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the distal radius, hamate, trapezium, pisiform, or ring and small
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metacarpals; hypothenar hammer syndrome; and repetitive and
188
prolonged pressure (ie, cyclist’s palsy).
ere may be an association between UTS and CTS. In a retrospective study, authors
reported a high percentage (85%) of individuals with idiopathic
UTS also had CTS.
204
Chen and Tsai
188
reported 20% to 30%
of patients with CTS have concurrent UTS, and in a recent
systematic review, authors found abnormalities in the shape and
pressure of the ulnar tunnel in individuals with CTS and improvement in ulnar nerve electrodiagnostic data in individuals
205
who underwent CTR.
Individuals with UTS complain of pain, numbness, tingling, and weakness in the ulnar nerve distribution of the hand
that aects grip and pinch strength. Patients with more severe,
or prolonged compression may demonstrate clawing of the ring
and small ngers, intrinsic muscle wasting, as well as atrophy
of the thumb web space. Patients with motor loss may display
a positive Froment sign. Electrodiagnostic studies may conrm
the clinical diagnosis.
e clinical presentation of UTS varies depending on the
location of the compression. Compression proximal to the
ulnar tunnel, before the bifurcation into supercial and deep
branches, results in sensory loss in the volar-ulnar distribution
of the hand (hypothenar eminence and small and ulnar half
of the ring ngers), and weakness of all ulnar-innervated in-
188,206
trinsic muscles.
Compression of the supercial branch of
the ulnar nerve produces sensory loss on the volar aspect of the
ulnar-innervated ngers, but there is no signicant motor weakness, because the supercial branch only innervates the palmaris brevis muscle and weakness is dicult to detect clinically.
188
Compression of the deep motor branch of the ulnar nerve in
206
the hand produces isolated motor symptoms.
In the event of
arterial involvement, the patient may have a positive Allen test.
Dierentiating between proximal and distal ulnar nerve
lesions includes sensory testing the ulnar-dorsal aspect of the
hand. e dorsal cutaneous branch of the ulnar nerve, which
traverses volar to dorsal 4 cm to 5 cm proximal to the ulnar tunnel, innervates this area. us, an ulnar-dorsal sensory loss indicates a more proximal lesion; whereas, retained sensation in this
206
area indicates a lesion distal to the dorsal cutaneous branch.
Nonsurgical management is indicated for patients with
mild UTS without motor decit and when there is no identiable structural abnormality, but early recognition is important.
Patient education should include rest, activity modication,
and use of equipment such as orthoses or gloves to minimize
compression. Cyclists should alter hand and upper extremity
positioning on longer rides and assure proper body mechanics through appropriate saddle and handle-bar positioning.
207
erapists should refer patients presenting with motor loss to
a hand surgeon for further diagnostic imaging and testing and
possible exploration. Surgery is indicated in patients who present with compressive lesions, motor decits, and failed non-
188
surgical management.
Surgery consists of resection of mass-
es, thromboses, aberrant brous bands, or bony protrusions
causing compression.
206
Patients undergoing surgery for UTS
regain ROM on their own and are unlikely to have postoperative therapy. Some individuals may develop complications such
as hypertrophic or hypersensitive scars, and these may warrant
a therapy examination. As with all nerve lesions, the therapist
educates the patient to avoid contact with items that may cause
damage to the insensate areas. is is especially important in the
ulnar aspect of the hand because of its potential for resting on
hot, sharp, or rough surfaces.
179
Radial nerve
Radial nerve injury, or compression, at the wrist, some-
times referred to as Wartenberg syndrome (or cheiralgia paresthe-
sia), causes sensory changes in the radial aspect of the wrist,
dorsal thumb, thumb web span, and radiodorsal aspect of the
hand. e nerve is very supercial in this area and can easily be
compressed by external forces. Causes of injury or compression
include trauma, diabetes, repeated exposure to cold, hand exertion, a tightly worn wristwatch or handcus, lipoma, surgeries,
or compression between the brachioradialis and ECRL mus-
208
cles.
Anomalous brous or fascial bands arising from these
muscles can also cause compression.
