Hand Disorders

Dr.Atef A. Nadier,PhD
Lecture Of Physical Therapy, PUA
Spring 2022- 2023
Cumulative Hand Disorders

Carpal tunnel
syndrome

Dupuytren’s Dequervain’s
Contracture tenosynovitis
Carpal tunnel syndrome (CTS)
• It is one of the spaces occupying lesion
in which there is compression and
ischemia of the median nerve at the
wrist as it passes through the carpal
tunnel.
• It is a confined space between the
carpal bones dorsally and the
transverse carpal ligament (flexor
retinaculum) volarly.
Carpal tunnel syndrome
Etiology of Symptoms:
local:
• Synovial thickness and scarring in the tendon sheaths (tendinosis).
• Inflammation, and swelling of the tendons (tendinitis) as a result of
repetitive or sustained wrist flexion, extension, or gripping activities .
• Compressive forces from sustained equipment usage, and vibration
against the carpal tunnel.
• Acute wrist trauma and fracture at the carpal bone.
Carpal tunnel syndrome
Etiology of Symptoms:
Systematic factors:
Pregnancy (hormonal changes and water retention).
Oral contraceptives.
Rheumatoid arthritis,
 Diabetes.
Infection .
Tumors.
Carpal tunnel syndrome
Clinically:
Most common in women between 40 to 60 years of age.
It is also commonly seen in younger patients who use
their wrists a great deal in repetitive manual labor or
exposed to vibration.
Most common in the dominant hand and may be
bilateral .
Carpal tunnel syndrome
Clinically:
Pain, parethesia at the palmer aspect of the thumb, index, middle
and lateral half the ring finger.
Numbness and tingling sensation at the distribution of median nerve
in the hand .
The symptoms of CTS are typically worse at night due to the position
of wrist flexion typically adopted during sleep and can be associated
with morning stiffness.
Carpal tunnel syndrome
Clinically:
Activities of daily living (such as driving a car, holding a cup, and
typing) often aggravate pain.
Hanging arm over the side of the bed or shaking the arm may relieve
the symptoms.
Carpal tunnel syndrome
Clinically:
Atrophy of thenar muscles and Ape hand
deformity may occur.
Muscle weakness and dropping object can
occur with sever cases.
• N.P: No paraethesia at the palm,
which is innervated by the palmar cutaneous
branch of the median nerve arising proximal to
the carpal tunnel)
 Physical examination of CTS

Special test

Carpal
Reverse Phalen
compression Static 2PD Phalen test.
test.
test
Physical examination of CTS
Carpal compression test :
• Test Position: Sitting.
Performing the Test: With the patient's arm in
supination, the examiner applies pressure with
his/her thumbs over the median nerve within
the carpal tunnel.
• This is located just distal to the wrist crease.
• A positive test occurs when the patient
complains numbness and tingling in the
median nerve distribution within 30 seconds.
• The examiner records the time of onset for the
symptoms.
 Physical examination of CTS

Phalen test:
 The patient places her flexed elbows on a table,
allowing her wrists to fall into maximum flexion.
 The patient is asked to push the dorsal surface of her
hands together and hold this position for 30-60
seconds.
 This position will increase the pressure in the carpal
tunnel, in effect compressing the median nerve
between the transverse carpal ligament and the
anterior border of the distal end of the radius.
Physical examination of CTS
Reverse Phalen's test:
 The patient maintains a position of full wrist
and finger extension for 1 to 2 minutes.
 The pressure on the carpal tunnel increases
after 10 seconds (compared to 20-30
seconds for the standard Phalen's test).
 The longer the position is held, the greater
the pressure on the wrist and carpal tunnel.
Physical examination of CTS
Static 2 Point Discrimination (2PD)
• The aime of the test is to find the minimal distance
at which the patient can distinguish between the
two stimuli, decreasing or increasing the distance
between the points depending on the response by
the patient.
• This distance is called the threshold for
discrimination.
• Normal discrimination distance is between 3 and
7mm.
Physical examination of CTS
Positive Tinel's sign:
 Tinel's sign is a way to detect irritated nerves.
 It is performed by lightly tapping (percussing) over
the median nerve to elicit a sensation of tingling or
"pins and needles" in the distribution of the nerve.
 The test is positive when there is pressure
neuropathy of the nerve.
Physical examination of CTS
Medical diagnosis tests:
• Median nerve conduction study
(NCS)
• Electromyography study (EMG).
Physical examination of CTS
Electrodiagnostic tests:
• Abnormal = across the wrist:
• Distal motor latency > 4.5ms
• Sensory latency > 3.5ms
Physical examination of CTS
Differntial diagnosis:
• Cervical Radiclopathy.
• Thoracic outlet Syndrome.
• Pronator syndrome and
• Anterior interosseous nerve syndrome.
• Benign joint hypermobility syndrome. ( non-progressive, non-inflammatory
connective tissue disorder that results in hypermobility and pain).
Nonoperative Management of CTS:

