Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrist and Hand ConditionsWrist and Hand Conditions

Chapter 16


AnatomyAnatomy


Wrist ArticulationsWrist Articulations

• Radiocarpal joint

– Radius with scaphoid, lunate, and triquetrum

– Condyloid joint

– Sagittal plane motions (i.e., flexion, extension, and hyperextension)

– Frontal plane motions (i.e., radial deviation and ulnar deviation)

– Circumduction


Wrist Articulations (cont.)Wrist Articulations (cont.)• Intercarpal joints

– Gliding joints

– Minimal contribution to wrist movement

• Distal radioulnar joint

– Immediately adjacent to radiocarpal joint

– TFCC – stabilizer


Hand ArticulationsHand Articulations

• Carpometacarpal joints (CM)

– Thumb

• Saddle joint

– Fingers

• Gliding joints

• Intermetacarpal joints (IM)

• Metacarpophalangeal joints (MP)

– Condyloid joints

• Interphalangeal joints (IP)

– PIP and DIP hinge joints


MusclesMuscles


Muscles (cont.)Muscles (cont.)


Muscles (cont.)Muscles (cont.)


Muscles (cont.)Muscles (cont.)• Tendon sheaths

– Level of the metacarpal heads – point where flexor tendons enter a flexor tendon sheath

– Annular pulleys

• Keep flexor tendons and sheath closely applied to phalanges

– Cruciate pulleys

• Collapse to allow full digital flexion


NervesNerves

• Median nerve

• Radial nerve

• Ulnar nerve


Blood VesselsBlood Vessels

• Radial artery

• Ulnar artery

• Numerous divisions


KinematicsKinematics• Wrist movements

– Flexion

– Extension/ hyperextension

– Radial deviation

– Ulnar deviation

– Circumduction


Kinematics (cont.)Kinematics (cont.)

• CM

– Thumb – flexion, extension, abduction, adduction

• MP – fingers

– Fingers – minimal motion

– Flexion

– Extension

– Abduction

– Adduction


Kinematics (cont.)Kinematics (cont.)

• MP – thumb– Flexion– Extension

• IP– Flexion– Extension


Kinematics (Cont’d)Kinematics (Cont’d)


KineticsKinetics• Wrist flexors of hand are 2× stronger than extensor muscles

• Grips

– Power

– Precision

– Lateral pinch; fencing

– Maximum grip strength – exerted with wrist in ulnar deviation and slight hyperextension


Prevention of InjuriesPrevention of Injuries

• Protective equipment

– Pads and gloves

• Physical conditioning

– Strength and flexibility

– Exercises for wrist and elbow

• Proper skill technique

– Instruction on falling


Contusions and Skin WoundsContusions and Skin Wounds

• Always important to consider an underlying fracture

• Contusion S&S: pain & discoloration

• Skin wounds – typically abrasions and lacerations

• Management

– Standard acute for closed wound & open wound


SprainsSprains• Wrist

– Mechanism: axial loading on proximal palm during fall on outstretched hand

– S&S

• Standard – sprain

• Specific

Point tenderness on dorsum of radiocarpal joint

↑ Pain with active or passive extension

– Need to rule out fracture, especially scaphoid fx

– Management: standard acute; NSAIDs


Sprains (cont.)Sprains (cont.)

• Gamekeeper’s thumb

– Tear of the UCL of the MP joint

– Mechanism: MP in extension and forceful abduction

– S&S

• Palmar aspect of joint – pain; swelling

• + abduction stress

– Management: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repair


Sprains (cont.)Sprains (cont.)• IP sprains

– Excessive valgus and varus: collateral ligaments

– Hyperextension stress: volar plate

– S&S

• Rapid swelling; masks condition

– X-ray: rule out fracture and dislocation

– Management: standard acute; “buddy” taping


DislocationsDislocations

• Distal radioulnar joint (DRUJ)

– Isolated or with radial fracture

– Mechanism: hyperextension

• With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation


Dislocations (cont.)Dislocations (cont.)

