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common instability pattern or dissociation, the SL dissociation.
https://t.me/med1917
is is also known as a scapholunate advanced collapse (SLAC)
wrist. In this case, one will note a signicant gap between the
scaphoid and the lunate and an abnormally rotated scaphoid.
e scaphoid, having freedom of motion due to its lack of association with the lunate, is exing excessively creating a view
where the distal portion of the bone appears as the base of a
ring and the proximal pole becomes the stone—the ring sign. A
lateral view typically shows an abnormally rotated lunate (tilted
in a dorsal direction) creating a DISI pattern. Compare Figure
23A, showing a positive DISI pattern on a lateral wrist lm to a
normal wrist (Figure 2B). e DISI pattern develops as the lunate has lost its exion tendency because of its ligamentous separation from the scaphoid and instead follows the triquetrum,
which tends to pull the lunate into extension. e result is the
dorsal tilt indicative of a SL ligament dissociation.
e much less common LT ligament disruption results in
the opposite positioning with the lunate following the scaphoid
into exion leading to a resting posture representative of a VISI
(Figure 23B). ese are both examples of carpal instability dissociative patterns where disruptions are occurring within the
same carpal row.
In contrast, a carpal instability non-dissociative pattern instability is evident between rows. Going back to the PA wrist
radiograph in Figure 22, there is also evidence of disruption of
the midcarpal row as the capitate is now pressing into the distal
surfaces of the lunate and scaphoid. is particular nding is
that of a carpal instability combined pattern where there is now
evidence of instability both within and between the carpal rows.
Once the wrist reaches this point, clinically, there are currently few options to provide relief with proximal row carpectomy
and partial wrist arthrodesis (ie, 4-corner fusion) being possible treatment options that show some success with maintaining
wrist mobility, recovering partial grip strength, and decreasing
121
pain levels.
Rehabilitation must be carefully progressed as recovering pain-free or minimal pain mobility within functional
ROM and strength are long-term goals at this point of wrist
disruption.
Figure 22.
Scapholunate Dissociation
Figure 23.
A
B
Wrist Instability
Posterior-anterior radiograph showing ring sign, gap
between scaphoid and lunate, impingement on radial
styloid, and disruption of both radiocarpal and midcarpal rows.
Academy of Orthopaedic Physical erapy, APTA.
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
A, Dorsal intercalated segmental instability; scapholunate angle >60°. B, Volar intercalated segmental instability; scapholunate angle <30°; refer to Figure 2B
for normal scapholunate angle (30-60°).
45
Symptoms and signs associated with the most common of
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the carpal instability patterns, the SL dissociation, include the
following:
Symptoms:
•
Pain on the radial side of the wrist at rest or with activities;
• Complaints of decreased grip strength; and
• Pain with attempts of wrist and hand weight-bearing (closed
chain) activities.
Signs:
• Tenderness to palpation over the scaphoid tuberosity, waist,
or SL joint line;
• Laxity of the SL joint with the ballottement test;
• Possibly a positive scaphoid shift test; and
• Radiographic evidence as noted earlier.
Surgeons treat acute ligament injuries with a primary re-
pair, pinning, and immobilization with the overall goal of re-
126
establishing soft tissue integrity.
Chronic injuries may lead
to the dynamic, and then static, conditions described above
necessitating more limited treatment options with expectations
of only partial mobility, strength, and varying levels of pain re-
126
lief.
Distal radius fractures
Due to the frequency of this fracture, particularly in the
older adult population, this injury deserves discussion; however,
the literature on both treatment and rehabilitation continues to
127
point to areas of disagreement. Levin et al
noted the distal
radius is the second most commonly fractured bone in elderly
persons. e majority of recent studies, dene the age range for
the elderly population as 50 to 75 years. Historically, patients
were treated with nonsurgical care (closed reduction and cast
stabilization) or surgical options such as percutaneous pinning
or external xation. Advances in surgical stabilization have led
to an increase in operative treatments with volar or dorsal plating systems. Common thinking is that better maintenance of
anatomical reduction with the opportunity to perform earlier
motion following ORIF would provide better outcomes. Bales
128
and Stern
noted several studies comparing nonoperative versus surgical treatment (pinning, external xation, volar and dorsal plating systems). Surprising was the lack of support for the
subjective superiority of surgical over nonsurgical treatment.
e most consistent nding was increased grip strength at most
data points with surgical interventions. Of note, however, is
that the majority of these studies involved patients 65 years of
age and older with varying levels of desired activity.
129,130
ough the use of named fractures is being discouraged to
minimize confusion in describing specic injury patterns, the
name Colles fracture is still often used clinically. A Colles fracture is an extraarticular fracture occurring 1.5 to 2 inches proximal to the articular surface of the distal radius with angular
displacement dorsally. e mechanism of injury is the FOOSH
with the wrist in hyperextension and some forearm supination.
Seen much less frequently, a fall onto the exed wrist and pronated forearm, results in a volar angulated distal fragment and
is termed a Smith fracture. Nonsurgical care for a dorsally displaced distal radius fracture includes an attempt at closed manual reduction and stabilization by an orthosis or cast for 6 to 8
weeks. Patients are often brought back for repeat radiographs
in the rst 3 weeks to assess maintenance of the reduction. Signicant loss of radial height or excessive dorsal angulation of
the distal radius may be cause for the patient to require surgical
xation. Distal radius fractures that involve shear displacement,
or articular surface step-os, may be treated with various hardware techniques that can range from percutaneous pinning to
external xators to volar or dorsal plating systems. e volar
plating systems have increased in popularity since the 1990s.
131
Proponents of this system note an improved restoration of the
articular surface, radial inclination, and bone length with fewer
postoperative complications compared to other xation tech-
127
niques.
e volar plate clinically has allowed earlier return to
motion of the wrist, decreased immobilization time, and posi-
132
tive patient reports on patient satisfaction surveys.
In a 2011
randomized prospective study, volar plating was compared with
closed reduction and cast immobilization in patients older than
65. ough the surgery group showed better wrist function in
the early postoperative period, at 6 and 12 months, there was
no signicant dierence in wrist function or pain between the 2
129
groups.
e authors also reported better grip strength in the
surgical group at all time points.
