Soft tissue lesion hand

Soft tissue lesion hand

1. Moderator : Ms. R. Angeline, Assistant Professor, Faculty of Physiotherapy Presenter : K. Soundararajan, Post Graduate SOFT TISSUE LESION OF HAND 4/13/2020 Faculty of Physiotherapy, SRIHER

2. Objectives The purposes of this presentation to provide an understanding about soft tissue lesion of hand- current evidence various methods of rehabilitation following soft tissue lesion of hand 4/13/2020 Faculty of Physiotherapy, SRIHER

3. Introduction The hands as the human executing organs are in the center of daily life activities ’ , thus are always exposed to injuries and overuse . We are more aware of our hands than any part of the body Are important out of all proportion to their apparent severity ,because of the need for perfect functions . Local edema and stiffness of the joints –common accompaniments of all injuries- are more threatening in the hand than anywhere else . 4/13/2020 Faculty of Physiotherapy, SRIHER

4. Problems of hand arise for 3 reasons : 1- the defect may be unacceptable 2- function is impaired 3- deformed part becomes nuisance during daily activities 4/13/2020 Faculty of Physiotherapy, SRIHER

5. Hand injuries the commonest of all injuries . In average the hand injuries account for 14-30% of all patient in ED . Fractures 46% , tendon injuries 29% and skin lesions 4/13/2020 Faculty of Physiotherapy, SRIHER

6. 4/13/2020 Faculty of Physiotherapy, SRIHER Hand Trauma Hand trauma account for 5-10 % of trauma. Mechanism of injury Blunt trauma Lacerations & punctures Avulsions ± soft tissue deficit Ring avulsions Structures injured Cutaneous injuries Muscles and Tendons Neuro-vascular injuries Bones and associated soft tissues

7. SOFT TISSUE Soft tissue refers to tissues that connect, support, or surround other structures and organs of the body. Soft tissue includes muscles, tendons, ligaments, fascia, nerves, fibrous tissues, fat, blood vessels, and synovial membranes. 4/13/2020 Faculty of Physiotherapy, SRIHER

8. Anatomy Bones/Joints Muscles Nerves Tendons Vascular 4/13/2020 Faculty of Physiotherapy, SRIHER

9. 4/13/2020 Faculty of Physiotherapy, SRIHER Finger Injury Pearls Treatment should restrict motion of the injured structures while allowing uninjured joints to remain mobile Patients should be counseled that it is not unusual for an injured digit to remain swollen for some time and that permanent deformity is possible even after treatment

10. 4/13/2020 Faculty of Physiotherapy, SRIHER Finger Pathology Fractures, Dislocations Distal Tuft Fractures/Crush injury Phalange fractures Metacarpal fractures Boxer’s fracture Dorsal PIP dislocations Ligament/tendon injuries Mallet Finger Jersey Finger Central slip extensor tendon injury (Boutonniere Deformity) Collateral ligament injury Volar plate injury Skier’s thumb

11. 4/13/2020 Faculty of Physiotherapy, SRIHER Common Deformities in the Hand Mallet Finger: DIP in flexion with loss of extension due to damage to extensor tendon

12. 4/13/2020 Faculty of Physiotherapy, SRIHER Mallet Finger (Baseball Finger) Injury to the extensor tendon at the DIP joint Most common closed tendon injury of the finger Mechanism: object striking finger, creating forced flexion Tendon may be stretched, partially torn, or completely separated by a distal phalanx avulsion fracture

13. 4/13/2020 Faculty of Physiotherapy, SRIHER Mallet Finger Presentation Pain at dorsal DIP joint Inability to actively extend the joint Characteristic flexion deformity On exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slip If can’t passively extend consider bony entrapment All of these need x-rays

14. 4/13/2020 Faculty of Physiotherapy, SRIHER Mallet Finger Treatment Splint DIP in neutral or slight hyperextension for 6 weeks Cochrane review- all splints same results Surgical wiring does not improve outcome Office visit every 2 weeks If not extension lag at 6 weeks, splint at night and for activity for 6 weeks. Conservative treatment effective up to 3 months delayed presentation Handoll . Interventions for treating mallet finger injuries. Cochrane Database 2004

15. 4/13/2020 Faculty of Physiotherapy, SRIHER Mallet Finger Referral Bony avulsion >30% of joint space Inability to achieve passive extension Despite proper treatment permanent flexion of the fingertip is possible No fracture reduction in the splint

