April- Wrist

[Kyle Feldman]

An 18 year old high school male golfer presents to the clinic direct access with a 4 month history of ulnar/dorsal-sided wrist pain and recurrent swelling since the injury. He reports during his district playoff match he hit an iron shot but on impact he hit a root in the ground that he did not see under the ball. He describes his pain as sharp initially, but can linger as a deep ache after activity. Aggs include golf, especially when hitting the ground on impact, picking up moderate to heavy objects with his right hand, (>10#), and weight-bearing through his hand when standing, getting out of bed. He is currently in season and unable to play or workout due to pain, but wants to return to play as soon as possible.

Questions for thought
Please discuss further relevant subjective questions and objective testing that would lead you to your differential diagnosis list. Include your differential list.

What are some key clinical examination tools that you would use or have used with similar patients?

No imaging has been performed, what would drive you to refer for an orthopedic exam and imaging?

Have a read of the following two articles to help review. Both are from the Journal of Hand Therapy – Special Issue Wrist in 2016.

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[helenrshep]

Some initial thoughts…

Possible differential diagnosis:
TFCC injury
DRUJ instability
ECU tendinopathy
Ulnocarpal impaction syndrome

Subjective:
– 24 hour symptom pattern – morning vs evening
– when does it swell? does ice help? has he tried a brace of any sort?
– numbness/tingling
– does it seem to be getting worse, better, or staying the same over the past 4 months
– snapping/clicking/popping?
– does hand/wrist position change pain while picking up an object? (supinated vs neutral wrist position)

Objective:
– elbow/wrist AROM, PROM, resisted testing
– carpal palpation, intercarpal mobility testing
– TFCC grind test

Imaging – I’d want to refer for imaging if I suspected a fracture or another condition that would require surgery… I haven’t seen many hand patients so I’m not exactly sure what subjective/objective findings would lead me that direction.

[Steven Lagasse]

Similar to Helen, I’ve yet to see many wrist/hand patients. My reply to this discussion is based on the two provided articles and Reiman’s Orthopedic Clinical Examination text.

Subjective Questioning:
– Does your wrist feel unstable?
– What activities cause swelling?
– Is gripping painful?
– Are you experiencing numbness and/or tingling?
– Is this getter better, worse, or staying the same?
– Nocturnal Symptoms?

Objective Testing:
– AROM, PROM, RROM
– Various grip strength testing
– Accessory motions
– Palpation
– Special Testing per article

Differential List:
– TFCC
– Kienbock’s disease
– Superficial distal RU ligament sprain
– Deep distal RU ligament sprain
– Ulnocarpal impact syndrome

Imaging:
I would have the patient pursue imaging if their symptoms were gradually worsening, were inconsistent with the examination, or worst at night with reduced activity

[Taylor Blattenberger]

I think Helen and Steve did a great job outlining some differential diagnoses and testing procedures.

It seems that all his c/c’s involve wrist extension (gripping heavy objects, weightbearing, golf swing/ground impact assuming he is RHD) which makes me more suspicious of a carpal instability. I would want to rule out traction, axial load, and active/resisted movements as stand alone aggs subjectively and objectively:
Sub:
-Pain with turning a doorknob (resisted mov’t w/o wrist ext)
-Pain with writing (repetitive resisted mov’t w/o wrist ext)
-Pain with pulling a door open (traction without need for power grip)

Obj:
WB on palm (ext) vs fist (neutral)
APR exam to examine A/PROM and confirm my suspicion of a passive restraint and rule out contractile involvement

In terms of urgent management, I agree with Steve in his stability question driving imaging decisions. Given the chronicity of this process, if the symptoms were worsening I would be concerned of AVN and would recommend imaging. Personally I think this report and the risk of prolonged pathology warrant this decision regardless of objective findings. To my knowledge, I don’t have anything to lean on to rule out this potentially sinister pathology without imaging. Does anyone have thoughts on this?