127
Levin et al
notes that patients need to be informed of the
high probability of a cosmetic wrist deformity when distal radial
fractures are treated nonsurgically, with malunion noted in up
to 89% of patients. Decision-making algorithms for the treatment of distal radius fractures may be reviewed in sources such
133
as the book, Green’s Operative Hand Surgery.
ese fractures
occur in patients of all ages, activity levels, and life demands
leaving the management decisions up to the treating physician
132
and the individual patient. Gordan and Hanel
emphasizes
that low-demand older adults may be a unique situation where
patients can accept some bone deformity (lack of complete anatomic reduction) yet do very well in their desired activities.
In their discussion of the postoperative care with this patient
population, they note the most appropriate rehabilitation intervention may include a home evaluation for balance and fall
risk assessment as opposed to the isolated focus on restoring
maximum wrist recovery.
Multiple associated injuries may occur with a distal radi-
134
us fracture. Rajah
lists the following: carpal and distal ulna
fractures, intercarpal ligament sprains, TFCC injuries, and median nerve injuries. Arthroscopic studies demonstrated rate of
SL interosseous ligament injury as high as 32% and TFCC in-
20
jury as high as 49%. Fowler
in a review paper notes SL and LT
interosseous ligament injuries occur in approximately one-third
46
Academy of Orthopaedic Physical erapy, APTA.
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of distal radius fractures, leading to the belief that arthroscopy
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may be required to adequately assess the integrity of the carpal
ligaments. ere appears to be a correlation of fractures involving the lunate facet as a predominant fracture pattern involving
the intracarpal ligaments.
135
Forward et al
136
found radial short-
ening >2mm was correlated with intercarpal ligament injuries.
137
Pilny et al
followed 75 patients post distal radius fractures.
Sixteen of the 75 patients developed radiographic and clinical
evidence of wrist instability with all 16 patients exhibiting evidence of increased wrist pain with use, decreased wrist motion, and decreased grip strength compared to those without
20
evidence of carpal instability. Fowler
concludes that high-level
evidence to guide clinical decisions is lacking regarding treatment of these associated ligament injuries.
Of note, rupture of the EPL can be a late complication
of nonsurgical treatment of a distal radius fracture. Potential
explanations for the spontaneous rupture are irritation across
fracture fragments and necrosis from a hematoma that often
develops in the connes of the third extensor compartment.
138
Roth et al
reported an incidence rate of 5% with the rupture
occurring on average 6.6 weeks post-fracture.
Current literature focusing on the superiority of outcomes
in regards to recovery of functional activities, pain relief, and
patient satisfaction show little dierence between surgical versus nonsurgical care, other than the improved grip strength as
noted earlier. Also, the role of formal rehabilitation as opposed
to an independent home program in this patient population
have been and continue to be an area of interest. A retrospective study noted that limitations in total ROM of the ngers
and the motion of the forearm (total active motion [TAM] in
supination and pronation) as the 2 indicators which increased
139
the number of visits to therapy.
Pain levels, edema, and wrist
motions did not appear to aect the number of visits signicantly in this retrospective review of 89 patients with distal radius fracture.
Care should always be taken that noninvolved joints of the
upper extremity are moved. Casting should be comfortable and
allow full motion of the ngers. is should include dierential tendon gliding exercises (4-stage tendon glide, supercialis
sting, and blocking exercises) and intrinsic muscle gliding exercises in which the patient moves actively from the intrinsic
plus (MP joints exed and IP joints extended) position to the
intrinsic minus (MP joints extended and IP joints exed) position. A cast distal to the distal palmar crease will block full
motion of the MP joints, and should be avoided if possible.
Edema management should also be initiated in this early immobilization stage.
Active wrist motion begins as early as 1 to 3 weeks post-surgery for an extraarticular fracture treated with ORIF, 4 to 6
weeks post-surgery for an intraarticular fracture treated with
ORIF, and after 5 to 6 weeks of cast immobilization for extraar-
134
ticular fractures treated nonsurgically.
e patient performs
active tenodesis exercises, gravity-assisted wrist ROM exercises,
and exercises using the place-hold technique. Forearm rotation
exercises also begin with the purpose to regain supination and
pronation. e late stages of rehabilitation focus on wrist and
hand strengthening, endurance, and return-to-work activities
as needed. Naughton and Algar
140
organize the treatment plan
following distal radius fracture into early, intermediate, and
advanced phases with suggestions for guidance into functional
and advanced strengthening as needed. Specic examples of exercises are included in their book chapter.
Clinical Pearl
e therapist should watch for substitution patterns
throughout rehabilitation. Two common substitution patterns are humerus adduction and shoulder external rotation to compensate for lack of supination and use of the
ED muscle to extend the wrist as a substitute for weak wrist
extensor muscles.
One of the most frequent complaints after a radius fracture
is ulnar column pain and swelling. is likely occurs because
ulnar styloid fractures and DRUJ injuries are common in displaced distal radius fractures. e ulnar styloid is usually not
repaired if the fragment is small and asymptomatic; however,
surgeons may deem pinning necessary with a signicant fragment. Ulnar wrist pain and discomfort often increases when the
patient begins isometrics or gentle strengthening because the
force relationships that normally are 80% through the radius
and 20% through the ulna shift to the ulnar side if the radius
is shortened after fracture. e therapist must ascertain whether
the discomfort is within expectations after fracture or is possibly due to other complications such as DRUJ instability, a
nonunion or malunion of the styloid fracture, median or ulnar
nerve injury, complex regional pain syndrome, hardware problems, or associated carpal ligament injuries.
Several publications have compared home exercise programs versus formal therapy (clinical supervised rehabilitation).
ere is evidence that uncomplicated fractures may have good
outcomes with independent programs, however 2 recent studies
note patients greater than 60 years of age or patients with complications or comorbidities are found to benet from a clinically
supervised program.