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17. 4/13/2020 Faculty of Physiotherapy, SRIHER Flexor Digitorum Profundus Tendon Injury (jersey finger) Athlete’s finger catches another player’s clothing Forced extension of the DIP joint during active flexion 75% occur in the ring finger Force can be concentrated at the middle or distal phalanx

18. 4/13/2020 Faculty of Physiotherapy, SRIHER Jersey Finger Presentation Pain and swelling at the volar aspect of DIP joint Can often feel fullness proximally if tendon retracted Need to isolate the DIP to properly test

19. 4/13/2020 Faculty of Physiotherapy, SRIHER Jersey Finger Physical Exam

20. 4/13/2020 Faculty of Physiotherapy, SRIHER Jersey Finger Treatment/ Referral All need to be referred for surgery immediately

21. 4/13/2020 Faculty of Physiotherapy, SRIHER Deformities in the Hand Boutonniere: hyperextended DIP and flexed PIP central slip of extensor tendon insertion into middle phalanx

22. 4/13/2020 Faculty of Physiotherapy, SRIHER Central Slip Extensor Tendon Injury- Boutonnière deformity PIP joint is forcibly flexed while actively extended Volar dislocation of the PIP joint Examine with PIP joint in 15-30 degrees of flexion, can’t active extend but can passively extend Tenderness over dorsal aspect of the middle phalanx

23. 4/13/2020 Faculty of Physiotherapy, SRIHER Central Slip Extensor Tendon Injury Treatment A delay in proper treatment will cause boutonniere deformity Deformity can develop over several weeks or occasionally acutely Splint PIP in extension for 6 weeks Can still play sports

24. 4/13/2020 Faculty of Physiotherapy, SRIHER Central Slip Extensor Tendon Injury Referral Avulsion fracture involving more than 30 percent of the joint Inability to achieve full passive extension

25. 4/13/2020 Faculty of Physiotherapy, SRIHER Collateral Ligament Injuries Forced ulnar or radial deviation Can cause partial or complete tear PIP is usually involved Present with pain at the affected ligament Evaluate with involved joint at 30 degrees of flexion and MCP at 90 degrees of flexion

26. 4/13/2020 Faculty of Physiotherapy, SRIHER Collateral Ligament Injuries- Treatment If joint stable and no large fracture- can buddy tape Never leave the pinky alone ?Physical Therapy- if joint stiff

27. 4/13/2020 Faculty of Physiotherapy, SRIHER Volar Plate Injury Hyperextension, such as dorsal dislocation PIP is usually affected Collateral damage is often present The loss of joint stability can cause hyperextension deformity

28. 4/13/2020 Faculty of Physiotherapy, SRIHER Volar Plate Injury- Diagnosis Maximal tenderness at volar aspect of affected joint Bruising, swelling Full extension and flexion possible if joint stable Collaterals should be tested Radiographs may show an avulsion fracture at the base of involved phalanx

29. 4/13/2020 Faculty of Physiotherapy, SRIHER Volar Plate Injury- Treatment Progressive splinting starting at 30 degrees flexion Followed by buddy taping If less severe, can buddy tape immediately Can play sports if splinted

30. 4/13/2020 Faculty of Physiotherapy, SRIHER Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb) (Game Keeper’s Thumb) Caused by forced abduction of the 1 st MCP joint Left untreated the joint will be unstable with weak grip strength

31. 4/13/2020 Faculty of Physiotherapy, SRIHER Skier’s Thumb- Diagnosis Difficulty opposing pinky to thumb Swelling and black and blue over thenar eminence Can’t hold an OK sign Consider digital block and to facilitate ligament testing

32. 4/13/2020 Faculty of Physiotherapy, SRIHER Stener Lesion

33. 4/13/2020 Faculty of Physiotherapy, SRIHER Skier’s Thumb Grading/Treatment Grade 1 Pain without instability with stress Splinting 1-2 weeks Grade 2 Pain with mild instability: gapping <20 degrees Casting 3-6 weeks Grade 3 Stenner’s Lesion Instability: gapping > 20 degrees or > 35 degrees compared to unaffect thumb Early surgical intervention within 2-3 weeks

