10.1177/1753193408092787. [PubMed: 18694915] CrossRef + TRIGGER FINGER Download Section PDF Listen Patrick S. Pabian, DPT, PT, SCS, OCS, CSCS ++ +++ CONDITION/DISORDER SYNONYMS ++ Flexor tenosynovitis Locked finger Stenosing tenosynovitis Trigger digit Trigger thumb +++ ICD-9-CM CODE1 ++ 727.03 Trigger finger (acquired) +++ ICD-10-CM CODE2 ++ M65.30 Trigger finger, unspecified finger +++ PREFERRED PRACTICE PATTERN3 ++ 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction ++ PATIENT PRESENTATION A 45-year-old female receptionist presents with pain over the volar aspect of her second metacarpophalangeal (MCP) joint that has been present for the past 5 months. She reports the pain is worsening and now noting “catching” or feeling that her finger “gets stuck” when bending and straightening. The patient has a palpable nodule over the volar aspect of the first MCP, which is painful to palpation and has crepitus during finger flexion. She notes that she is having difficulty grasping dishes or utensils when eating or cooking due to pain and weakness. She has also recently been in consultation with a rheumatologist for other medical concerns unrelated to this specified hand pain. ++ FIGURE 178-1 (A) Extensor expansion. (B) Movements of the lumbrical and interossei muscles. (C) Ligaments and joints of the hand. (From Morton DA, Foreman KB, Albertine KH. The Big Picture: Gross Anatomy. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 178-2 (A) Trigger finger occurs when a fibrous thickening of the tendon does not allow it to slide through the pulley. (B) Clinical photo of a finger locked in place due to trigger finger. (From Simon RR, Sherman SC. Emergency Orthopedics. 6th ed. www.accessemergencymedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ KEY FEATURES +++ Description ++ Painful snapping or catching/locking of finger or thumb Inflammation of the fluid-filled sheath (tenosynovitis) surrounding the flexor tendons of the phalanges Painful nodule at the distal flexion crease Inflammation causes interference with gliding of tendon at the location of the A1 pulleys +++ Essentials of Diagnosis ++ Thickening of sheath or tendon leads to constriction of the sliding tendon, and nodules can develop Crepitus and nodules may be palpable at location of A1 pulley Cause is typically nonspecific overuse Pain with digit motion precedes triggering or locking sensations +++ General Considerations ++ Pain may precede symptoms of triggering. Mechanical symptoms exacerbate condition, leading to increased pain and decreased motion of the digit. Can be managed surgically or nonsurgically depending upon signs and symptom severity, response to conservative treatment, and orthopedic physician recommendations. +++ Demographics ++ Unknown etiology, idiopathic Middle-aged women Increased incidence with diabetic population, young children, and menopausal women Associated in population with rheumatic disease/changes in the hand +++ CLINICAL FINDINGS ++ SIGNS AND SYMPTOMS Pain in palmar MCP joint region with digit motion, especially flexion Nodule along the A1 pulley Crepitus Palpable tenderness and possible swelling over palmar MCP joint Palpable crepitus over the palmar MCP joint Catching, locking, triggering with flexion of the digit +++ Functional Implications ++ 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 ++ Rheumatoid arthritis, or other rheumatic or connective tissue disorders Diabetes mellitus Infection: Mycobacterium kansasii Carpal tunnel syndrome Psoriatic arthritis Gout Sarcoidosis Tuberculosis De Quervain’s stenosing tenosynovitis Overuse activity of the hand and fingers +++ Differential Diagnosis ++ Rheumatoid arthritis Ganglion of tendon sheath Dupuytren disease Loose body in the MCP joint Subluxation of the extensor digitorum communis Diabetes mellitus +++ MEANS OF CONFIRMATION OR DIAGNOSIS +++ Imaging ++ No indication +++ Diagnostic Procedures ++ Start with a full fist, and then ask patient to open the hand and extend the fingers +++ FINDINGS AND INTERPRETATION ++ Radiographs can be taken to rule out fracture +++ TREATMENT +++ Medication ++ NSAIDs Corticosteroid injection into flexor sheath +++ MEDICAL PROCEDURE ++ Surgical release possible after failed