141,142
SOFT TISSUE DISORDERS
Ganglion Cysts
Ganglion cysts are the most common soft-tissue mass in
the wrist and hand. ey are synovial cysts lled with mucoid
material that arise from the synovial lining of a joint or tendon
sheath. ere is no consensus on the cause, but many authors
agree that ganglion cysts arise from mesenchymal cells at the synovial capsular junction as a result of repetitive microtrauma.
Repetitive microtrauma stimulates broblasts and production
of hyaluronic acid that results in the mucin material found in
143
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47
ganglion cysts.
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143
McKeon et al
144
found an association between
symptomatic dorsal wrist ganglions and generalized ligament
hyperlaxity. ey reported 2.9 times greater odds of ligament
laxity in patients with dorsal wrist ganglions.
e clinical course of a ganglion cyst is variable. Ganglion
cysts generally begin small and progressively increase in size, but
they can spontaneously disappear and reappear later in life.
145
Ganglion cysts are usually asymptomatic but can be painful and
interfere with extremes of motion eventually impairing an individual’s activity level. Approximately 70% of wrist ganglion
cysts are on the dorsal surface and arise from the SL ligament or
143,146
SL articulation.
with a dorsal ganglion.
ey arise from the scaphotrapezial joint or radiocarpal joint.
Scapholunate instability can be associated
146
Volar wrist ganglia are less common.
143
Volar ganglia can adhere to the radial artery or cause ulnar or
median nerve compression. Ganglion cysts are identied during
a clinical examination as a rm, palpable mass, usually 1 to 3
143
cm in size.
e dierential diagnoses include solid tumors,
proliferative tenosynovitis, and a carpal boss.
In tenosynovitis, the cyst moves during tendon excursion,
147
but a ganglion cyst remains stationary.
A carpal boss is described as an osseous protuberance on the dorsal base of the
second or third metacarpal that may involve the trapezoid or
148
capitate, but there is a lack of a standard denition.
Plain
lm radiographs or computed tomography scans may be useful in conrming the presence of a carpal boss, but clinicians
rarely use imaging to diagnose a ganglion cyst. Imaging may be
used when the clinician is evaluating the patient for coexisting
conditions, and in these cases, the preferred studies include ul-
145
trasound or MRI.
dierentiating a ganglion cyst from a vascular malformation.
Diagnostic ultrasound can be helpful in
143
ere is no treatment indicated for patients who are asymp-
tomatic and electrophysical agents are generally ineective.
147
e 3 treatment options for symptomatic wrist ganglia are observation, aspiration (often combined with steroid injection),
149
and surgical excision (open or arthroscopic).
149
review and meta-analysis, Head et al
found a mean recurrence
In a systematic
rate of 21% for open surgical excision versus 59% for aspiration. In their study, the mean recurrence for arthroscopic cyst
excision was 6%; however, this result came from low-quality evidence, and the authors identied the need for more data from
higher quality comparative trials using arthroscopy.
Postsurgical management includes edema control through
elevation and nger AROM exercises initiated immediately following surgery. Wrist ROM may also begin immediately un-
146
less there is a ligament repair.
erapy, either supervised or
through a home exercise program, continues until the patient
achieves full nger and wrist ROM and functional activities.
Once the wound is healed, the patient begins scar management
through compression and scar mobilization. It is important for
the patient to achieve full excursion of the extrinsic wrist and
nger exor (volar ganglia) and extensor (dorsal ganglia) tendons so there is no loss in ROM or resultant stiness. Com-
plications of surgical excision include infection, excessive scar
formation, arterial or nerve damage, and postoperative stiness.
Open surgical excision carries the highest complication rate,
149
14%.
Dupuytren Disease
Dupuytren disease (DD) or contracture, is a broprolifer-
150,151
ative disease of the digital and palmar fascia.
It begins as
a palpable nodule or mass in the palm at the level of the distal
152
palmar crease.
As the disease progresses, cords form and extend distally and proximally. Over time, the cords shorten and
thicken and eventually cause joint exion contractures at the
MP and/or PIP joints although the clinical manifestations are
quite variable.
152
e condition can be painful, but the pain is
often self-limiting, nodules may regress, and contractures may
150
progress rapidly or go through periods of inactivity.
e origin of DD is attributed to both genetic and envi-
151
ronmental factors.
European descent.
Lanting et al
151
e typical patient is a male of northern
150
In a systematic review and meta-analysis,
found prevalence rates ranging from 0.6-31.6%
in the general population of Western countries with increasing
prevalence with increasing age. ere is conicting evidence
regarding suspected risk factors such as alcohol consumption,
smoking, manual labor, hand use, diabetes, and epilepsy.
Clinicians diagnose DD on a clinical examination through
visual observation and palpation of the palmar nodules and
cords. Due to the eects DD may have on many hand structures, it is important to assess MP and IP joints AROM and
PROM as well as integrity of soft tissue and neurovascular
structures. e eects of DD on surrounding tissue include
(1) attenuation of the extensor mechanism in zone III due to
long-standing PIP joint exion, (2) development of a Boutonnière deformity, (3) MP and PIP joints capsular contracture, (4)
adaptive shortening of digital nerves, (5) encasement of digital
nerves and arteries in Dupuytren cords, (6) exor muscle-tendon tightness, (7) intrinsic (lumbrical and interosseus muscle)
tightness and adaptive shortening, (8) joint incongruity, and (9)
skin contracture and breakdown.
153
ere is limited and inconclusive evidence on the use of
154
rehabilitative interventions in management of DD.
Instead,
treatment options include surgical approaches such as collagenase clostridium histolyticum (CCH) Xiaex (Auxilium Pharmaceuticals, Inc, Malvern, PA) injection and manipulation,
needle aponeurotomy, percutaneous needle fasciotomy, and fa-
150,153
sciectomy (open, limited, and segmental).
Indications for
surgical treatment include an MP joint contracture of 30º or
greater or a PIP joint contracture of 20º or greater with documented progression, but surgery is considered on an individual
152
When treating a patient with CCH, the surgeon injects
basis.
the CCH into the cord, which weakens it. Twenty-four hours
later, the surgeon manipulates the digit by passively extending
155
the nger, disrupting or distending the cord.