General goals:
 Protect the nerve.
 Splint wrist in neutral.
Teach patient about provoking activities and how to modify them .
Teach safe exercises for home exercise program .
 Teach patient how to protect areas of decreased sensitivity in the
hand .
Nonoperative Management of CTS:
Mobilize restricted joints, • Tendon gliding exercises.
connective tissue, and
muscle/tendon.
Mobilize carpals if restricted.
 Tendon gliding exercises.
 Median nerve mobilization
exercises(https://www.youtube.c
om/watch?v=Fv_EJV8q2E0).
Nonoperative Management of CTS:
Positions for median nerve glides and
mobilization in the hand:
(A) wrist neutral with fingers and thumb flexed;
(B) wrist neutral with fingers and thumb extended;
(C) wrist and fingers extended, thumb neutral;
(D) wrist, fingers, and thumb extended;
(E) wrist, fingers, and thumb extended and forearm
supinated;
(F) wrist, fingers, and thumb extended, forearm supinated,
and thumb stretched into extension.
Nonoperative Management of CTS:
Orthoses :
• Patients should be instructed in
the use of a neutral-positioned
wrist orthosis for night wear.
• Duration of orthosis use may be
increased to include day time
wear,
• MCP joints may be included if
night time wrist-neutral
positioning alone does not
provide sufficient relief.
Nonoperative Management of CTS:
• Assistive technology :Use a • Self streching
keyboard that limits key-strike
force .
• Thermotherapy .
• Electrotherapy : (Interferential )
or Phonophoresis.
• Stretching :May add lumbrical or
general stretching to a program
that includes an orthosis.
Surgical Management for CTS:

Indication:
If conservative measures do not relieve the nerve symptoms or
The neurological symptoms are severe (persistent numbness,
weakness, pain, decreased functional use of the hand).
Surgical Management for CTS:
Surgical decompression :
• Involving transaction of the transverse
carpal ligament is performed to increase
the volume of the carpal tunnel and
relieve the compressive forces on the
median nerve.
• Also, any scar tissue is excised.
• Surgery may be an open carpal tunnel
release or endoscopically assisted carpal
tunnel release.
Postoperative Management for CTS:

Maximum Protection Phases:

The wrist may be immobilized 7 to 10 days postoperatively in slight
extension with the fingers free to move.
With the wrist stabilized :Active finger and thumb flexion/extension,
abduction/ adduction, and thumb opposition.
Postoperative management for CTS:

Maximum Protection Phases:

Passive wrist flexion followed by active wrist extension (After splint
remove) .
 Active radial and ulnar deviation of the wrist (the wrist supported in
slight extension),
Pronation and supination of the forearm, and all shoulder and elbow
motions.
Postoperative management for CTS:

Moderate and Minimum Protection Phases:

Sutures are usually removed around the 10th to 12th postoperative
day, and more active treatment is allowed.
The patient should be able to return to full activity by 6 to 12 weeks.
Impairments may include residual weakness and sensory deficits,
persistent edema, limited motion, hypersensitivity, and pain.
Postoperative management for CTS:

Moderate and Minimum Protection Phases:

Scar tissue mobilization. Use soft tissue mobilization to the palmar
fascia and scar.
Progressive stretching and joint mobilization of restricted tissue.
 If restricted, lengthen the abductor pollicis brevis and opponens
pollicis.
Mobilize restricted tendons or nerve tissue (same techniques as
described previously except with a stretch force).
Postoperative management for CTS:
Moderate and Minimum Protection
Phases:
Dexterity exercises.
• Begin as soon as signs of motor recovery
occur.
• Suggestions include picking up small
objects using pad-to-pad, tip-to-tip, and
tip-to pad prehension patterns; writing;
and having the thumb move around the
edge in a circumduction motion.
• https://www.youtube.com/watch?v=Z3g
P3UF9CbQ
Surgical and Postoperative Management for CTS:
Sensory stimulation and discriminative sensory reeducation:
• Begin by using a moving touch stimulus, such as the eraser
• End of a pencil, and stroke over the area.
• The patient first watches, then closes his or her eyes, and tries to
identify where touch occurred.
• Progress from stroking to using constant touch.
• When the patient is able to localize constant touch,
• Progress to identification of familiar objects (toothbrush & Keys) of
various sizes, shapes, and textures.
Dequervain’s tenosynovitis
• De Quervain’s disease is a progressive
tenosynovitis which involves the tendon sheaths
of the first posterior (dorsal) compartment of the
wrist, resulting in :
A degeneration and thickening of the extensor
retinaculum, a stenosing of the fibro-osseous canal,
and an eventual entrapment and compression of
the tendons (APL and EPB tendons ).
• 0.5% in men and 1.3% in women.
Dequervain’s tenosynovitis

