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case interpretation

Discussion in 'Physical Therapy' started by studentwt, May 29, 2008.

  1. studentwt

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    Other Health Professions Student
    25 year old male. Presents with dorsal wrist pain 4 months duration. Healthy otherwise. Pain observed on resisted hyperextention of wrist. Passive hyperextention of wrist has little to no pain. Unknown onset, possible overuse injury. Braced for 3 weeks in neutral position with no relief. X-rays came back negative, only noting upper limits on scapholunate joint space. Pain localized to lunate region. Ice/heat, ultrasound, laser, muscle stripping all utilized with no relief of pain.
    What do you think?
     
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  3. AussiePT

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    studentwt, I'm not sure how things are done in America or wherever you are that isn't Australia, but hand conditions are difficult enough with the patient there let alone on the internet. You definitely need to provide more information which I can suggest to you the prompting questions, however I am concerned with how many treatments you are trying without a diagnosis, the way we work is diagnosis (or atleast a pathology) first, then treat that. I am also concerned of your use of expensive and non-evidenced based (or evidence proved ineffective) treatments

    Anyway! Perhaps we can help if you can provide more of a Hx
    Does the pain EVER extend into the fingers or forearm?
    What sort of pain is it? Sharp/dull/burning. Scale/10. Any pins & needles or numbness?
    24/24 pain behaviour, is it worse in AM, PM , does it wake during sleep?
    What aggravates the pain? (writing, playing guitar, typing etc)
    What relieves the pain (Hot pack? Panadol? Self-massage?)

    Objectively :
    Passive range in all wrist movements (ROM + ?Pain)
    IMT in all movement (Which you have identified as painful on IMT extension* Will mention this later)
    Elbow screening
    Palpation of hand + forearm (swelling, heat, spasm etc)

    Passive Accessory movements to all joints in hand+wrist (theres more than you think)
    And the big one, why haven't you tried (or mentioned) any of the orthopaedic tests for the hand? eg. watsons test, Finkelsteins test etc.

    I suspect those last two (PAMS + special tests) will provide the most information
    Once again I raise my concern of spending most of the consult trying treatments instead of listening to the patient and diagnosing


    * To mention the IMT, I understand the typical uni teaching (atleast here) is IMT = active/contractile structure. Especially in the case of the hand this is not always true as the muscle belly is in the forearm, so whats happening in the hand during this contract? The tendons are exerting a force on the carpal bones, in this case what you could a force that pulls the carpals in the dorsal direction. What happens during IMT flexion? Does it relieve the pain?

    One hypothesis would obviously be scapholunate instability which is somewhat correlated by the xray.
    I dont want to give you all the answers but I will make suggestions, its your responsibility to learn, especially considering I haven't seen the patient, Im probably wrong

    Why dont you try this:
    * Do the above Hx and objective exam
    * Put your thumb over the lunate, and push it anteriorly (ventrally). While your pushing it, repeat the isometric extension, is the pain still there?
    * Phalens test, Watsons test and Finkelsteins test

    If it is your (and your clinical supervisors) opinion he has this lunate instability I wonder if the patient is best served by referral to a specialist hand clinic?
     

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