Literature suggests the manipulation can occur up to 7 days following the
48
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injection without a change in outcome.
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156,157
After the manip-
ulation, the patient works on passive stretching exercises and
152
uses an extension orthosis at night for 3 months.
Side eects
include skin breakage, tendon rupture, pulley and/or ligament
damage, nerve injury, and allergic reaction.
153
Peimer et al
158
reported a 5-year recurrence rate of 47% after CCH injection,
which is comparable to surgery.
Postoperative therapy usually involves edema control,
wound care, tendon-gliding exercises to promote tendon excursion through the surgical site, AROM of the shoulder, elbow,
and wrist, and scar management following suture removal and
wound closure. Gentle PROM begins 3 to 4 weeks post-surgery
once edema and inammation subside and there is no attenuation of the extensor mechanism or PIP joint extension lag.
ere is no consensus in the literature on the type of orthosis or
duration of orthosis use following surgery, but it is the authors’
experience that patients wear either a volar or dorsal extension
153
orthosis up to 6 to 8 months. Sweet and Blackmore
provided
postsurgical recommendations for patients with long-standing
PIP joint exion contractures and attenuation of the extensor
tendon at the PIP joint, which included using a PIP joint extension orthosis for several weeks post-surgery and limiting
composite sting during this time. e DIP joint can remain
free during this time, and the patient performs active DIP joint
exion to maintain the length of the oblique retinacular ligament. e patient gradually begins PIP joint exion and is able
to progress the arc of motion if a PIP joint lag does not occur.
Evans et al
159
recommends a no-tension technique when
153
managing patients following fasciectomy, which is based on
basic science literature describing the detrimental eects of excessive mechanical stress that occur on a cellular level, which
include capillary endothelial occlusion and tissue anoxia. In
the no-tension approach, the patient avoids strenuous exercise,
stretching, and orthoses that create excessive mechanical stress
to the skin and healing tissues to minimize alterations in neurovascular function and tissue nutrition that may in turn facilitate
159
scar hypertrophy and increase edema and inammation.
De Quervain Tendinopathy
De Quervain tendinopathy is a tenovaginitis, or tendon
entrapment. It causes impaired tendon gliding under a thickened retinaculum in the rst dorsal extensor tendon compart-
160
ment of the wrist (APL and EPB tendons).
ere are many
anatomical variations in this region with the most common
being an intercompartmental septum between the tendons of
the APL and EPB, and another being the presence of multiple
160
tendon slips of either the APL (more common) or EPB.
De
Quervain tendinopathy is a clinical diagnosis more common in
women than men. It is especially common in the later stages of
pregnancy and during lactation. Studies have shown inconsistent inammatory ndings that may relate to dierent stages of
the disease.
160,161
A study by Shen et al
161
found levels of estrogen
receptor expression correlated to disease activity.
e clinical presentation includes complaints of pain in the
rst dorsal compartment, tenderness upon palpation along the
tendons’ course, and in some cases, tenderness 1 cm to 2 cm
78
proximal to the radial styloid.
Special tests for this condition
include the Finkelstein and Eicho tests and resisted thumb extension (described earlier); however, special tests alone lack sufcient diagnostic accuracy. Clinicians rarely use imaging studies; but, imaging may be necessary to rule out arthritic changes
at the rst CMC and STT joints or, in cases of trauma, to rule
78
out distal radius or scaphoid fractures.
Dierential diagnoses
also include ruling-out irritation of the radial sensory nerve and
162
intersection syndrome.
Diagnostic ultrasound can be used to
identify anatomical variations.
163
Following a recent systematic review, Abi-Rafeh et al
recommended a multi-modal treatment approach including both
a corticosteroid injection and an orthosis. ese authors also
concluded that an ultrasound-guided injection resulted in better outcomes likely due to the improved accuracy and ability
to visualize the intercompartmental septum. Menendez et al
164
studied the eectiveness of 2 dierent orthosis protocols in patients with De Quervain tendinopathy: wearing a thumb-spica
orthosis full time compared to as-desired. Results showed no
signicant dierences in pain, grip strength, DASH scores, or
treatment satisfaction at the end of the intervention (nal follow-up mean ± standard deviation: 7.5 ± 3.3 weeks, range, 3.6
to 24 weeks).
Factors associated with poor outcomes for individuals undergoing nonsurgical management include the presence of metabolic syndrome and hypothyroidism, use of growth hormone,
a history of trigger nger or CTS, extensor tendon triggering,
and presence of psychological factors including pain anxiety,
163
depressive symptoms, and catastrophizing.
Some individuals
may require surgical intervention. Rehabilitation goals following surgery include full wrist and thumb ROM and tendon
gliding, a mobile, non-painful scar, and full return to activity.
Trigger Finger
Trigger nger or trigger thumb, is a stenosing tendovag-
initis that includes snapping or locking of a nger or thumb
165
during exion, with or without pain.
It usually occurs in the
palm at the level of the distal palmar crease, or MP joint, due
to a size mismatch between a swollen exor tendon and a thick-
166
ened A1 pulley.
e tendon sheath extends more proximally
than the pulley system and a palpable, tender nodule may develop at the proximal edge of the sheath. During nger exion,
the exor tendon glides proximally, then as the patient tries to
extend the nger, the tendon (or nodule) gets “stuck” on the
proximal border of the pulley, momentarily preventing nger
extension. In more severe cases, the patient reports the need to
manually straighten the nger. Dierential diagnoses include
DD, ganglia, lipomas, and other exor tendon masses, such as
167
tumors.
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49
Uchihashi et al
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166
described histopathological ndings in
trigger ngers, identifying chondrocytoid cells that produce
hyaluronic acid and a hypocellular collagen matrix in the tenosynovium. ese abnormal cellular changes result in hypertrophy causing constriction in the bro-osseous A1 pulley. ese
authors suggest that excess hyaluronic acid synthesis and an
edematous collagen matrix are involved in the condition’s progression. In their study, the incidence of those histopathological
ndings was much greater than those that typically occur in
tissue aected by synovitis.