209
Compression can also
result from a cast that is applied too tight, or from a surgical
intervention around the base of the thumb, such as an interposition arthroplasty for rst CMC joint osteoarthritis or De
Quervain decompression.
Patients may complain of pain, numbness, tingling, or hypersensitivity in the distribution of the nerve along the dorsal
aspects of the thumb and radial hand. ere may be a positive
Tinel sign over the radial side of the wrist, at the radial styloid,
or distal radius. Manual muscle testing of the brachioradialis
or radial wrist extension may elicit symptoms. Dierential diagnosis includes cervical radiculopathy (particularly C6 nerve
root entrapment), De Quervain tendinopathy, rst CMC joint
osteoarthritis, intersection syndrome, and lateral antebrachial
cutaneous nerve neuritis.
210
Patient education for care of the insensate area and prevention of further injury is important. Management includes
eliminating compression and avoiding wrist positions that
recreate symptoms. Gentle nerve gliding may be benecial;
however, any treatment should not recreate an inammatory response or reproduce symptoms. Surgical intervention includes
release of fascial bands or restrictions between the brachioradialis and ECRL, or removal of space-occupying lesions (eg, lipomas or bone spurs).
209
erapy post-surgery is rarely indicated
in these patients unless there is a need for wrist or thumb ROM
exercises, scar or nerve mobilization, or desensitization.
Double-crush and reversed double-crush syndromes
Double-crush syndrome is an important concept for physicians and therapists to understand when diagnosing nerve lesions in the upper extremity. Double-crush syndrome implies
that proximal interference with axonal transport will make the
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55
distal aspect of the nerve more susceptible to injury, such as in
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the case of a patient with a cervical lesion who develops CTS.
211
With reversed double-crush syndromes, retrograde transport
from the axon to the nerve cell body is disrupted making the
211
proximal aspect of the nerve more susceptible to injury.
is
awareness allows more accurate diagnosis of patients with cervical radiculopathy who present with mixed nerve symptoms
and patients with nerve compression syndromes who do not
demonstrate classic patterns of nerve injury.
Nerve Regeneration
Following nerve compression, laceration, or surgical repair,
the therapist should assess nerve regeneration. A positive Tinel
sign distal to the lesion is the rst sign of nerve regeneration.
74
Begin by tapping distally to proximally along the course of the
injured nerve. e level of axonal regeneration corresponds to
the point where tapping produces tingling in the nerve’s distribution. e therapist can use the Tinel sign repeatedly over
212
time to track the level of axonal regeneration.
More research
needs to be done to validate use of the Tinel sign in this manner.
Monitor motor return through muscle testing or observing individual muscle, strength, hand function, substitution patterns,
and postural changes.
Sensory recovery can be monitored by testing the patient’s
ability to sense pain (through use of a pin prick). As recovery
progresses, track the individual’s response to moving 2PD and
then static 2PD. Monolaments can be used to assess sensory
threshold. If using monolaments, when the patient senses the
4.31 monolament (diminished protective sensation), there is
74
also a gross appreciation for static 2PD (7-10 mm).
CONCLUSION
Evaluation of the hand and wrist requires a therapist to be
mindful of the intricate anatomy and appreciate the careful palpation required about the small and closely approximated structures. Early referral allows a therapist to assess for well-tting
casts or orthoses and initiate active eorts to minimize edema
formation. Tendon glide exercises as early as allowed by tissue
healing constraints may minimize adhesion formation thereby
improving motion of multiple small joints within the hand.
A sensory examination can assist in identifying a patient who
could benet from either desensitization activities or sensory
reeducation. Finally, one must appreciate injuries and pathologies that may be treated with nonsurgical care (eg, soft tissue
mallet, volar plate avulsion, mild nerve compression symptoms)
versus those best referred for surgical or medical intervention
(eg, stener lesion, wrist instabilities, advanced compression neuropathies).
