● Press test : The patient lifts themselves out of a chair while pushing up on the arms with the wrists in an extended position. Pain with this movement indicates a positive test. ● Supination test : With the forearms in supination, the patient grabs the underside of a table. This causes a load on the TFCC and dorsal impingement. If there is a peripheral dorsal tear, this test will cause pain. ● Piano key test : The client places both hands on a table and presses the palms into it. If the distal ulna is more prominent on the affected side, this suggests radioulnar instability, which is often associated with TFCC injuries. Once the hands are relaxed, if the ulnar head goes back to a normal position, this is considered a positive test. ● Grind test : The examiner compresses the radius and ulna while the patient pronates and supinates the forearm. Pain may indicate degenerative changes. (Casadei & Kiel, 2023) Clinical Presentation Kienbock’s disease creates central dorsal wrist pain over the lunate (Camus et al., 2021). It often appears spontaneously, causing limited wrist motion and handgrip weakness. These symptoms, along with tenderness with palpation over the lunate, can lead to suspicion of Kienbock’s disease, but imaging must be used to confirm it (Camus et al., 2021).
Clinical Presentation Clinical presentation typically includes ulnar-sided pain with activities involving wrist rotation such as turning a doorknob or opening a jar. Pain may be accompanied by grip weakness as well as pronation and supination weakness (Jawed et al., 2020). Clicking or point tenderness may be present between the pisiform and the ulnar head (Casadei & Kiel, 2023). Several tests can be used for the diagnosis of TFCC injuries: ● TFCC compression test : This test is performed with the forearm in neutral position. The patient ulnarly deviates the wrist. If this reproduces the patient’s symptoms, the test is positive. ● TFCC stress test : With the client’s wrist in ulnar deviation, a force is applied across the ulna. The test is positive if it reproduces the patient’s symptoms. Kienbock’s disease Kienbock’s disease is avascular necrosis of the lunate. It is a rare condition with unknown etiology (Kazmers et al., 2020). Proposed mechanisms of onset include excess loading of the lunate via ulnar variance, differences in lunate morphology, vascular anomalies, and ulnar translation.
FINGER INJURIES
Dislocations Metacarpophalangeal (MCP) joint dislocation MCP joint dislocation can occur with hyperextension or high-energy axial loads. MCP dislocations are relatively rare because of the stability of the joint. The most common site for MCP dislocation is the index finger, and the most common direction is dorsally. The typical presentation is the MCP joint in extension and the IP joint in flexion (Taqi & Collins, 2022). Proximal Interphalangeal (PIP) joint dislocation Most dislocations in the hand occur at the PIP joint and are most common in ball handling sports like football and basketball (Gil & Weiss, 2020). Sudden finger extension will lead to dorsal dislocation and rupture of the volar plate. This is the most common type of PIP dislocation and occurs most frequently at the middle finger (Taqi & Collins, 2022). Swan neck deformity can occur and is the result of volar plate injury. Volar dislocations are the consequence of sudden radial or ulnar deviation accompanied by a volarly directed force. Volar dislocations are associated with central slip, collateral, and transverse retinacular ligament injuries (Gil & Weiss, 2020). Lateral PIP joint dislocations involve disruption of the collateral ligaments (Taqi & Collins, 2022).
Clinical Presentation Typically, patients with a PIP dislocation will present with a deformity at the involved joint, decreased range of motion, and pain. During examination, hyperextension of the joint can be completed passively to assess the competency of the volar plate. Lateral stress to the joint can be used to assess the collateral ligaments. The Elson test can be used to assess the integrity of the central slip (Taqi & Collins, 2022). For this test, the client rests their hand on the table with the PIP joint of the involved finger flexed to 90 degrees over the edge of the table. The examiner palpates the middle phalanx of the involved finger then asks the patient to extend the PIP while providing some resistance. The test is positive if extension of the PIP is weak with hyperextension at the distal phalangeal (DIP) joint. The test is negative if PIP joint extension is strong while the DIP remains lax (Elson, 1986). PIP joint fracture and fracture-dislocation Fracture and fracture-dislocation of the PIP joint often occur secondary to axial load, resulting in a fracture of the middle phalangeal at the dorsal or volar lip or both (Gianakos et al., 2020). Clinical Presentation Patients with a fracture or fracture-dislocation of the PIP joint will complain of pain at the injury site, and gross observation typically reveals swelling and deformity. Range of motion is limited, and the injury site demonstrates instability (McDaniel & Rehman, 2023).
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