Trigger ngers are usually idiopathic and occur much more
frequently in women than men. e goal of treatment is to restore a smooth, painless, full ROM in the aected ngers.
167
Nonoperative treatment includes ROM and tendon gliding
167
exercises, modalities, orthoses, or steroid injection,
although
there is no evidence to support nonsurgical interventions other
168
than orthoses and injection. Lunsford et al
concluded that
an orthosis could be used when injection or surgical intervention were not viable options. ese authors concluded that the
orthosis should be worn at all times for 6 to 12 weeks, and the
decision to block, or immobilize, MP joint exion versus PIP
joint exion should be determined by the therapist and patient
preference.
According to a consensus study on the treatment of trigger
nger, one should determine treatment according to the severity
156
and duration of the patient’s symptoms.
In patients with early, mild symptoms (symptoms < 3 months and no snapping or
locking), an orthosis that holds the MP joint in extension (MP
blocking orthosis) is indicated.
As the duration and severity of the disease progresses, au-
thors of the consensus study recommend corticosteroid injec-
156
tion or corticosteroid injection plus orthosis use.
169
series showed 45%
and 69%
using corticosteroid injection. Wojahn et al
170
success rates with treatment
169
Two case
reported higher
success in females presenting with their rst trigger nger. Factors associated with success in their study included female sex
and single rather than multiple nger involvement. In a review
167
of literature, Oh et al
reported the deleterious eects of corticosteroid injections on subcutaneous fat atrophy, pain, skin
depigmentation, transient elevation of urine and blood glucose
levels, and tendon tensile strength. ese authors recommended
avoiding physical activity and overload to the aected part for
approximately 3 weeks following the injection to allow tendon
healing to avoid tendon rupture.
Patients who fail nonsurgical management may progress to
surgery, which includes percutaneous or open release. Patients
patients will not need postoperative therapy following trigger
nger release unless complications arise. e therapist then focuses the treatment on complications that may include localized
pain, swelling, and/or scarring; AROM loss; and joint stiness.
e therapist may perform therapeutic ultrasound, gentle painfree massage, scar compression, and dierential tendon gliding
exercises, while avoiding new signs and symptoms of inammation. e patient does not begin strengthening or resisted
activities until 3 weeks post-surgery. Strengthening begins with
submaximal, isometric activity in a pain-free position and progresses gradually to avoid pain and tenosynovitis. Forceful composite sting should be delayed or minimized in patients prone
165
to triggering in multiple digits.
NERVE INJURIES
Peripheral nerves in the upper extremity consist of myelinated and unmyelinated axons that project from the nerve cell
bodies. A connective tissue sheath, known as the endoneurium,
surrounds the axon as it travels from the nerve cell body to its
target organ. e endoneurium is comprised of broblasts (responsible for collagen synthesis), capillaries, and lymphatics.
171
e perineurium, another connective tissue layer, holds togeth-
172
er a bundle of axons.
is bundle of axons is known as a
fascicle. e perineurium, along with the endoneurium, form
172
the blood-nerve barrier.
e perineurium also provides tensile
strength and regulates diusion into the fascicles. e epineurium, a thick connective tissue layer holds together groups of
fascicles. It provides additional protection and cushioning, as
171
well as a nutrient-rich blood supply.
e epineurium is thick-
er where the nerve crosses joints, likely for additional protec-
171
e number of fascicles in an individual nerve can vary
tion.
from 1 to 3 in small sensory nerves to 200 in large nerves.
172
Classication of Nerve Injuries
173
Seddon
form of nerve injury and generally carries a good prognosis.
outlined 3 types of nerve injury: neurapraxia,
174
It
is characterized by a transient reduction, or complete blocking
173
of nerve conduction at the lesion site,
from etiologies such as
compression or repetitive strain. In neurapraxic injuries, axon
continuity remains intact, but there is disruption in neural
175
circulation with formation of endoneurial edema.
Resulting
ischemia metabolically blocks conduction by interrupting the
176,177
energy source required for axonal transport.
Clinically, it
results in sensory dysfunction, the Tinel sign is not present, and
172
electrophysiologic studies are negative.
ing compression can result in brosis within the epineurium.
However, long-stand-
175
In neurapraxic injuries, recovery begins immediately following
removal of the compression, recovery is complete, and occurs
between hours to 3 months after removal of compression.
Axonotmesis is a more severe type of nerve injury. In these
injuries, there is axonal damage but the surrounding connective tissue structures (ie, perineurium and epineurium) are
172,178
preserved.
the injury, causing complete denervation.
Axon and myelin degeneration occur distal to
178
e potential for
recovery is good in axonotmetic injuries because the uninjured
nerve latticework provides a path for subsequent sprouting ax-
178
ons to reinnervate their target organ.
In axonotmetic inju-
ries, there is sensory and/or motor dysfunction and the Tinel
50
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sign is positive at the site of the injury.
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172
Electrophysiologic
studies reveal decreased nerve conduction and regional muscle
178
denervation with fasciculations.
immediately in axonometic injuries.
Regeneration occurs almost
179
In neurotmesis, the most severe type of nerve injury, such
as a laceration, there is complete disruption to the nerve. In
these injuries, there is complete functional loss. Also, there is no
potential for recovery without surgical intervention due to scar
formation and loss of the endoneural tube that would otherwise
178
properly direct axonal regrowth.
Following nerve laceration,
the distal aspect of the nerve disintegrates, Schwann cells lose
180
their myelin sheath, and some Schwann cells die.
Interesting-
ly, sensory neurons show greater cell death than motor neurons
180
over time if not repaired.
As many as 20% to 50% of neurons
in the dorsal root ganglia may also die following an injury to a
sensory nerve.
176
Nerve Repair and Regeneration
Nerve repair can include a direct, or end-to-end repair, or
in cases where the gap between the ends of the nerve is significant, surgeons may use nerve conduits or tubes that serve as a
tunnel to bridge nerve ends, and nerve grafting. Axonal regeneration and remyelination begins as early as 2 to 3 weeks after re-
179
e smallest diameter bers tend to be the rst to show
pair.
return, thus making pain one of the rst senses to reappear following injury or repair, while the large diameter bers that carry
vibration, proprioception, and motor function tend to be the
last to recover.