34. 4/13/2020 Faculty of Physiotherapy, SRIHER Skier’s Thumb Treatment

35. 4/13/2020 Faculty of Physiotherapy, SRIHER Dupuytren’s Contracture Dupuytren contracture is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and aponeurosis of the palm Physical findings: Blanching of the skin when the finger is extended Proximal to the nodules, the cords are painless Pits and grooves may be present The knuckle pads over the PIP joints may be tender If the plantar fascia is involved, this indicates more severe disease

36. 4/13/2020 Faculty of Physiotherapy, SRIHER Physical and occupational therapy including ultrasound waves and heat can help during the early stage of the disease. Some patients may also benefit from a brace/splint to stretch the digits. The range of motion of the fingers is necessary to prevent adhesions. Corticosteroid injections may be beneficial for some patients eg those with painful nodules. 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. Needle aponeurotomy is typically reserved for mild contractures. The procedure is minimally invasive and is often performed in an office setting. Collagenase injections provide a minimally invasive treatment derived from Clostridium Histolyticum. Night extension splinting is maintained for 6 months. Collagenase injections result in a 75% contracture reduction with a 35% recurrence rate. Complications include edema, skin tearing, tendon rupture,  complex regional pain syndrome , and pulley rupture. Surgical fasciectomy can be either limited or radical. The recurrence rate at 1 to 2 years is 30%, 15% at 3 to 5 years, and less than 10% after ten years.

37. 4/13/2020 Faculty of Physiotherapy, SRIHER Conservative Approach Physical therapy may include: ultrasound waves: heat (early stage of the disease); brace/splint to stretch the digits; range of motion of the fingers to prevent adhesions.

38. 4/13/2020 Faculty of Physiotherapy, SRIHER Trigger finger Commonly, trigger finger is referred to as "stenosing tenosynovitis." Histologic studies showing that the inflammation occurs more so in the tendon sheaths rather than the tendosynovium , making this name a false depiction of the actual pathophysiology of the condition. [ Open Surgical Technique Endoscopic Surgical Technique Percutaneous Release Extracorporeal Shockwave Therapy Patient Education

39. 4/13/2020 Faculty of Physiotherapy, SRIHER Distal Tuft Fractures Common due to crush injuries Painful Splint in extension for 3 weeks

40. 4/13/2020 Faculty of Physiotherapy, SRIHER Fraction Alignment

41. 4/13/2020 Faculty of Physiotherapy, SRIHER Proximal and Middle Phalange Fractures Most common in athletes Fall or direct blunt trauma More difficult than metacarpal fractures Close relationship between fractured bone and pulley system

42. 4/13/2020 Faculty of Physiotherapy, SRIHER Phalanage Fracture Treatment Early motion (3-5 days) Splint and take out Can buddy tape

43. 4/13/2020 Faculty of Physiotherapy, SRIHER Proximal Phalange Fractures- Referral Inability to maintain proper alignment Rotation Irreducible Injury Any intra-articular fracture

44. 4/13/2020 Faculty of Physiotherapy, SRIHER Metacarpal Fractures Most common hand fracture 30-35% Usually involves the neck Fight or fall common mechanism 4 TH and 5 th most common fractures

45. 4/13/2020 Faculty of Physiotherapy, SRIHER Wrist Pathology Fracture Scaphoid Ligament-Tendon Injuries TFCC tear Scapholunate dissociation DeQuervain’s Intersection Syndrome Ganglion Cyst Nerve Injury Carpal tunnel Other Kienbocks

46. 4/13/2020 Faculty of Physiotherapy, SRIHER Scaphoid Fracture Most common fractured bone in the wrist Peanut shaped bone that spans both row of carpal bones Does not require excessive force and often not extremely painful so can be delayed presentation

47. 4/13/2020 Faculty of Physiotherapy, SRIHER Scaphoid Fracture Treatment Cast 6-12 weeks Short arm vs. long arm Follow patient every 2 weeks with x-ray CT and clinical evaluation to determine healing Consider screwing early

48. 4/13/2020 Faculty of Physiotherapy, SRIHER Triangular Fibrocartilage Complex (TFCC) Tear Fall on dorsiflexed and ulnar deviated wrist Axial load with forearm in hyperpronation Positive ulnar variance predisposes to injury

49. 4/13/2020 Faculty of Physiotherapy, SRIHER TFCC Tear Diagnosis Exam Ulnar sided wrist pain Often experience a click Imaging Radiographs MR arthrogram