CASE SCENARIOS
Case Scenario 1
A 22-year-old male college student presents to the clinic
via direct access 2 days after he felt a ‘pop’ in his right ring
nger while attempting to grab another player’s jersey during a
football game. He presents with pain, ecchymosis on the volar
aspect of the ring nger distal interphalangeal (DIP) joint, and
an inability to actively ex the ring nger DIP joint. His passive
range of motion (ROM) at the DIP joint is normal but painful. He has 90° of active ROM at the proximal interphalangeal
(PIP) joint. His active extension is normal.
1.
After taking a history and observing his active and passive
ROM, you suspect:
a. Collateral ligament sprain.
Ruptured extensor tendon.
b.
c. Ruptured exor digitorum profundus tendon.
d. Ruptured exor digitorum supercialis tendon.
e correct answer is c. Ruptured exor digitorum pro-
fundus tendon. Lack of active ROM at the DIP joint could be
the result of a exor tendon rupture. e mechanism of injury
is most often a forceful extension of a exed DIP joint, such as
grabbing another player’s jersey, and it occurs most often in the
ring nger. e injury spares the exor digitorum supercialis
tendon leaving PIP joint active ROM intact. In collateral ligament sprains, PIP and DIP joint active ROM are intact. In this
patient, PIP and DIP joint extension are normal, ruling out a
ruptured extensor tendon.
includes:
a. Fabricate a wrist cock-up orthosis to position the wrist
in a neutral position.
Instruct the patient in passive exion exercises to be
b.
done 10 times every 1 to 2 hours.
c. Refer him to a hand surgeon for a surgical consultation.
d. Use an orthosis to position the DIP joint in extension
and have him return in 8 weeks.
e correct answer is c. Refer him to a hand surgeon for
a surgical consultation. ese injuries require surgical xation
immediately to avoid tendon retraction into the forearm. e
patient will also require a radiograph to rule out an avulsion
fracture.
3. Following a 4-strand tendon repair, which of the following should be addressed early in the postoperative period to
minimize friction and load to the healing tendon?
a. Edema control and full passive ROM of all digits.
b. Edema control and full passive ROM of the wrist.
c. Restore full active ROM of the uninvolved digits.
d. Restore full active ROM of the wrist.
e correct answer is a. Edema control and full passive
ROM of all digits. Following a 4-strand tendon repair, the
therapist instructs the patient in strategies to reduce edema and
56
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minimize nger stiness to reduce load on the healing tendon.
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is also maintains joint ROM while allowing the tendon repair to heal. Because the exor digitorum profundus tendons
are connected via the same muscle belly, active ROM at the index, long, or small ngers places excessive tension on the repair
site that may lead to gapping or rupture.
Based on the patient history, what structure/area(s) would
2.
you focus your palpation upon?
a. Anatomical snu box.
b. Hook of the hamate.
c. Scaphoid tubercle.
d.
Ulnocarpal joints.
4.
Which of the following exercises would be appropriate on
the rst postoperative visit following a repair of the exor
digitorum profundus in zone 1?
a. Active PIP joint extension with the metacarpophalange-
al joints positioned at 0°.
b. Grip strengthening with putty.
c. Passive DIP and PIP joint exion with the ngers posi-
tioned in the intrinsic plus position.
d. Passive stretching to increase PIP joint extension with
the metacarpophalangeal joints positioned at 0°.
e correct answer is c. Passive DIP and PIP joint ex-
ion with the ngers positioned in the intrinsic plus position.
e intrinsic plus position allows the repaired tendon to be on
slack. Passive joint motion allows the patient to work on joint
exibility and does not jeopardize the healing tendon. e other
choices would place too much tension across the repair site and
risk rupture.
Case Scenario 2
A 32-year-old female presents to the clinic with an acute
onset of ulnar-sided wrist pain that began after a fall on an outstretched hand 3 days prior. She complains of pain at rest and
with all directions of wrist active range of motion (ROM). She
also complains of clicking in the extremity with active wrist
ROM. Her grip is painful, and her grip strength is decreased
compared to the opposite side. She denies numbness or tingling. Initial radiographs taken by her primary care physician
were read as normal. Treatment up to this point has included
ice and rest. e patient was referred to physical therapy for
evaluation and treatment with a diagnosis of “wrist sprain.”