179
Dellon et al
181
proposed the following order of
sensory recovery: (1) pain measured via pin prick, (2) 30-cycle
per second vibration, (3) moving touch and moving 2PD, (4)
constant touch and static 2PD, and (5) 256-cycle per second vi-
182
bration. Although, Waylett-Rendall
found that some patients
have return of 30-cycle per second vibration prior to pain.
e widely understood rate for axonal regrowth is about 1
183
mm per day.
Outcomes following nerve injury vary among
patients. e literature provides signicant factors inuencing
recovery. ese include (1) age (children under 10 years have
superior outcomes); (2) verbal and visio-spatial learning capacity; (3) timing (earlier repair is associated with less cell death,
scarring, and Schwann cell atrophy and facilitates easier blood
vessel visualization during surgery); (4) pure motor or sensory
nerve injury (unlike mixed nerve repairs, there is no chance of a
mismatch between bers); (5) level of injury (distal injuries only
have to travel short distances to reach their target tissue); and
(6) type of injury (a clean, sharp laceration with minimal to no
184
loss of tissue has improved chances at recovery).
Early surgical repair and pharmacological agents can help
decrease neuronal cell death and help in achieving a reasonable
outcome, although in adults, there will be some permanent
180
dysfunction.
Researchers speculate that cortical and subcortical (thalamus and brain stem) reorganization occurs almost
immediately after transection injuries and may be a factor in
185
the suboptimal recovery of these injuries.
For example, after
a median nerve injury, there is a silent black hole in the somatosensory brain cortex that corresponds to the median nerve
184
distribution.
Soon, adjacent areas of the brain take over and
previously inhibited areas of the brain are unmasked to compen-
184
Another deterrent to complete recovery is misdirection
sate.
of axons to the incorrect target tissue. As healing progresses, a
new axon may innervate a dierent area of the skin or a motor
nerve may innervate a sensory area, and vice versa. Clinically, patients complain of problems with touch localization. is
misdirection produces additional changes in the cortex, further
complicating recovery.
184
Clinical Presentation of Traumatic Nerve Injuries
Median nerve
Traumatic median nerve injuries are usually open injuries.
ere is a usual pattern of sensory decit potentially involving
the volar aspect of the thumb and index, long, and radial half of
the ring ngers. Motor loss in traumatic median nerve injuries
is more extensive when the injury is in the proximal forearm
compared to the distal forearm. Motor loss in proximal median nerve injuries can include the pronator teres, FCR, palmaris
longus, FPL, and FDP (index and long) muscles, and the hand
muscles including the lumbrical muscles I and II, FPB (supercial head), APB, and OP muscles. Distal injuries will preserve
function of the forearm, wrist exor, and extrinsic nger exor
muscles, but there will be weakness of opposition and pinch
due to involvement of the median-innervated thenar muscles.
186
Loss of thenar musculature results in an ape hand deformity,
ie, loss of thumb opposition causes the thumb to rest in the
plane of the palm. is deformity impairs ne motor function,
including writing, prehension, ne motor manipulation, dexterity, coordination between the thumb and index nger, and
stereognosis (also known as tactile gnosis or object identication by touch).
Ulnar nerve
Traumatic ulnar nerve injuries in the proximal forearm
(high injuries) and wrist or hand (low injuries) usually result
from lacerations, fractures, or dislocations, and suicide attempts. Injuries to the ulnar nerve may occur along with injuries to muscles, tendons, or arteries that complicate the patient’s
prognosis and rehabilitation. High injuries result in sensory loss
in the volar and dorsal surfaces of the small and ring (ulnar half)
ngers. Motor loss occurs in the FCU, FDP (ring and small
ngers), hypothenar, dorsal and palmar interossei, lumbricals to
the ring and small ngers, AP, and FPB (deep head) muscles.
187
Lower injuries spare sensation on the dorsal-ulnar aspect
of the hand due to branching of the dorsal branch of the ulnar nerve in the forearm. In low lesions, the sensory and motor
patterns are dependent on the specic location of the injury
with relation to the ulnar tunnel. Lesions proximal to the ulnar tunnel will result in sensory loss in the ulnar aspect of the
hand (volar only) and motor loss in the hand similar to high
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51
lesions (excluding the FCU and FDP muscles). Lesions distal
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to the bifurcation of the ulnar nerve into its deep and supercial branches will have dierent clinical manifestations. Patients
with injuries to the deep branch will have normal sensation but
lose motor function of the ulnar-innervated hand intrinsic muscles. Lesions to the deep branch that occur distal to the abductor digiti minimi branch will aect the interossei but spare the
hypothenar muscles. Injuries to the supercial branch of the ulnar nerve result mostly in sensory loss to the volar-ulnar aspect
of the hand. Motor loss includes the palmaris brevis, but this
is rarely noticeable to the patient and dicult to detect upon a
clinical examination.
188
Patients with ulnar nerve injuries are at risk for developing
a claw-hand (intrinsic minus) deformity in the ulnar ngers.
Loss of the muscles of the hypothenar eminence leaves the ED
muscle unopposed at the MP joints, resulting in excessive MP
joint extension. Loss of intrinsic muscle contribution to PIP
joint extension allows the FDS and FDP muscles to overpower
the ED muscle, resulting in excessive PIP joint exion. A patient with clawing has diculty grasping around objects with
the ulnar aspect of the hand. Patients also lack the ability to key
pinch and have a positive Froment sign, in which they attempt
to substitute for loss of the thumb adductor by activating the
FPL muscle (innervated by the AIN) that produces thumb IP
joint exion (Figure 17). ere is also atrophy in the thumb
web space.
