Diagnosis and Treatment of the Upper Extremities Nonoperative Orthopaedic and Manual Therapy - DOS WINKEL

20 Treatment Techniques in Lesions of the Wrist and Hand DISTAL RADIOULNAR JOINT ARTHRITIS Functional Examination • Passive pronation and supination are painful and sometimes slightly limited at end-range. Intra-articular Injection Traumatic arthritis, rheumatoid arthritis, and other arthritides that are rhewnatoid in nature are the most significant indications for an intra-articular injection (Figure 20- 1) . Position of the Patient The patient sits at the short end of the treatment table with the pronated forearm resting on the table. Position of the Physician Figure 20-1 Intra-a rt i c u l a r injection of the d i stal radioulnar joint. The physician sits diagonally across from the patient, next to the long side of the treat­ ment table. The physician palpates the tendon of the extensor digiti minimi, which lies directly ra­ dial to the ulnar head (the patient extends the little finger). This tendon runs directly over the distal radioulnar joint (Figure 20-2) . Performance does not hinder the injection) . After approxi­ mately 1.5 cm, if the needle comes into con­ A syringe is filled with 0.5 to 1.0 mL of tri­ tact with bone, the direction of the needle can amcinolone acetonide, 10 mg/mL. A 2-cm be altered slightly so that it can go deeper long needle is inserted vertically (the tendon 400 Copyrighted Material

Treatment Techniques in Lesions oj the Wrist and Hand 401 Figure 20-2 Local ization of the distal rad iou l n a r joint by pa l pating the tendon of the extensor digiti minimi. without any resistance. Because the needle is • Passive extension and radial deviation of only 2 em long, there is no d anger of going the v{rist can be painful. through the joint to the other side. • Pain and crepitation can be elicited by Follow-Up passive movement of the pisiform against the triquetrum. Activities should be lim.i.ted for 1 week. The Injection patient should be reassessed in 2 weeks. Usu­ ally, one or two inj e c tions are sufficient to Differentiation be tween a sprain of the achieve complete relief of pain. triquetro-pisiform joint and an insertion tendopathy of the flexor carpi ub1aris is not SPRAIN OF THE TRIQUETRO­ always easy. Injection of a local anesthetic PISIFORM JOINT can help to confirm the diagnosis. Functional Examination Position of the Patient • Resisted palmar flexion and ulnar devia­ The patient sits next to the short end of the tion of the wrist are usually painful. treatment table. The forearm rests in maxi­ mal supination on the table. Copyrighted Material

402 DIAGNOSIS AND TREATMENT OF' THE UPPER EXTREMITIES Position of the Physician The physician sits diagonally facing the pa­ tient, next to the long side of the treatment table. If the right side is being treated, the physi­ cian grasps the patient's hand from the radial aspect with the left hand. The patient's hand is held in slight palmar flexion and ulnar de­ viation, with the forearm positioned in supi­ nation. Using the middle finger, the physician shifts the pisiform ulnarly. Performance A syringe is filled with 0.5 to 1.0 mL of tri­ amcinolone acetonide, 10 mg/mL. Directly dorsal to the pisiform, a 2- to 3-cm long needle is inserted horizontally between the tri­ quetrum and pisiform (Figure 20-3). With the pisiform shifted in an ulnar direc­ tion, the joint surface of the bone is partially palpable. Note: The pisiform bone is often larger than expected. GANGLION AT THE DORSAL ASPECT Figure 20-3 Injection of the joint between the OF THE WRIST pisiform a n d the triquetrum. Functional Examination If the patient has significant complaints, aspiration and subsequent injection are indi­ • Passive extension of the wrist is painful cated. and sometimes limited. Position of the Patient • Passive palmar flexion of the wrist is The patient sits next to the short end of the usually painful. treatment table with the forearm supported Aspiration/lnjection on the table in a pronated position. The hand hangs over the edge of the table with the wrist A ganglion on the dorsal aspect of the wrist in palmar flexion. is not always visible or palpable. Differentia­ tion between a ganglion and a subluxation of Position of the Physician a carpal bone or a ligamentous lesion is neces­ The physician sits diagonally facing the pa­ sary, but not always easy. tient next to the long side of the treatment In making a prognosis, it is significant to table. With one hand the physician grasps the note whether the ganglion comes from the patient's hand, holding it in slight palmar flex­ joint capsule or from a tendon sheath. Gangli­ ion. ons coming from thejoint have a stronger ten­ dency to recur. Copyrighted Material