50. 4/13/2020 Faculty of Physiotherapy, SRIHER TFCC Tear Treatment Splinting Time Injection Surgical treatment Debridement Repair Open vs. arthroscopic Ulnar shortening osteotomy

51. 4/13/2020 Faculty of Physiotherapy, SRIHER Scapholunate Dissociation Most common ligamentous instability of the wrist Patients may have high degree of pain despite apparently normal radiographs Physicians should suspect this injury if patient has wrist effusion and pain seemingly out of proportion to the injury If improperly diagnosed can lead to chronic pain Located proximal axial line from 3 rd metacarpal

52. 4/13/2020 Faculty of Physiotherapy, SRIHER Scapholunate Dissociation- Diagnosis Exam Watson’s test Scaphoid shuck test Pain/swelling over dorsal wrist, proximal row Imaging Plain films: >3mm difference on clenched fist view Scaphoid ring sign

53. 4/13/2020 Faculty of Physiotherapy, SRIHER Scapholunate Dissociation Treatment If discovered within 4 weeks, surgery After 4 weeks, conservative treatment reasonable Bracing NSAIDS Consider evaluation by hand surgery to confirm no surgery needed

54. 4/13/2020 Faculty of Physiotherapy, SRIHER DeQuervain’s Tenosynovitis Pain due to inflammation of the short extensor and abductor tendons of the thumb Repetitive or unaccustomed griping and grasping causes friction over the distal radial styloid

55. 4/13/2020 Faculty of Physiotherapy, SRIHER DeQuervain’s Tenosynovitis: Diagnosis Swelling and pain over 1 st dorsal compartment +Finkelstein’s test

56. 4/13/2020 Faculty of Physiotherapy, SRIHER DeQuervain’s Tenosynovitis: Treatment Splint Injection- 1 st line up to 90% are pain free if injected within 6 months Splinting performs poorly in comparison to steroid injection Coldham F.. British Journal of Hand Therapy .2006

57. 4/13/2020 Faculty of Physiotherapy, SRIHER Intersection syndrome Friction point where muscle bellies of 1 st compartment- Abductor Pollicis Longus and Extensor Pollicis Brevis cross 2 nd and 3 rd dorsal compartments Inflammatory peritendinitis Common with rowers due to clenched fist and thumb abduction Friction and crepitus felt 4-5cm proximal to radial styloid with rest flexion and extension and radial deviation

58. 4/13/2020 Faculty of Physiotherapy, SRIHER Intersection Syndrome Diagnosis Pain and swelling about 2-3 finger breadths proximal to dorsal wrist joint Palpable crepitus (“squeaker’s wrist”

59. 4/13/2020 Faculty of Physiotherapy, SRIHER Intersection Syndrome Treatment Splinting Activity modification Icing Nsaids Corticosteroid injection

60. 4/13/2020 Faculty of Physiotherapy, SRIHER Ganglion Cyst Account for 60% of soft tissue, tumor-like swelling affected the hand and wrist Develop spontaneously in 20-50 year olds Female to male, 3:1 Cyst filled with soft, gelatinous, sticky, and mucoid fluid Location 65% dorsal scapholunate joint 20-25% volar distal aspect of the radius 10-15% flexor tendon sheath

61. 4/13/2020 Faculty of Physiotherapy, SRIHER Ganglion Cyst Diagnosis Usually obvious on exam- may be helpful to flex and extend wrist Radiographs, ultrasound, or MR not usually indicated

62. 4/13/2020 Faculty of Physiotherapy, SRIHER Ganglion Cyst- Treatment Watchful waiting- most resolve spontaneously over time Bible treatment- not recommended Aspiration/Injection No recurrence in 27-67% of patients

63. 4/13/2020 Faculty of Physiotherapy, SRIHER Carpal Tunnel Syndrome Most common nerve entrapment disorder Pain and parasthesias from high pressures in the carpal tunnel causing compression and inflammation of the median nerve Carpal bones dorsally and transverse carpal ligament (flexor retinaculum) ventrally

64. 4/13/2020 Faculty of Physiotherapy, SRIHER Carpal tunnel syndrome

65. 4/13/2020 Faculty of Physiotherapy, SRIHER Hand Diagrams Sn = 0.64; Sp = 0.73 NPV = 0.91 Tinel + hand diagram – PPV = 0.71 Ann Intern Med 1990 Mar 1;112(5):321-7.