Which of the following structures was most likely injured
1.
based on the history and complaints?
a. Hook of the hamate.
b. Scapholunate ligament.
c. Triangular brocartilage complex (TFCC).
Ulnar nerve.
d.
e correct answer is c. Triangular brocartilage com-
plex (TFCC). e location of the pain and mechanism of injury are consistent with an injury of the TFCC. Scapholunate
injuries tend to produce pain in the radial side of the wrist.
Choice d. is a nerve injury that produces paresthesia, and this
is not a complaint. Choice a. would have been ruled out with
radiographs assuming the correct view was taken.
e correct answer is d. Ulnocarpal joints. Patients complaining of pain in the ulnar side of the wrist should have a
thorough examination of all structures in this area. Palpation of
the anatomical snubox, hook of hamate, and scaphoid tubercle
would be done but would not be the focus of the examination.
Which of the following pathologies produces radial-sided
3.
wrist pain?
Distal radioulnar joint instability.
a.
b. Extensor carpi ulnaris tendinopathy.
c.
Triangular brocartilage tear.
Scapholunate ligament tear.
d.
e correct answer is d. Scapholunate ligament tear. Of
the choices given, this is the only condition that produces pain
on the radial side of the wrist. All others produce ulnar-sided
wrist pain.
4.
Which of the following special tests would be useful in differentiating between a lesion of the triangular brocartilage
complex (TFCC) and instability of the distal radioulnar
joint (DRUJ)?
a. Piano key sign or test.
b. Pisiform boost test.
c. Ulnar compression test.
d. Ulnar fovea sign.
e correct answer is a. e piano key sign or test. Both
special tests aid in identifying instability in the DRUJ. e pisiform boost test is performed to examine the integrity of the
ulnocarpal ligaments and the ulnar compression test to examine
the DRUJ for inammation or arthritis. e ulnar fovea sign is
a good screening tool for ulnar-sided wrist pathology but does
not dierentiate between a TFCC lesion and DRUJ instability.
Case Scenario 3
A 57-year-old male presents to an outpatient clinic complaining of an insidious onset of right-hand pain that started
2 months ago. e patient reports a past medical history that
includes type II diabetes and hypothyroidism. e pain is localized to the palm at the distal palmar crease, proximal to the
ring nger. He also complains of ring and small nger stiness
and diculty opening his hand in the morning. He reports the
stiness resolves in 20 to 30 minutes. He denies numbness or
tingling. Upon examination, the physical therapist notices a
nodule in the palm at the level of the pain complaints and normal active range of motion (ROM).
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1. Which of the following conditions should be ruled out?
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a. Collateral ligament sprain.
b.
Flexor tendon rupture.
c. Extensor tendon rupture.
d. Trigger nger.
e correct answer is d. Trigger nger. e patient has
normal active ROM, so tendon rupture would be incorrect.
A patient with a collateral ligament sprain would present with
pain on the radial or ulnar border of the metacarpophalangeal
or interphalangeal joint and likely report a mechanism of injury.
2. Which of the following questions would help the physical
therapist in determining an accurate diagnosis?
Does the ring nger get “stuck” in a exed position?
a.
b. Does pinching recreate symptoms?
c. Is there any numbness or tingling?
d. Do you recall a specic mechanism of injury?
usually at the distal palmar crease. However, with Dupuytren
disease, the nodules are in the palmar fascia and do not move
proximally with active movement. It is not a nerve compression
because the patient denies numbness and tingling. e location
of the pain is not consistent with dorsal intercalated segmental
instability.
5. During the examination, the physical therapist notes the
nodule moves proximally with active ring nger exion. In
the early phases of trigger nger, which of the following interventions would be most appropriate?
a. An orthosis that blocks proximal and distal interphalan-
geal joint exion.
b. An orthosis that blocks metacarpophalangeal joint ex-
ion.
c. Grip strengthening with putty.
d. Passive stretching to improve metacarpophalangeal and
proximal interphalangeal joint exion.
e correct answer is a. Does the nger get “stuck” in a
exed position? A nodule formed with a trigger nger slides
proximally during exion and gets stuck on the A1 pulley. is
is the classic sign for trigger nger. Pinch and sensation are normal. While asking about a mechanism of injury may be an important part of the history, it is less useful for determining an
accurate diagnosis in this scenario.