Radial nerve
Traumatic injuries to the radial nerve in the proximal
arm are often associated with a humeral shaft fracture or elbow dislocation. Lesions proximal to the radial head will aect
the anconeus, brachioradialis, as well as all the wrist, thumb,
and nger extensors. ese proximal lesions produce a classic
wrist drop deformity due to loss of the wrist and thumb extensors. Also, there will be sensory loss in the radial side of the
hand including the dorsal aspect of the thumb and index and
long ngers. Lesions distal to the bifurcation of the radial nerve
into the PIN and supercial sensory branches produce isolated
motor loss (PIN injuries) or isolated sensory loss (supercial
sensory branch injuries), respectively. Individuals with injuries
to the PIN will be able to extend the wrist with a radial deviation bias due to branching to the ECRL muscle proximal to
the bifurcation of the PIN and supercial sensory branch. Otherwise, motor examination of the PIN-innervated muscles in
proximal-to-distal order is important to determine the location
of the injury. Lesions to the supercial sensory branch have little
functional consequences.
Management of Traumatic Nerve Injuries
More severe traumatic nerve injuries require surgical management, if only for purposes of exploration and neurolysis, and
if explored early (within 5-7 days) most sharp lacerations can
186
be primarily repaired.
When primary repair is not an option,
gaps can be bridged using allografts, conduits, or grafts. A therapist must have a good understanding of the surgical repair to
individualize a rehabilitation protocol for a patient.
e position of immobilization after surgery is determined
by a variety of factors that include location and type of repair
(ie, primary, conduit, etc.). Also, immobilization should prevent
both over stretching of the denervated muscle-tendon units and
179
typical deformity that result from nerve injury.
e early re-
habilitation should focus on edema control through elevation
179
and active movement of noninvolved joints.
e use of ice
is controversial at or distal to the repair because it slows nerve
conduction and may harm insensate tissues. It is imperative for
the therapist to educate the patient throughout rehabilitation to
prevent injuries, such as burns, to the ngers because of sensory
loss.
Once the surgeon removes the postoperative dressings and
clears the patient for activity, AROM and PROM may begin,
including place-and-hold activities. In place-hold exercises, the
therapist passively places the limb or ngers in the desired position based on the nerve repaired and asks the patient to hold
the position using their own muscle contraction. If needed, the
therapist provides assistance with the hold phase. e therapist
also initiates gentle wrist, nger, and thumb ROM in a protected range with gravity eliminated and progresses to full range
179
against gravity.
Care must be taken not to place excess tension
on the nerve during this phase when regaining active motion.
It is important for the therapist to instruct the patient in maintaining PROM of all aected joints to minimize stiness and
avoid joint contractures, because, while awaiting motor recovery, patients will tend to develop stiness and contractures in
typical patterns depending on the nerve repaired. Surgeons may
choose to use an orthosis for optimal positioning to minimize
contractures and preserve function while awaiting return of innervation.
Following median nerve injuries, the patient will tend
to develop a thumb adduction contracture or stiness in the
179
thumb web space. Du et al
recommended use of a resting
hand orthosis with a thumb component or forearm-based opponens (thumb spica) orthosis to support the thumb in opposition. e patient may also use a static, hand-based opponens
orthosis during the day to position the thumb, facilitate pre-
179
hension, and allow some use of the ngers.
With ulnar nerve
injuries, the patient uses a dorsal MP joint blocking orthosis
that positions the ring and small nger MP joints in exion to
minimize the claw-hand deformity. is orthosis helps prevent
MP joint extension stiness and redistributes ED muscle force
to the IP joints to minimize IP joints exion stiness (Figure
179
In radial nerve injuries, the patient uses a palmar resting
24).
orthosis to support the ngers and wrist in extension.
When motor function begins to return, the therapist instructs the patient in specic exercises as well as functional activities for the involved muscles. Sensory reeducation and dexterity training are important components of the rehabilitation
52
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Figure 24.
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Hand-based Anti-claw Orthosis (Ulnar
Gutter Orthosis)
program. e use of alternating current electrical stimulation
should be considered as an adjunct to sensory and motor reeducation.
179
Sensory Reeducation
Rosen et al
189
described sensory reeducation, or relearning,
as a process required for decoding and adapting to new and
distorted aerent sensory input. ey have divided sensory reeducation into 2 phases. Phase 1 occurs immediately after repair when the patient has no protective sensation.
189
e goal
of phase 1 is to maintain the cortical hand map in the brain.
Activities in this phase include motor and sensory imagery. e
therapist can also instruct the patient in mirror therapy, where
the patient hides the involved hand behind a mirror and someone touches the uninjured hand. e patient, looking in the
mirror sees touch as if it were happening to the injured hand
(Figure 25).
Phase 2 begins when the axons have reached the hand or
when the patient can feel, at minimum, the 6.65 (300 g) monolament in the palm and when touch localization is present.
189
In this phase, patients perform shape, texture, and object identication activities.
189
Beginning sensory reeducation too early
can lead to failure and cause frustration for the therapist and pa-
190
tient.
Because pain is the rst sensation to recover following
nerve injury or repair, many patients will develop hyperesthesia,
or allodynia. In these cases, a desensitization program should
precede sensory reeducation.
189
e therapist accomplishes this
by instructing the patient to expose the hypersensitive area to a
Figure 25.
Mirror erapy*
e patient is seated perpendicular to a mirror. e
involved hand is hidden behind the mirror. e
patient performs activities with both hands while
watching the uninvolved hand in the mirror, which
appears as if it were the involved hand.
*Reprinted with permission from Wadsworth C, Barch E, Erickson M. e Wrist and Hand: Physical erapy Patient Management Utilizing Current Evidence: Home Study Course 21.2.4. La
Crosse, WI: Orthopaedic Section, APTA Inc; 2011.
variety of textures, beginning with soft cotton and progressing
to more coarse textures. Additional interventions for hypersensitivity include compression, percussion, vibration (low to high
cycle), and dowel textures (moving stimulus), moving the hand
through particle bins (static stimulus), transcutaneous electrical
nerve stimulation, and ultrasound.
191
Compression Neuropathies
Carpal tunnel syndrome
Carpal tunnel syndrome is the most common compression
neuropathy. Incidence, prevalence, and risk factors have been
reported in the 2019 Clinical Practice Guideline of the Academy of Orthopaedic Physical erapy.