Predisposing factors:
• Overuse.
• Repetitive tasks which involve overexertion of the thumb, or radial
and ulnar deviations of the wrist as painting and cutting with scissors
• Arthritis .
Dequervain’s tenosynovitis
Clinical:
• A gradual and insidious onset of a dull ache over the radial aspect of
the wrist made worse by such activities as turning doorknobs or keys.
• A reproduction of the pain can also be reported with thumb
extension and abduction.
• Swelling over the radialstyloid.
• Patients also may note a “creak” in the wrist as the tendon moves.
• A positive Finkelstein test.
Dequervain’s tenosynovitis
• A positive Finkelstein test.
• The test is used to detect stenosing
tenosynovitis of the APL and EPB.
• The clinician grasps the patient’s thumb,
stabilizes the forearm with one hand, and
then deviates the wrist to the ulnar side
with the other hand .
Dequervain’s tenosynovitis
Treatment:
Rest.
Modification of activities.
Splinting.
Anti inflammatory medication.
Acupuncture.
Ice.
Ultrasound or iontophoresis.
Strengthening and stretching exercise.
Dequervain’s tenosynovitis
Non invasive treatment:
A thumb spica splint is fabricated with the
wrist in 15 degrees of extension, the thumb
midway between anterior and radial
abduction, and the thumb MCP joint in 10
degrees of flexion ( 3–6 weeks).
The splint is supposed be worn all day.
ROM exercises are prescribed, with a gradual
progression to strengthening following the
removal of the splint .
Dequervain’s tenosynovitis
Non invasive treatment:
Strengthening and
Stretching exercise.
Dequervain’s tenosynovitis
The invasive treatment:
Cortisone injections:
• Two to three injections only.
• Advised for patients who are experiencing moderate wrist pain.
• Associated with high rates of recurrence.
• Post-injection complication rates of up to 36% have also been
reported as :
Radial sensory nerve injury, atrophy of subcutaneous fat,
and tendon rupture.
Dequervain’s tenosynovitis
Surgical tendon sheath release:
• Complications of surgery: i.e.
• Infection ,
• Delayed wound healing,
• Tendon subluxation .(very few complications)
Dequervain’s tenosynovitis
Systematic review with meta-analysis,2016.
• Combined orthosis/corticosteroid injection approaches are more
effective than either intervention alone in the treatment of de
Quervain's disease. (Level of evidence: 1a).
• No statistically significant differences between corticosteroid
injections and hand therapy modalities in the treatment of de
Quervain’s disease when used in isolation.
Dupuytren’s Contracture:
• It is an active cellular process in the fascia of the
hand, followed by nodules in the palmar and digital
fascia.
• Thickening and shortening of the fascia.
• Mainly at the MCP and PIP joint, and occasionally at
the DIP joint.
• The most commonly involved digit is the little finger
(70%) .
(may be followed by the index, the middle finger and
the thumb.)
Dupuytren’s Contracture:
Risk factors :
 Advanced age,
 Male sex, family history of Dupuytren’s disease,
 Diabetes mellitus.
 Heavy alcohol drinking, cigarette smoking.
Dupuytren’s Contracture:
Clinical :
• A palpable nodule, characteristic skin changes, changes in the fascia, and
progressive joint contracture.
• Usually bilateral,
• May be severe in one hand, although there appears to be no association with
hand dominance.
• May be increases with advancing age (55-75 years ).
• Men are 7–15 times more likely to have a clinical presentation requiring surgery
than women.
Dupuytren’s Contracture:
Biological classification:
First stage:Small nodules appear under the digits
of palmer crease.
Second stage: The condition becomes more
extensive and involves the fascia and the digits.
Third stage : Creation of strong cords which result
in the flexion of the fingers and loss of normal
extension.
(Similar to wound healing stages : proliferation of
the fibroblasts and deposition of the collagen and
myofibroblast contraction).
Dupuytren’s Contracture:
Conservative Treatment:
• Cryotherapy.
• Cold laser.
• Ultrasound.
• Splinting.
• Extracorporeal shockwave
therapy.
Dupuytren’s Contracture:
Conservative Treatment:
Educating the patient to either
avoid or decrease repetitive hand
motions.
Gradual stretching and ROM
exercises, and as the patient
progresses.
 Strengthening exercises.
A home-exercise program .
Dupuytren’s Contracture:
Xiaflex injections :(Injectable collagenase Clostridium histolyticum )
• Night extension splinting is maintained for 6 months.
• Collagenase injections result in a 75% contracture reduction with a
35% recurrence rate.
Dupuytren’s Contracture:
Conservative Treatment:
• Steroid injections do not work in all patients and a 50% recurrence
has been reported.
• Corticosteroid injections can lead to fat atrophy, pigmentation change
and there is the potential to cause rupture of the tendons.
Surgery :(Fasciectomy)
• It is the intervention of choice when the MCP joint contracts to 30
degrees and the deformity becomes a functional problem.
Dupuytren’s Contracture:
Postoperative:
• Edema control.
• Scar management and splinting .
• The initial splint is positioned to provide slight MCP joint flexion of 10
degrees with PIP joint extension to allow maximal elongation of the
wound.
• Active, active-assisted, and passive exercises are usually initiated
immediately.
Dupuytren’s Contracture:
Study kitridis et al. 2019:
• Fasciectomy followed by a 24-week night splint, combined with home
hand exercises for at least 8 weeks reduces the rates of recurrence of
DC.
 REFERENCES
Cavaleri et al. Hand therapy versus corticosteroid injections in the
treatment of de Quervain’s disease: A systematic review and meta-
analysis., Journal of Hand Therapy 29 (2016) .
Carolyn Kisner, Lynn Allen Colby Therapeutic Exercise Foundations and
Tec,2020.
Comparison of Two Manual Therapy Programs, including Tendon Gliding
Exercises as a Common Adjunct, While Managing the Participants with
Chronic Carpal Tunnel Syndrome. Pain Research and Management Volume
2022.
David J ORTHOPEDIC PHYSICAL ASSESSMENT 5ThEdition, David et al.2011.
Dutton’s Orthopaedic Examination, Evaluation and Intervention, Fourth
Edition 4th Edition,2020.
Orthopedic & Sports Clinical Practice Guidelines by JOSPT ,2017.
kitridis et al Dupuytren's disease: limited fasciectomy, night splinting, and
hand exercises-long-term results.Eur.J Ortho.Surg. Traumatol,2019
Thank you