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Musculoskeletal Case study 8 (M8)

Subjective Assessment
PC - James Anderson is a 20 year old apprentice plumber who has been experiencing pain in his right hand for 2 months since he sustained a fracture to the 5th Metatarsal shaft following a punch injury. This was fixed internally with a plate and screws. He is now noticing wasting of the muscles around the thenar and hypothenar eminence and has decreased grip strength and limited MCP and IP movement of the 3rd and 4th digits. He is currently off work but needs to grip for prolonged periods but the pain and lack of grip makes it difficult to return to work.
HPC - Sustained a fracture to the 5th Metatarsal shaft following a punch injury. This was fixed internally with a plate and screws.
PMH - NIL
DH - NIL
SH - He lives with his parents and teenage brother in a 3-bed house.
Other;
- R/L handed?- General health ok?- PMH- osteoporosis, bone disease, diabetes, HBP, respiratory disease, steroid use, major operations, previous fractures?
- RA/FHRA
- Drugs being taken?
- Claiming for compensation for accident?
- Hobbies
- Anyone else who may be able to help round the house, what sort of tasks is she struggling with?
Identification of Pathology
Boxer’s Fracture
It is usually caused by punching something harder than the hand, such as a wall or another person's head. The end of the metacarpal bone takes the brunt of the impact, which usually breaks through the narrowest area near the end (the "neck"), and bends down toward the palm.
Typical signs and symptoms –
The typical symptoms of a boxer's fracture are pain or tenderness centred in a specific location on the hand corresponding to one of the metacarpal bones, around the knuckle. You may also note pain with movement of your hand or fingers. When a bone is broken, you may experience a snapping or popping sensation in the affected bone. Your hand may swell, discolour, or bruise around the injury site. Deformity of the broken bone or the knuckle may also be noted. There may also be abnormal movement of the broken bone fragments. The doctor may be able to produce pain by pressing on the broken bone. In addition, pain can be produced by grabbing the finger that attaches to the metacarpal bone that was hurt and pushing it inward toward the broken bone. If you make a fist with the affected hand, the doctor may notice misalignment of the associated finger. The doctor may see a deformity of the broken bone. When making a fist, the finger involved may bend toward the thumb more than is usual. This is known as rotation, and, though not always seen, its presence may indicate the possibility of a more serious type of boxer's fracture. Another common sign of a possible boxer's fracture is a cut on the hand. A cut in the skin associated with a boxer's fracture may indicate a more serious type of boxer's fracture.
Area of concern (relationship; muscles, bone, tendons, nerves)
Thenar eminence - Fleshy (muscular) area formed by intrinsic (thenar) muscles of thumb.
Hypothenar eminence - Fleshy (muscular) area formed by intrinsic (hypothenar) muscles of 5th digit.
Proximal crease - The proximal portion of the wrist joint indicates the site of articulation between the distal radius and the proximal row of carpal bones
Distal crease - Distal surface marking of the wrist joint indicates the articulation between the distal row of carpal bones with the base of the metacarpal bones.
Proximal digital crease - Proximal knuckle of thumb and site of the metacarpophalangeal joints (MCP) of fingers.
Proximal interphalangeal crease - Middle knuckle of fingers is the site of the proximal interphalangeal joints (PIP) of fingers.
Distal interphalangeal crease - Distal knuckle of fingers is the site of distal interphalangeal joints (DIP) of fingers.
Hand
There are 5 Metacarpals;
- Proximal articulation - distal row of carpal bones of wrist
- Distal articulation - proximal phalanx of fingers
Digits
There are 5 Fingers, and 3 joints;
- 3 Phalanges ( proximal, middle, distal)
Thumb
- 2 phalanges ( proximal, distal)
MCP Joint;
Condyloid joints,
Flexion / Extension
Abduction / Adduction
Head of metacarpals and base of proximal phalanx
PIP Joint
Hinge joint
Proximal and middle phalanges
Flexion / Extension
DIP Joint
Hinge joint
Middle and distal phalanges
Flexion / Extension
PIP Joint of Thumb
Hinge joint
Proximal and distal phalanges
Flexion / Extension