66. 4/13/2020 Faculty of Physiotherapy, SRIHER Carpal Tunnel Syndrome

67. 4/13/2020 Faculty of Physiotherapy, SRIHER Carpal Tunnel Syndrome Treatment Ice Activity modification Workspace modification Splinting Injection Surgery

68. 4/13/2020 Faculty of Physiotherapy, SRIHER Kienbock Disease Avascular necrosis/vascular insufficiency ?repetitive microfractures of lunate Young adults 15-40 years old Risk factors: negative ulnar variance

69. 4/13/2020 Faculty of Physiotherapy, SRIHER Kienbock Disease: Diagnosis EXAM Wrist pain that radiates up the forearm stiffness, tenderness, swelling over lunate passive dorsiflexion of middle finger produces characteristic pain Radiographs, MRI

70. 4/13/2020 Faculty of Physiotherapy, SRIHER Kienbock Disease Stage I – IV Stage I: MRI only Stage II: Sclerosis Stage III: Some collapse Stage IV: Total collapse

71. 4/13/2020 Faculty of Physiotherapy, SRIHER Kienbock Disease: Treatment Primarily surgical EARLY: Radial shortening, ulnar lengthening LATE: proximal row carpectomy, arthrodesis

72. 4/13/2020 Faculty of Physiotherapy, SRIHER Metacarpophalangeal Joint Relatively rare injury Dorsal displacement Hyperextension forces Dorsal displacement Volar plate can enter joint space Volar dislocations Usually surgical T r ea t m e nt R edu c e Splint in flexion Dislocation of MCP joint

73. 4/13/2020 Faculty of Physiotherapy, SRIHER Dislocation of MCP joint The thumb is most frequently affected and clinically the injury resembles a BENNETT’ fracture –dislocation Dx : by Xrays The displaced is easily reduced by traction & hyperpronation , but reduction is unstable and can be held by a K-wire for 5 wks and then protective splint for 8 wks because risk of instability .

74. 4/13/2020 Faculty of Physiotherapy, SRIHER Dislocation Interphalangeal Jt 1)Proximal Interphalangeal Joint Dislocation pattern Dorsal Most common ligamentous hand injury Lateral Volar Associated fracture > 33% of articular surface = unstable Violent twist with finger flexed (palmer) or extended (dorsal) SHARP, deformity, disability RICE, splint, meds, reduction/surgery, protect

75. 4/13/2020 Faculty of Physiotherapy, SRIHER Nondisplaced Fx: Initially use extension block splint for first 2-3 weeks followed by buddy taping in sight flexion. Work on restoring ROM. Healing Time: 6-12 weeks; monitor progress every 2-3 weeks

76. 4/13/2020 Faculty of Physiotherapy, SRIHER Cutaneous injuries Cutaneous injuries are very common injury. Two Types Open: Incised, laceration, punctured (bites), penetration, abrasion. Closed: Contusions, Hematomas Vary in depth May need to explore for underlying structural Injuries. Conservative excision of the skin is the rule. 32

77. 4/13/2020 Faculty of Physiotherapy, SRIHER Mana g eme n t Skin Laceration: Small: Rinse and cover. Large: Wound exploration under LA Irrigate wound profusely with betadine or sterile water and Explore Close the skin wound with simple sutures. Wounds older than 6-8 hours should not be closed primarily. Irrigate, explore then apply sterile dressing. Delayed primary closure at 4 days. 33

78. 4/13/2020 Faculty of Physiotherapy, SRIHER Bites : S h oul d no t be clo s ed prim arily b u t del a y ed closure at 4 days if needed Antibiotic prophylaxis is indicated in human (including fight-bites) and cat bites and may be of benefit in dog bites as well. Contusions: Cold packs with pressure for 30 to 60 min. several times daily for 2 days. Then use warm compresses for 20 minutes at a time. Rest, elevate Do not bandage a bruise. 34

79. 4/13/2020 Faculty of Physiotherapy, SRIHER Abrasions: Superficial: Rinse and cover. Prophylactic antibiotic ointment Deep: Rinse with antiseptic or warm normal saline. Scrub gently with gauze if necessary. Dress with semi-permeable dressing (Tegaderm) Changed every few days. Keep wound moist. Enhance healing process.

