Clinical Kit - 22/9/2015 - The Hands Have It

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'I hand it to you', 'He has the whole world in his hands', 'Give him a hand' .... the metaphors relating to the importance of our hands are extensive and in common use. Practically without good hand/thumb control, the elbow and shoulder are of limited use. When I was studying physiotherapy, the Australian Physiotherapy Association's logo was an icon of a stylised hand and person within (the hand being much larger than the person) and we all know about the relative sensory representation of the hand on the homunculus. Yet when studying undergraduate and postgraduate physiotherapy, bar the 10 carpal tests, we glossed from the elbow, basically right past the hand.

In clinical practice (in a rural situation) we see quite a few hand injuries. Some post surgical rehab but more often simply traumatic - shearers and locked hand pieces, mothers with new born children, tradespeople and their wayward tools (perhaps they could install avoidance software and a GPS into the heads of hammers). Regardless, treating wrists & hands is a very interesting clinical area and this case study demonstrates the importance of trigger points and clinical reasoning when managing chronic pain.

The young man presented three weeks prior with the following.

History:

On the 16/3/2105, a 25 y.o. male while working at the abattoirs was lifting slippery weight (dead calf), that he dropped and knocked his right (dominant) wrist/hand medial boarder against the edge of a steel strut. He stopped working due to pain and presented to Esperance District Hospital A & E. There he was examined and the placed in POP for 6/52 (had XR, but wasn't reported as fractured). After removal of cast, he returned to work on light duties (

In mid August (5 months later) due to non resolution of symptoms, he was referred to plastic surgeon for examination and review. He had a MRI that found a triangular fibrocartilage (TFC) tear and the surgeon recommended a physiotherapy trial before undertaking surgery.

Qualified boiler maker and light diesel mechanic
Working normal hours 5.30am - 4.30pm, lifting restriction to 5kg.
Cigs: 10/day
Meds: nothing regular, has tried intermittent para 500, 'not effective'
Sleep: goes to bed 21:00 but awake till 03:00 and then up 05:00hrs.
24HR AM NPRS 8-9/10, builds to 9.5/10 through work. Has a load lifting limit of 5kg but employer is regularly asking him to lift 10-15kgs. No regular exercise, overweight.

Questionnaires Completed on day:

Orebro Musculoskeletal Screening Questionnaire. Score = 73
57 = Low risk of failed return to work
57-72 = Moderate risk of failed return to work
> 72 = High risk of failed return to work
painDetect Questionnaire. Score =10. Greater than 19 indicates neuropathic pain source
Hospital Anxiety & Depression Score. Score Anxiety = 10, Depression = 17
0-7 Non case, 8-10 Doubtful case, 11+ Definite case

Assessment:

Elbow Active Movements: good, Supination 80 pain and Pronation 80 pain (around TFC area)
Wrist Active Movements: Flexion and extension good, RD pain end of range, UD same
Palpation: 4th & 5th MC spaces painful and abd digiti minimi sore, TFC not sore
Strength: Grip dynamometer - nil due to pain, very weak abduction of 4th & 5th MCs and adduction of 5MT all with increases in pain.

Treatment:

Explanation that pain source seemed not related to MRI findings - explained that imaging often picks up 'normal' abnormalities. Explain nature of disuse atrophy and need to find a baseline of activity and build, so that functional tasks no longer are overloading tissue and provoking pain. Explain that needs to stay within lifting guidelines, otherwise jeopardise his claim's status. I later talked with employer about same matter.

Dry needling as taught on our 2-day Master Needling Course, to 3rd and 4th dorsal interossei and 2nd and 3rd palmer interossei and abductor digiti minimi.

Home Program: Active movements in warm water, plus isometric finger adduction and abduction *15 mins

After initial treatment, resting pain reduced to 3-4/10 and was achieving 6 - 7 hours sleep a night.

In the last 2 weeks, pain further reduced and light weights exercises for hand and upper limb have been commenced.

Going Forward:

With the long duration between injury and seeing this young man, plus his elevated Orebro and HADs scores, it was important to spend time listening and explaining where he was at in his injury cycle and what steps lay before him. These will need to be repeated, but I am sure they have dropped to below clinical significance.

I wasn't sure how he would respond following his initial treatment, but with the quick turnaround in pain, reasoned that his pain was of trigger point origin and reversible. The next step is to progressively build up his strength in his hand and upper limb over a sensible period of time, say 4 - 6 months and given the nature of his employment, goals of 5 kg for wrists curls being reasonable.

He is happy with his progress, compliant with home exercise requests and looking forward to resuming normal duties at work over the next 6-8 weeks.

Love to hear your thoughts and experiences.

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

email: doug@aapeducation.com.au

ph/fx: 08 90715055

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