Flexor Muscles
Flexor digitorum superficialis
- Flexes the proximal interphalangeal joint of the fingers (digits 2 -5)
- Stimulated by the median nerve
Flexor digitorum profundus
- Flexes the distal interphalangeal joints of the fingers
- Muscles to fingers 1 & 2 -innervated by deep branch of median nerve
- Muscles to fingers 1 & 2 -innervated by ulnar nerve
Flexor Pollicis Longus
- Flexes interphalangeal joint of thumb
- Stimulated by deep branch of median nerve.
Extensor Muscles
Extensor digitorum
- Extends metacarpophalangeal joints of fingers.
Extensor indicis
- Helps extends metacarpophalangeal joints of 1st finger.
Extensor Digiti V
- Helps extends metacarpophalangeal joints of 4th finger.
Extensor pollicis longus and brevis
- Extends the M.P. & I.P. joints of the thumb respectively.
Abductor pollicis longus
- Abducts the 1st. carpometacarpal joint.
Hypothenar
- Located on ulnar side of hand
- Act on M.C.P. joint of 4th finger.
Interossei
- Palmar (3 in number)
§ Arise from palmar surface of metacarpal bones 2,4,5
§ Adduct the MP joint of fingers 2,4,5
- Dorsal (4 in number)
§ Arise from dorsal aspect adjacent metacarpal bones
§ Abduct digits 2, 3, 4
- Interossei innervated by ulnar nerve
- Act as flexors of MP joint
Extension of the Fingers
- M.C.P. joints strongly extended
- Extensor digitorum
- Extensor indices
- Extensor digiti minimi
P.I.P. joints extended together as a unit
- Extensor digitorum
- Weak extenders of PIP joints
Flexion of the Fingers
M.C.P. Joints
- Interossei
- Prime movers of MP joint flexion
Proximal Interphalangeal Joints ( P.I.P.)
- Flexor digitorum superficialis
Distal Interphalangeal Joints (D.I.P)
- Flexor digitorum profundus
· Adduction of the Fingers
- Motion occurs at M.C.P. joints
- Palmer Interossei (3)
- 2nd finger is center of hand
- Fingers 1, 3 & 4 move toward 2nd. finger
Abduction of the Fingers
- Motion occurs at M.C.P. joints
- Dorsal Interossei (4)
- 2nd finger is center of hand
- Any movement of 2nd finger is considered abduction
- Fingers 1, 3 & 4 move away from 2nd finger.
Movements of Thumb
- Flexion - thumb moves across the palm
- Extension - thumb moves away from the palm
- Abduction - thumb moves away from hand towards you
- Adduction - movement of thumb towards hand
- Opposition - flexion and rotation of thumb to touch pads of other fingers

Where is the pain (patients complaints)
Pain around the third and fourth digits; also decreased grip strength.

Easing and aggravating factors
Aggravating;
- Trying to grip or pick up objects
- Extension, flexion, abduction and adduction of the lateral 3 digits.
What happens as a result of Boxer’s Fracture;
However, if the bone heals with too much of a bend, it may mess up the action of the tendons which straighten the other finger joints, and result in a permanent bend in the middle knuckle of the finger.



Objective assessment
Sensory tests
- Test each finger separately; especially the fingers that share the same nerve as the affected finger; third and fourth digit share the same nerve; ulnar nerve as the affected fifth digit. Then comparing this to the unaffected hand.
- If patient has pins and needle or numbness in these fingers it is likely there is a nerve lesion; possibly caused by the surgery or local anaesthetic.
Movements;
- Ask patient to make a fist; if there is limited movement as the M.C.P joints of the affected finger and possibly the third and fourth digit, this usually indicates a Boxer’s Fracture. Limited movement all together in these joints is also a common symptom.
- Also ask the patient to pick u p various sized objects; usually, the smaller the object the harder it is for the patient to pick it up, if a Boxer’s fracture is present.
Measurements
- Goniometer measurements;
- Average joint flexion of fingers;
- MCP Joint - 0-90º
- PIP Joint – 0-100º
- DIP Joint – 0-80º
- Average ROM of Thumb
- PIP Joint flexion – 0-80º
- PIP joint extension – 0-20º
- MCP Joint flexion – 0-55º
- MCP extension (passive) – 0-5º
- Carpo-metacarpal abduction – 0-20º
- Carpo-metacarpal adduction – 0-15º
Other affected muscles/areas due to pathology
Possible wrist affected;
Flexion- 0-70º
Extension – 0-70º
Radial deviation – 0-20º
Ulnar deviation – 0-35º
Pronation – 0-75º
Supination – 0-80º

Speak to patient when performing tests and measurements.