Nerve entrapments, wrist, and hand conditions

These entrapments occur at the elbow and forearm. As elsewhere, baseline care is acetaminophen or NSAIDs and phase-appropriate physical therapy, and the entries below note only what differs.

• Nerve entrapments
  • Median nerve entrapment
    • Tightness of the pronator teres muscle and under the superficial head of the flexor digitorum superficialis secondary to repetitive gripping activities
    • Symptoms
      • Pain, numbness, tingling, and weakness in the median nerve distribution in the forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in the median nerve distribution
  • Radial nerve entrapment
    • Entrapment of the posterior interosseous nerve within the radial tunnel as a result of overhead activities and throwing
    • Symptoms
      • Lateral elbow pain
      • Pain, numbness, tingling, and weakness in the radial nerve distribution in the forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in radial nerve distribution
  • Ulnar nerve entrapment
    • Compression or trauma at the cubital tunnel, thickened retinaculum, or hypertrophy of the flexor carpi ulnaris muscle
    • Symptoms
      • Medial elbow pain
      • Pain, numbness, tingling, and weakness in the ulnar nerve distribution in the forearm and below
    • Diagnosis
      • Clinical presentation
      • Manual muscle test of forearm muscles
      • Positive Tinel’s test in the ulnar nerve distribution
  • Physical therapy management for all nerve entrapments
    • Early interventions - rest, modalities to reduce inflammation/pain
    • Nerve glides matched to the entrapped nerve (median, radial, or ulnar), progressing tension gradually along the nerve’s pathway
    • Night splinting as appropriate
    • Functional training
    • Patient education

Contrasting conditions of wrist and hand

• Carpal tunnel syndrome

  • Compression of the median nerve at the carpal tunnel at the wrist due to inflammation of the wrist flexor tendon or inflammation of the median nerve
    • Caused by repetitive wrist motions; other causes may be pregnancy, diabetes, or rheumatoid arthritis

• Symptoms

  • Numbness and tingling in the thumb, index, and middle fingers
  • Pain, often described as burning, aching, or electric shock-like
  • Sensitivity to cold or touch
  • Weakness in the hand, especially when gripping or making fine movements
  • Clumsiness or difficulty with tasks like buttoning clothes or writing
  • Dropping objects

• Diagnosis

  • Clinical presentation
    • Special tests
      • Tinel’s
      • Phalen’s
  • Electrodiagnostic testing - tests if a nerve signal is moving and its speed

• Physical therapy management

  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Bracing is the most appropriate option during pregnancy

• De Quervain’s tenosynovitis

  • Inflammation of the extensor pollicis brevis and abductor pollicis longus
    • Due to repetitive microtrauma or occur during pregnancy

• Symptoms

  • Pain at the base of the thumb that radiates into the forearm.
  • Swelling and tenderness on the thumb side of the wrist.
  • A feeling of catching or snapping when moving the thumb or wrist.
  • Pain or stiffness when grasping, pinching, or extending the thumb.
  • Difficulty gripping or holding objects.
  • Numbness or tingling in the thumb or index finger.

• Diagnosis

  • Clinical presentation
    • Special tests
      • Finkelstein’s test
  • MRI

• Physical therapy management

  • Range of motion, strengthening
  • Corrections of biomechanical causes
  • Functional exercises
  • Bracing is the most appropriate option during pregnancy

• Colles fracture

  • Fracture causing posterior displacement of the distal radius with radial shift of the wrist and hand
    • Most common fracture from falling on an outstretched hand with the wrist in extension and radial deviation.
    • Can cause median nerve damage if edema is unmanaged

• Symptoms

  • Sharp, immediate pain, especially when bending or gripping the wrist.
  • Pronounced swelling and bruising around the wrist.
  • The wrist may appear bent or crooked, often resembling a “dinner fork”.

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Immobilization for 5-8 weeks in a position opposite the injury, wrist flexion and ulnar deviation

• Physical therapy management

  • After removal of the cast
    • Range of motion, gaining wrist extension is most important before strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

• Scaphoid fracture

  • Due to falling onto an outstretched hand
    • This is the most common fractured carpal bone

• Symptoms

  • Pain located in the anatomical snuff box and weakness on the thumb side of the wrist, especially when gripping or pinching objects.

• Diagnosis

  • Clinical presentation
    • Diagnosis of rule-out
  • X-ray

• Medical management

  • Immobilization for 6-8 weeks due to poor blood supply to this bone

• Physical therapy management

  • Before cast removal
    • Range of motion exercises to proximal and distal joints, the scaphoid, to maintain pre-injury flexibility
  • After removal of the cast
    • Range of motion, strengthening
    • Pain, edema control
    • Use of modalities as appropriate
    • Functional exercises

• Dupuytren’s contracture

  • Contracture of the palmar fascia leading to flexion of the digits towards the palm
    • Common in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the fourth and fifth digits in non-diabetic and the third and fourth in diabetic

• Symptoms

  • Small, hard lumps in the palm, often near the base of the ring or little finger.
  • Thickened bands of tissue that run from the nodules to the fingers.
  • The affected fingers are gradually pulled into a bent position, making it difficult to straighten them out.

• Diagnosis

  • Clinical presentation

• Medical management

  • Wound care may be indicated
  • Surgery may be indicated

• Physical therapy management

  • Splinting
  • Flexibility exercises
  • Restoration of normal hand function

• Boutonnière deformity

  • Rupture of the central tendon slip of the extensor hood
    • Commonly occurs after trauma to the hand or with the diagnosis of rheumatoid arthritis
    • Deformity noted is flexion of the PIP with hyperextension of the DIP (the MCP is usually neutral or hyperextended)

• Symptoms

  • Deformity as noted above

• Diagnosis

  • Clinical presentation

• Medical management

  • Management of rheumatoid arthritis

• Physical therapy management

  • Splinting
  • Taping
  • Flexibility exercises

• Swan neck deformity

  • Contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
    • Commonly occurs after trauma to the hand or with the diagnosis of rheumatoid arthritis
    • Deformity noted is flexion of the MCP and DIP with hyperextension of the PIP

• Symptoms

  • Deformity as noted above

• Diagnosis

  • Clinical presentation
  • Possibly x-ray imaging (rarely used)

• Medical management

  • Management of rheumatoid arthritis

• Physical therapy management

  • Splinting
  • Taping
  • Flexibility exercises

• Mallet finger

  • Rupture or avulsion of the extensor tendon at its insertion into the distal phalanx digit
    • Commonly occurs after trauma, forcing the distal phalanx into a flexed position
    • Deformity noted is flexion of the DIP

• Symptoms

  • Deformity as noted above

• Diagnosis

  • Clinical presentation
  • Possible MRI (rarely used)

• Physical therapy management

  • Continuous splinting of the DIP in extension (or slight hyperextension) for about 6-8 weeks; the DIP must not flex during this period, including when the splint is removed for skin care
  • Active range of motion of the uninvolved PIP and MCP joints to prevent stiffness
  • Night splinting and gradual DIP motion after the continuous-splinting period

• Ape hand deformity

  • Median nerve dysfunction causes thenar muscle weakness with the first digit moving dorsally until it becomes aligned with the second digit

• Symptoms

  • Inability to move the thumb in and out of the palm
  • Inability to oppose the thumb
  • Limited ability to flex and extend the thumb
  • Sensory loss or tingling in the thumb
  • Weakened forearm pronation
  • Weakened finger flexion

• Diagnosis

  • Clinical presentation
  • Electrodiagnostics

• Physical therapy management

  • Splinting
  • Taping
  • Flexibility exercises
  • Functional strengthening and coordination activities