80. Nerve I n juries Primary repair Delayed repair 4/13/2020 Faculty of Physiotherapy, SRIHER

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86. Vascular injuries R e- v asuc u lar i z a t i on Replantation 4/13/2020 Faculty of Physiotherapy, SRIHER

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90. Replantation Replantation is the reattachment of a completely detached body part. Fingers and thumbs are the most common but the Hands, ear, scalp, hand, arm and penis have all been replanted. 4/13/2020 Faculty of Physiotherapy, SRIHER

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95. Generally replantation involves restoring blood flow, restoring the bony skeleton and connecting tendons and nerves as required. Initially, success was defined in terms of a survival of the amputated part alone. However, as more experience was gained in this field, surgeons began to understand that survival of the amputated piece was not enough In this way, functional demands of the amputated specimen became paramount in guiding which amputated pieces should and should not be replanted. 4/13/2020 Faculty of Physiotherapy, SRIHER

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100. 4/13/2020 Faculty of Physiotherapy, SRIHER Congenital Hand Deformities Syndactyly is classified according to the length of the syndactyly—partial to complete and according to the tissue within the syndactyly—simple if only skin is involved, complex if bone is also involved and complicated if there are extra, missing or angulated bones within the syndactyly.

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102. 4/13/2020 Faculty of Physiotherapy, SRIHER Camptodactyly Camptodactyly means “bent finger.” This can occur sporadically or as part of a syndrome. It usually involves the small and ring fingers at the PIPJ. When camptodactyly is part of a syndrome all the fingers may be affected. When it occurs in childhood, the cases are equally divided between male and female.

103. 4/13/2020 Faculty of Physiotherapy, SRIHER Duplication Post axial or small finger duplication is quite common and it often consists of a small tag along the ulnar border of the hand. This is often excised or tied off soon after birth. In the black population this is not associated with systemic findings whereas in Caucasians it is associated with congenital systemic conditions. Preaxial or thumb duplication is sporadically seen and is usually unilateral. It is classified according to the Wassel Classification from I to VII: I. Bifid distal phalanx II. Duplicated distal phalanx III. Bifid proximal phalanx IV. Duplicated proximal phalanx—most common V. Bifid metacarpal VI. Duplicated metacarpal VII. Triphalangism with duplication ( Triphalangism without duplication is inherited as autosomal dominant and associated with many anomalies)

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106. 4/13/2020 Faculty of Physiotherapy, SRIHER Thumb Hypoplasia A small or absent thumb is often associated with radial dysplasia but maybe seen as an isolated deformity

107. 4/13/2020 Faculty of Physiotherapy, SRIHER Gigantism in early childhood is commonly seen and is usually associated with lipofibromatosis . It is also seen with neurofibromatosis, vascular anomalies, and other bony conditions but usually not until adolescence or later in life. Lipofibromatosis is seen in childhood with uniform enlargement of fingers, toes and sometimes the entire extremity.

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109. Congenital anomalies Polydactyly Syndactyly Macrodactyly Congenital trigger finger Streeter’s dysplasia Camptodactyly Cleft hand Mirror hand Kirner’s deformity 4/13/2020 Faculty of Physiotherapy, SRIHER

110. Fracture & Dislocation of Hand Bone Meta carpal bone # involve carpometa -carpal joint Meta carpal shaft # ( Boxer’s #) Meta carpal neck # Meta carpal head # Proximal phalanx # Middle phalanx # # dislocation of proximal IP joint Dislocation of MCP joint 4/13/2020 Faculty of Physiotherapy, SRIHER

111. Other injury Flexor tendon injury Extensor tendon injury Jersey finger Boutonniere deformity Subungual hematoma Nail bed lacerations Fingertip avulsion Frostbite injury Crush injury Infection ( paronychia , distal pulp space, web space infection) Tenosynovitis 4/13/2020 Faculty of Physiotherapy, SRIHER

112. Others RA OA Burns Amputations Lupus erythematosus Psoriasis Reiters syndrome Gout Paralytic hand Alien hand syndrome 4/13/2020 Faculty of Physiotherapy, SRIHER