192
With CTS, patients
complain of pain, numbness, and tingling in part or all the
median nerve distribution, which includes the volar aspect of
the thumb and index, long, and radial half of the ring ngers.
Sensation of the skin around the scaphoid tubercle is normal
because the palmar cutaneous branch of the median nerve innervates this area.
Management of CTS begins with making an accurate diagnosis, which includes ruling out conditions that mimic CTS,
such as cervical radiculopathy, thoracic outlet syndrome, diabetic neuropathy, demyelinating disorders, and pronator teres
syndrome (where the median nerve becomes entrapped between the 2 heads of the pronator teres muscle). e examina-
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53
tion should include a medical screening and history, risk factor
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and symptom assessment, and self-report measures such as the
192
Katz hand diagram, CTQ-SSS, CTQ-FS, or DASH.
Authors
of a clinical prediction rule for the diagnosis of CTS reported
98% sensitivity and 54% specicity for diagnosing CTS if 3 of
the following are present: shaking hands provides relief, wrist
ratio (anterior-posterior width/medial-lateral width) greater
than 0.67, CTQ-SSS score greater than 1.9, decreased thumb
193
sensation, and age greater than 45 years.
e best likelihood
ratio (4.60) came when 4 of the 5 items were present, or pos-
193
is clinical prediction rule requires further validation
itive.
in additional samples. Clinicians should also combine ndings
from multiple special tests including the carpal compression
and Phalen tests and the Tinel sign.
192
If the clinical examination shows ndings consistent with
CTS, a clinician should assess the severity of nerve compression. is is done through assessing for presence of a Tinel sign,
192
sensory threshold testing, and 2PD testing.
e Tinel sign is
important when assessing severity because it is a sign of axonal regeneration that appears in the later stages of compression.
Baseline grip and pinch strength and dexterity testing could be
done to assess functional implications of nerve compression.
Electrodiagnostic studies, such as electromyography or nerve
conduction studies, can be useful in conrming the diagnosis of
CTS and in grading its severity when the clinical examination
is inconclusive. However, there are some individuals who have
surgically relieved median nerve compression but show normal
electrodiagnostic studies prior to surgery.
194,195
Nonsurgical management of CTS begins with the use of a
thosis), with increasing dosage as needed to include full-time
wear. One may also consider extending the orthosis distally to
192
immobilize the MP joints in a neutral position,
especially in
the absence of electrodiagnostic studies. Classications based
on clinical signs and symptoms alone or combined with electrodiagnostic studies are largely based on anecdotal evidence,
expert consensus, or the pathophysiology of nerve compression
and lack independent validation. According to evidence presented, the frequency of symptoms (mild demonstrating more
intermittent symptoms and moderate demonstrating more constant symptoms) immobilizing the MP joints prevents lumbrical muscle moving proximally into the carpal tunnel (lumbrical
incursion) where they compromise space. Weaker evidence exists for interventions such as supercial heat, interferential current, phonophoresis, manual therapy, and lumbrical or general
stretching.
192
is monograph’s authors agree that patient education,
including activity modication during ADLs, work activities,
and recreational activities, are other important components of
nonsurgical management. Computer workstations and hand
tools should position the wrists as close to neutral as possible,
and the patient should attempt to avoid prolonged palm and
volar wrist pressure, vibration, and cold exposure. Other pro-
longed positions to avoid include a tight full (composite) st
and the intrinsic plus positions. Patients should be advised to
use large handle grips and padded work gloves. Patients should
avoid forceful gripping (especially combined with wrist exion
or extension) and loading the nger exors with the wrist in a
neutral, exed, or extended position and pinching because these
positions increase intraneural pressure.
Clinicians managing patients nonoperatively for CTS
should realize the detrimental eects of prolonged nerve compression including the potential for permanent loss of sensation and motor function. In a systematic review, Shi et al
196
showed that benets of nonsurgical management plateau after
3 months, while the clinical benets of surgery continue for
at least 12 months. Surgical outcomes often surpass those seen
with nonsurgical care on symptom, function, and electrophysiologic measures.
196
According to Boyd et al,
197
the CTQ-SSS,
an 11-item self-report questionnaire, is the best predictor of
failed nonsurgical management. Other authors have shown that
CTQ-SSS scores of 2.5 or less are 89% specic for a positive
198
response to nonsurgical management.
Individuals with severe symptoms or who fail to respond to
nonsurgical management may progress to surgery. For those undergoing carpal tunnel release (CTR), early mobilization is rec-
199
ommended.
ere is no evidence to support the routine use
of therapy following CTR. It should be reserved for those who
demonstrate complications, including but not limited to scar
200
hypersensitivity, ROM decits, or prolonged pain.
Patient
education described previously for nonsurgical management
continues to be important after surgery. After suture removal,
2 weeks post-surgery, the patient can begin scar mobilization.
Repetitive gripping and pinching as well as strengthening with
putty or hand grippers is not recommended at this point because these activities can contribute to inammation in the ex-
201
or sheath, the A1 pulleys, and the thumb.
Return to work
depends on hand involved and handedness, patient occupation,
199
and the availability of return to work.
Results show favorable outcomes in the majority of pa-
202,203
tients following CTR.
In a recent prospective cohort study,
results showed symptom duration and electrophysiological severity were signicant predictors of change score in the CTQSSS, while age was the only predictor of change in the CTQFS. Preoperative grip strength was the only predictor of patient
203
satisfaction following CTR.
In another study, authors found
that higher preoperative Pain Catastrophizing Scores (>30) neg-
202
atively inuenced patient satisfaction.
Ulnar nerve
Ulnar tunnel syndrome (UTS), or compression of the ulnar nerve at the wrist, occurs near the ulnar tunnel, or Guyon
canal. It is generally accepted that the incidence is less than both
188
CTS and cubital tunnel syndrome at the elbow.
Common
causes of UTS include ganglia; anatomical abnormalities such
as anomalous muscles, brous bands or ligaments; fractures of
54
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