3.
Which of the following would help the physical therapist
conrm the diagnosis?
a.
Determine if the nodule moves with active nger movement.
Measure active ROM of the ring nger.
b.
c. Perform a collateral ligament stress test.
d.
Use Semmes-Weinstein monolaments to assess sensation.
e correct answer is a. Determine if the nodule moves
with active nger movement. A nodule formed with a trigger
nger slides proximally during exion and gets stuck on the A1
pulley. is is the classic sign for trigger nger. Active ROM
and sensory assessment may be useful but would not help in
conrming the presence of a trigger nger. A collateral ligament
stress test is not indicated due to the nature of the patient’s
symptoms.
Which of the following conditions would the therapist have
4.
to also rule out given the patient’s signs and symptoms?
a. Carpal tunnel syndrome.
b. Dorsal intercalated segmental instability.
c. Dupuytren disease.
d. Radial sensory nerve compression.
e correct answer is c. Dupuytren disease. Individuals with Dupuytren disease also present with palmar nodules,
e correct answer is b. An orthosis that blocks metacar-
pophalangeal joint exion. It is the active movement of the
metacarpophalangeal joint that causes the nodule to stick on
the proximal edge of the A1 pulley, so that is the joint incorporated into the orthosis. ere are rare cases where blocking
the distal interphalangeal joint would need to be added. Grip
strengthening is not indicated because it may increase the tenosynovitis and worsen the symptoms. Because the patient has
normal active ROM, passive stretching would not be indicated.
Case Scenario 4
A 45-year-old female presents to the physical therapy clinic
via direct access with right wrist pain that began 2 weeks prior
following a fall from her bicycle. Immediately following the accident, she was treated in the emergency department for a laceration to her scalp. While in the emergency department, she had
a radiograph of her wrist that was read as negative. She reports
her wrist pain at rest is 3/10 and with motion or weight-bearing activities, it increases to 6/10. Palpation reveals the patient’s
pain is localized to the anatomical snubox. Her wrist active
range of motion (ROM) is limited in all directions.
Which of the following would least likely be the source of
1.
the pain?
a. Extensor pollicis longus muscle/tendon.
b. Hook of hamate.
c. Scapholunate ligament.
d. Waist of the scaphoid.
e correct answer is b. Hook of hamate. Tenderness in
the anatomical snubox can indicate an injury to the scaphoid
or the scapholunate ligament. e extensor pollicis longus tendon is one of the borders of the anatomical snubox. e hook
of the hamate however is on the volar, ulnar side of the hand.
58
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2. Of the following special tests, which would be most appro-
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priate for the physical therapist to perform rst?
a. Scaphoid shift test.
b. Lunotriquetral ballottement test.
c. Eicho test.
d. Midcarpal instability test.
e correct answer is a. Scaphoid shift test. e scaphoid
shift test is used to assess the integrity of the scapholunate ligament, which can be injured in a fall onto an outstretched hand.
e Eicho test is used to look for De Quervain tendinopathy.
While the lunotriquetral ballottement and midcarpal instability
tests may be appropriate, the more important test at this point
is the scaphoid shift test based on reported symptoms.
3.
Which of the following orthoses would be appropriate for an
individual with a suspected scaphoid fracture?
a. Resting hand orthosis.
b. umb spica orthosis.
Ulnar gutter orthosis.
c.
d. Wrist cock-up orthosis.
e correct answer is b. umb spica orthosis. e ulnar
gutter and wrist cock-up orthoses are not appropriate because
the thumb would not be immobilized. e resting hand orthosis, which would immobilize the thumb also immobilizes
the ngers, which is not necessary when a scaphoid fracture is
suspected.
4. Of the following scaphoid fractures, which type is least likely
to require surgical xation?
a. A displaced fracture.
b. An unstable fracture.
c. A proximal pole fracture.
d. A waist or mid-pole fracture.
e correct answer is d. A waist or mid-pole fracture.
