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What are the functions of the wrist?
- - to position hand in space
- - wrist transmits forces to and from hand
- - requires great mobility and stability
- - tactile organ
- - means of expression
- - weapon
- - placement of digits
- - grip (prehension)- precision + power
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What is the precision grip?
- - pick upand manipulate object between fingers and thumb
- - radial- sided movement
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What is power grip?
- -objects picked up and held tightly: hand stable
- - ulnar 2 fingers flex toward thenar eminence
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What is the anatomy of the hand?
- - radiocarpal jt between distal radius and scaphoid, lunate , lunate, triquetrum
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Radiocarpal joint
- - between carpals and radius/ ulnar
- - synovial, ellipsoid
- - biaxial
- - radial and ulnar collateral ligaments
- - palmar and dorsal radiocarpal ligaments
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What ligaments link carpal rows?
- scaphoid
- interosseous ligaments
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Midcarpal joint
- - compund joint
- - synovial, ellipsoid medially
- - synovial plane laterally
- - short capsule
- - radiate ligament
- - intercarpal ligaments
- - acts as a hinge- flexion/ ext
- - aids wrist
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Carpometacarpal joint
- - synovial plane- at digits- gliding
- - synovial saddle- at thumb, angular movements
- - radial and ulnar collateral ligaments
- - palmar and dorsal radiocarpal ligaments
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What movements are availble at the wrist
- - abd/ adduction (15- 45 respectively)
- - flexion/ extension 85*
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What are the movements at the thumb?
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Where does flexion of the wrist take place?
- mainly in the midcarpal jt
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Where does ext of the wrist take place?
- mainly in the radiocarpal jt
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What is the usual plane of movement of the wrist from?
- - ext/ radial devn
- - flex/ ulnar devn
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Where does sup/pron take place in the wrist?
- radius rotates around ulna head (inferior radioulnar jt)
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Where does radial dev ocur in the wrist?
- - radiocarpal jt
- - proimal carpal row slides in ulnar direction
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Where does ulnar deviation occur in the wrist?
- - radiocarpal jt
- - proximal carpal row slides in radial direction
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What movements are available at the thumb CMC jt?
- - flexion
- - ext
- - abd
- - add
- - rot
- - circumduction
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What movements occour at the 2-5 CMC jts?
- - rot which alows horizontal flexion (cupping)
- - horizontal ext (flattening palm)
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What movements are available at MCP jts?
- adb/ add- limited by collateral ligaments and capsule
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What type of jts are IP jts?
- hinge jts
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What is the lose packed position of the wrist?
- - Radiocarpal- slight flex, slight lnar deviation
- Midcarpal- slight flex
- Distal radioulnar- 10-35* supination
- Carpometacarpal 1- neutral
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What is the closed packed position of the wrist?
- - Radiocarpal: full ext and radial deviation
- Midcarpal- full ext
- Distal radioulnar: 0-5* supination
- Carpometacarpal 1: full opposition
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What are the capsular patterns of the wrist?
- - radiocarpal: equal dgree of limitation of flexion and ext
- -midcarpal: equal degree of limitaion of flex, etx
- - distal or inf radioulnar: pain at both extremes of rot
- - CMC 1: limitation abd, ext
- - thumb and fingers: more F than E
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Extrinsic wrist/hand disorders
- - referred pain from elbow, shoulder, radiculopathy, and somatic cervical spine dysfunction/ arthritis
- -vascular, neurological, metabolic and skin disorders
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What are some intrinsic wrist/ hand disorders?
- - peripheral nerve entrapment (carpal tunnel syndrome)
- - tendinopathy/ tendon rupture
- - tenosynovitis (de Quervain's disease)
- - trigger finger
- - dupuytren's contracture
- - finger deformities
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Carpal tunnel syndrome
- - compression of median nerve
- - usually dominant hand
- - paraesthesia/ anaesthesia/ pain in median nerve
- - may disrupt sleep, radiate
- - atrophy of thenar eminence
- - weak APB
- - poisitve tinels and phalen's teswts
- - nerve conduction studies
- - occurs between proxiaml and distal row of carpal bones
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How do you manage Carpal tunel syndrome?
- - depends on cause: wrist #, haematoma, hypothyroidism, pregnancy, diabetes, flexor tenosynovitis, ganglion cysts, OA, oedema
- - rest, night splint
- - passive mobilise flexor retinaculum, intercarpal jts, median nerve
- - cortisone injection, NSAIDs
- -decompressive surgery
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Tendinopathy
- - common ECR, ECU, FCU, FCR
- - follows trauma or overuse
- - tender just proximal to insertion or at tenoperiosteal junction
- - pain on isometric contraction and stretching
- - extensor tendon rupture: digit heald in fex, no active ext, normal passive ext, wweak and painless resisted ext
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How do you manage tendinopathy?
- - avoid aggravating ADL
- - EPA
- - Deep friction masage
- - stretching exercises
- - carpal jt mobs
- - NSAIDs
- -cortisone injection
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Tenosynovitis (infalm of the lining of the sheath that surrounds a tendon)
- - usually pain felt over dorsal aspect of hand
- - locally tender, swollen synovium over extensor tendons
- - pain on resisted finger ext through range- crepitus
- - pain on stretching mm
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What is De Quervian's disease?
- - type of tenosynovitis of EPB + APL over radial styloid
- - inflammation of common synovial sheath
- - radial rain on thum ext, abd, pinch grip
- - tender swollen at styloid
- - positive finkelstein's test (careful of OA)
- - may need to splint or decompreeive surgery
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What is trigger finger?
- - nodular thickening of flexor tendon
- - after flexion, ext limited as nodule isunable to pass under MCP ligament
- -MCP jt pain, sweling, inflammation
- - clinking sensation palpable on ext
- - inability to actively ext finger
- - RX: rest, cortisone injection, surgery
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What is dupuytren's contracture?
- - fibrous proliferation of palmar fascia
- - flexion deformity of MCP, prox IP jt
- - expanding fibrous, nodular thickening
- - becomes cord- like band
- - skin dimples
- - elderly, caucasian males
- - commonly bilateral; aetiology unknown
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How do you treat dupuytren's contracture?
- - US, moist heat, extension splints, stretching in early stage disease
- - surgery- fasciectomy
- - post surgery- scar tissue massage lanolin, splints, passive jt mobs, active tendon gliding exercises
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# of the wrist
- - schaphoid #
- - skiers thub
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