113. Occupation related hand injury Musicians String instrumentalists : Guitarist, violinists are prone to hand injury due to muscle strain from overuse or repetitive stress ( C/O pain, numbness, mm stiffness) Wind instrumentalists : horn, trumpet, flute are prone to hand injury stemming from strained shoulder or arm Percussionists : xylophone, drums, piano are prone for hand, wrist, arm, shoulder injury.( most carpal tunnel syndrome) Other Carpal tunnel, Cubital tunnel , thoracic outlet –syndrome Flexor tenosynovitis, Thumb arthritis, tendonitis 4/13/2020 Faculty of Physiotherapy, SRIHER

114. Occupation related hand injury Dentist / surgeon – carpel tunnel syndrome on dominant hand predominantly but often bilateral Carpenters - carpel tunnel syndrome (CTS) Construction worker : Raynaud’s phenomenon or white finger disease, CTS, Tendinitis ( especially powered hand tool workers) Clerical workers Typist Washer man House wife Students 4/13/2020 Faculty of Physiotherapy, SRIHER

115. Kirner’s deformity Polydactyly Mirror hand Congenital trigger finger Syndactyly Macrodactyly Cleft hand Camptodactyly Streeter’s dysplasia 4/13/2020 Faculty of Physiotherapy, SRIHER

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119. Examination – soft tissue of Hand Evaluations must be sufficiently comprehensive to provide information necessary to make or verify a treating diagnosis, identify patient/client goals, develop a plan of care, guide treatment and re-evaluations as needed. 4/13/2020 Faculty of Physiotherapy, SRIHER

120. STAGE I 4/13/2020 Faculty of Physiotherapy, SRIHER

121. STAGE II Assessment Evaluation Diagnosis STAGE III POC Dosage Follow up Outcome 4/13/2020 Faculty of Physiotherapy, SRIHER

122. The hand is a very vital part of the human body 4 requirements for a functioning hand: Supple (moving with ease) , pain free Sensate , co ordinate Account for 5-10 % of hospital ER visits. Great potential for serious handicap Good understanding of hand anatomy and function, good physical examination skills, and knowledge of indications for treatment. Proper Initial diagnosis and timely appropriate treatment would reduce morbidity. 4/13/2020 Faculty of Physiotherapy, SRIHER

123. Subjective examination Patient profile Body chart Chief complaints Subjective examination Present complaints Past complaints Present / past medical and surgical history Personal history Family history Occupation / socioeconomic history Investigations 4/13/2020 Faculty of Physiotherapy, SRIHER

124. Questions 1. What is the patient's age? 2. What is the patient's occupation? 3. What was the mechanism of injury? 4. What tasks is the patient able or unable to perform? 5. When did the injury or onset occur, and how long has the patient been incapacitated? 6. Which hand is the patient's dominant hand? 7. Has the patient ever injured the hand before? Was it the same type of injury? Was the mechanism of injury the same? If so, how was it treated? 8. Which part of the hand is injured? 4/13/2020 Faculty of Physiotherapy, SRIHER

125. Past medical H/O 4/13/2020 Faculty of Physiotherapy, SRIHER

126. Surgical H/O 4/13/2020 Faculty of Physiotherapy, SRIHER

127. Social H/O 4/13/2020 Faculty of Physiotherapy, SRIHER

128. Drug H/O 4/13/2020 Faculty of Physiotherapy, SRIHER

129. 4/13/2020 Faculty of Physiotherapy, SRIHER Surgical repair of tendon: (within 24 hours). (1-14 days). (2-5 weeks). (> 5 weeks). Primary. Delayed primary. Early secondary. Late secondary. Tendon grafts. Tenolysis .

130. Subjective examination Pain assessment Onset Site Side Type Duration Character Behavior pattern Aggravating factor Relieving factor Severity Irritability Nature 4/13/2020 Faculty of Physiotherapy, SRIHER

131. Subjective examination Investigations Plain film radiography Computerized Tomography Magnetic Resonance Imaging Ultrasound Bone scan Electro diagnosis Nerve conduction studies Electromyography Others Blood test Microbiological test 4/13/2020 Faculty of Physiotherapy, SRIHER

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141. 4/13/2020 Faculty of Physiotherapy, SRIHER Advanced Technologies for Partial Hand and Transmetacarpal Amputees

142. 4/13/2020 Faculty of Physiotherapy, SRIHER Clinical Applications for Platelet Rich Plasma Therapy

143. Thank you  4/13/2020 Faculty of Physiotherapy, SRIHER