Due to the tendency for delayed union and nonunion among
scaphoid fractures, unstable and displaced fractures require surgical xation. Due to the limited vascularity to the proximal
pole of the scaphoid, these injuries may also warrant surgical
xation.
5. What should the physical therapist’s next course of action be
based on the patient’s history and examination?
Initiate active ROM exercises.
a.
b. Initiate light grip strengthening.
c. Provide the patient with a neutral wrist orthosis.
d. Refer the patient to a hand surgeon for further imaging.
e correct answer is d. Refer the patient to a hand sur-
geon for further imaging. Even though initial radiographs
were read as normal, the patient still may have a scaphoid fracture and may require cast xation or more advanced imaging.
Initiating rehabilitative exercises when suspecting an acute fracture would be contraindicated. e correct orthosis would be a
thumb orthosis rather than a neutral-wrist orthosis.
Case Scenario 5
Your patient is a 28-year-old carpenter. He fell 10 feet o a
ladder and sustained a right (dominant hand) distal radius fracture 2.5 weeks ago. He is now 14 days post-open reduction with
internal volar plate xation and a prophylactic carpal tunnel
release was also performed. He was referred to physical therapy
for range of motion (ROM) exercises.
1.
Which of the following examination procedures would be
most appropriate to perform prior to exercise prescription?
Active wrist ROM.
a.
b. Dexterity.
c. Grip strength.
d. Pinch strength.
e correct answer is a. Active wrist ROM. At 2 weeks
post-surgery, the patient’s fracture is not healed enough for assessing or performing strength activities. e therapist instead
should collect data on mobility of the wrist, where an active
ROM assessment would be safe. Dexterity assessment may be
performed at a later time but this is not the most appropriate for
the rst postoperative visit.
2.
Primary goals for this early phase of recovery should include:
a. Achieve full tendon excursion and a full st.
b. Achieve full wrist active and passive ROM.
c.
Achieve grip strength at least 75% of the uninvolved
side.
Achieve pinch strength at least 75% of the uninvolved
d.
side.
e correct answer is a. Achieve full tendon excursion
and a full st. A priority for the rst 1 to 2 visits should be to
achieve a full st. While the patient will be working on wrist
ROM, at this point, nger ROM should be priority. Strengthening is contraindicated at this point.
3. Treatment at postoperative week 2 for an individual with a
distal radius fracture and volar plating should include:
a. Edema management, dierential tendon gliding exercis-
es, and gentle wrist ROM.
b. Edema management, object manipulation, and stretch-
ing exercises for the wrist.
c. Object manipulation, grip strengthening, and uido-
therapy.
d. Scar management, grip strengthening, and stretching
exercises for the wrist.
e correct answer is a. Edema management, dierential
tendon gliding exercises, and gentle wrist ROM. Edema con-
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trol is very important in the hand so that it does not become
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chronic and limit tendon excursion. Tendon gliding is also important because it will help improve nger ROM, decrease edema, and allow tendon excursion over the surgical plate. Tendon
scarring over the surgical plate will limit nger ROM and possibly lead to the need for another surgery. Gentle wrist ROM is
important at this point to allow joint mobility but also protect
the healing fracture site. Stretching exercises are too aggressive
and should not be implemented at 2 weeks after surgery, and
grip strengthening is also contraindicated at this point due to
the acuity of the fracture.
4.
At 8 weeks post-surgery, the patient is able to make a full
st, his wrist active ROM is 90% of the opposite side, and
his baseline grip strength measurement shows grip strength
REFERENCES
that is 30% of the opposite side. Assuming the patient has
adequate bone healing at this point, which of the following
exercises would be appropriate to initiate?
Intrinsic muscle stretching.
a.
b. Light, progressive resisted wrist exercise with dumbbells.
c. Plyometrics.
d. Stretching the extrinsic tendons.
e correct answer is b. Light, progressive resisted wrist
exercise with dumbbells. At 8 weeks and with adequate healing, it is safe to allow resisted activities to increase forearm
strength. Plyometrics are too aggressive at this point and intrinsic and extrinsic stretching are not likely appropriate given the
patient’s current ROM at the ngers and wrist.
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