conservative care ++ REFERRALS/ADMITTANCE To radiologist for imaging, X-ray to rule out other pathology To primary care to rule out rheumatic causes or other connective tissue disorders To orthopedist for corticosteroid injections or surgical consult +++ IMPAIRMENTS ++ Decreased strength and pain for grasping activities such as dressing and eating Pain, and locking or catching with opening hand to reach for objects Decreased ability to open or close hand due to joint stiffness +++ TESTS AND MEASURES ++ Thenar muscle strength test (lateral pinch dynamometry) Manipulative ability test (nine-hole peg test) +++ INTERVENTION ++ Objective of treatment is to reduce inflammation in the flexor tendon sheath and restore mobility of the tendon under the A1 pulley at the MCP joint Acute phase PRICE: Protection, rest, ice compression, elevation Immobilization/splint Buddy taping to reduce exacerbating activities Ice massage Pulsed ultrasound Chronic phase Gradually increase workload as pain and discomfort diminish Continue intermittent taping or splinting to reduce repeated motions that may exacerbate symptoms Addressing pain Ice High-voltage pulsed stimulation Iontophoresis Ultrasound Extracorporeal shockwave therapy Addressing swelling Ice Massage Addressing weakness, joint instability As symptoms improve, gradually resume activities Establish full, pain-free finger ROM Incorporate stretching and progressive strengthening exercises as warranted to restore full mobility and strength ++ FIGURE 178-3 The examiner holds the untested fingers in full extension, preventing contracture of the flexor digitorum profundus. In this position, the patient is asked to flex the finger, and only the flexor digitorum superficialis will be able to fire. (From Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ FUNCTIONAL GOALS ++ Patient will be able to Use all kitchen and dining utensils without catching symptoms, pain, or restricted mobility. Lift a gallon milk carton from refrigerator at shoulder level, without pain. Reach for kitchen and household items without pain or catching. Garden tools, without pain. +++ PROGNOSIS ++ Good. Symptoms reduction can be slower if associated with connective tissue disorders, rheumatoid arthritis, or in the presence of patient inability to control exacerbating activities. +++ ADDITIONAL INFORMATION ++ For more information, please review the Iontophoresis Case Study 6-2 on AccessPhysiotherapy.com. ++ PATIENT RESOURCE Trigger Finger. American Society for Surgery of the Hand. http://www.assh.org/Public/HandConditions/Pages/TriggerFinger.aspx. Accessed July 7, 2013. +++ REFERENCES +1. +ICD9Data.com. http://www.icd9data.com. Accessed July 7, 2013. +2. +ICD10Data.com. http://www.icd10data.com. Accessed July 7, 2013. +3. +Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction. In: Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2001. Revised 2003. +++ ADDITIONAL REFERENCES + +Dutton M. The forearm, wrist, and hand. In:Dutton M Dutton’s Orthopedic Survival Guide: Managing Common Conditions. New York, NY: McGraw-Hill; 2011:Chapter 7. http://www.accessphysiotherapy.com/content/8653078. Accessed July 7, 2013.+ +Dutton M. The forearm, wrist, and hand. In:Dutton M Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 3rd ed. New York, NY: McGraw-Hill; 2012.+ +Finsen V, Hagen S. Surgery for trigger finger. Hand Surg. 2003; 8(2):201–203. [PubMed: 15002098] CrossRef + +Garnham A, Ashe M, Gropper P. Wrist, hand, and finger injuries. In: Clinical Sports Medicine. 3rd ed. Australia: McGraw-Hill; 2009:308–339.+ +Hwang M, Kang YK, Shin JY, Kim DH. Referred pain pattern of the abductor pollicis longus muscle. Am J Phys Med Rehabil. 2005;84(8):593–597. [PubMed: 16034228] CrossRef + +Prentice WE. The forearm, wrist, hand, and fingers. In:Prentice WE Principles of Athletic Training: A Competency-Based Approach. New York, NY: McGraw-Hill; 2011:702–732.+ +Prentice WE, Quillen WS, Underwood F Therapeutic Modalities in Rehabilitation. 4th ed. New York, NY: McGraw-Hill; 2011. http://www.accessphysiotherapy.com/content/8136922. Accessed July 7, 2013.+ +Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain’s tendinitis. J Hand Surg Am. 1998;23(1):89–96. [PubMed: 9523961] CrossRef