[awilson12]

Differentials:
TFCC lesion
Midcarpal instability
Distal radio-ulnar joint instability secondary to ligamentous injury
ECU or ED tenosynovitis or tendinopathy
Fracture- ulna, carpal(s)

Subjective questions: more specific location of pain, any clicking/clunking when moving wrist, pain with twisting forearm/wrist (opening jar/top/etc, turning doorknob, dressing, pulling off covers), positions of comfort

Objective exam: tuning fork, functional exam to observe movement (esp weight bearing), grip testing in various positions, quality and quantity of movement with AROM and PROM help w/ identifying any capsular pattern or specific movements that are painful or restricted, resisted testing to r/o muscle/tendon component, special tests specific to above differentials, palpation

A few things could lead to decision to refer to ortho for imaging: if not seeing improvement that expected with treatment, if concerned for fracture or significant instability that may warrant further intervention

[lacarroll]

Subjective info:

– Alleviating factors or position of comfort?
– Any previous treatments?
– Any other previous wrist injuries/issues?
– Dominant or nondominant hand?
– Any popping/clicking with movement?
– Any numbness or tingling?

Objective Info:

– ROM (A/P/R)
– Grip strength in multiple positions
– Special Tests (DRUJ Ballottement, dorsal RU ligament shift test)
– Palpation

Differential List:

– TFCC pathology
– Superficial dorsal radioulnar ligament sprain
– Keinbock’s Disease
– ECU tendinopathy

As far as imaging, I think this patient could benefit from imaging to rule out fractures and more serious pathology, especially with the chronicity of the injury in an active 18-year-old. I agree with Steve’s point, I would feel much more confident in suggesting imaging with a discrepancy between symptoms and objective findings or a gradually worsening pattern for this particular patient.

[Kyle Feldman]

Great differentials

It looks like you are each on similar paths.

Imaging has been supported by all of you.

What imaging?

Would you send them back to the PCP and call saying your thoughts? Directly to an ortho doc?

If you think imaging, are you going to keep treating, put them on hold, or completely discharge?

When some therapists say imaging they believe there care is done. What are your thoughts on this?

Finally, any thoughts on bracing for this patient?

[Taylor Blattenberger]

I think this would definitely be a treat and refer case. Care would not be completed at the time of the referral.

I’m not 100% sure, but from what I’ve been reading, MRI or CT seem to be the most reliable ways to identify AVN in the hand. Anyone have any information conflicting with this?

Bracing would be an option in this pt, but could take many forms. Without making too many conditional applications: It would be beneficial for him to wear a brace limiting extension when he is doing activities that aggravate his wrist throughout his normal day. It could also be helpful to keep him performing some sort of practice such as putting or light chipping with a passive restraint. If this limits a painful ROM and allows more function in the short term, I think it is valuable.

[awilson12]

Once all information is gathered and I have decided that it is something that needs to be further assessed, for example Keinbocks like a lot of others mentioned, then at this point it would be a refer and hold on treatment until I know more. I think that getting in touch with the PCP with your recommendations/thoughts and seeing what they would like to do would be good to ensure you aren’t stepping on any toes.

Taylor- from what I have read for AVN it seems like MRI is go to for this. Also with MRI I feel like it could identify other soft tissue/ligamentous injury if AVN is not what is going on, so could give good information in addition to subjective and objective exam to help guide management. Anyone else have thoughts on that?

In terms of bracing, this is not something I have a lot of background to go off of so not really sure. It seems like with this going on for at least 4 months that it might be beneficial to have a brace to limit use and extremes of motion to decrease irritability.

[Kyle Feldman]

Great points Taylor and Anna.

MRI would be the best option and I like the reasoning of trying to rule out other pathologies.

You mentioned this may not be your wheelhouse.
Do you have other providers in your area who may be better with hands that you would refer them to?

We always think of referring to neuro, ortho, etc. Do you ever think of referring to other PTs?

[awilson12]

For us at UVA we are fortunate and have a hand clinic “within” our clinic, so I definitely wouldn’t hesitate to refer to them or have a discussion about a case to learn more.

I do think, though, that knowing other rehab professionals within the area that have a specific wheelhouse is beneficial and should be utilized if you feel that sending a patient to them is more appropriate healthcare utilization.

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