– S&S• Pain; deformity; extensive swelling

• Dorsal dislocation – ulnar head prominent dorsally; volar dislocation – wrist appears narrow (result of overlap of the distal radius and ulna)

• elbow flexion and extension – normal unless fracture present; pronation and supination of forearm – limited

– Management: immobilization of limb in vacuum splint; immediate transportation to physician


Dislocations (cont.)Dislocations (cont.)• Lunate

– Axial loading displaces in volar direction– S&S

• Point tenderness – dorsum of hand just distal to radius

• Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal)

• Passive and active motion may not be painful– Caution: bone into carpal tunnel – compression of

median nerve– Management: immobilization of limb in vacuum splint;

immediate transportation to physician



Dislocations (cont.)Dislocations (cont.)• Fingers

– Can involve collateral ligaments and volar plate– MCP

• Rare, but easily recognizable• Hyperextension or shear

– PIP • Hyperextension and axial loading (e.g., ball

striking extended finger)– DIP

• Usually occur dorsally • Individual often reduces injury on their own



– S&S: swollen, painful finger – Management: immobilization; ice; immediate

physician referral




StrainsStrains

• Jersey finger

– Rupture of flexor digitorum profundus from distal phalanx

– Mechanism: rapid extension (from active flexion)

– S&S

• Unable to flex the DIP

• Palpate tendon in proximal aspect of finger

• Hematoma formation along the entire flexor tendon sheath

– Management: standard acute; physician referral


Strains (cont.)Strains (cont.)• Mallet finger

– Rupture of extensor tendon from distal phalanx

– Mechanism: forceful flexion of PIP

– S&S

• Pain, swelling

• Lack of extension at DIP

– Management: standard acute; physician referral


Strains (cont.)Strains (cont.)• Boutonnière deformity

– Rupture of central slip of extensor tendon at the middle phalanx

– Mechanism: rapid forceful flexion of PIP– Result: hyperextension at MCP, flexion of PIP,

hyperextension of DIP– S&S

• No active extension• Deformity usually not present immediately, but

develops over 2-3 weeks– Management: standard acute; injury that limits PIP

extension to <30º: immediate physician referral



Strains (cont.)Strains (cont.)

• Tendinopathies


Strains (cont.)Strains (cont.)• Tendinopathies

– Trigger finger• Finger flexors contract but are unable to re-extend • Due to a nodule within tendon sheath or sheath too

constricted to allow free motion • S&S

Locking usually occurs when wakening from sleep Painful popping sensation when PIP joint is

passively returned to extension• Management: NSAIDs, resting finger; splinting when

necessary; possible cortisone injections into the sheath



Strains (cont.)Strains (cont.)– de Quervain's tenosynovitis

• Stenosing tenosynovitis of APL and EPB

• A forceful grasp, combined with repetitive use of thumb and ulnar deviation

• S&S

Pain over radial styloid process ↑ with thumb and wrist motion

Point tenderness over the tendons

Pain with RROM thumb abduction

+ Finkelstein’s test

• Management: standard acute; NSAIDS


Strains (cont.)Strains (cont.)– de Quervain's

tenosynovitis


Strains (cont.)Strains (cont.)• Intersection syndrome

– Tendinitis or friction tendinitis in 1st and 2nd dorsal compartments of wrist

– Overuse of radial extensors by excessive curling

– S&S

• Point tenderness on the dorsum of the forearm, 2-3 finger breadths proximal to the wrist joint

• Crepitus with AROM or PROM

– Management: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activities



• Dupuytren’s contracture

– Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformity

– S&S

• Fixed flexion deformity is visible

• Finger cannot be extended

– Management: surgical repair



• Gymnast’s wrist

– Stress fracture to distal radial epiphyseal plate

– Mechanism: compression (maximum dorsiflexion)

– S&S:

• Diffuse tenderness – dorsum of midcarpal area

• ↑ pain with extreme motion

– Management: splinting; NSAIDs; activity modification



• Ganglion cysts

– Benign tumor mass on dorsal aspect of wrist

– Associated with tissue sheath degeneration

– Treatment: symptomatic


Finger Tip InjuriesFinger Tip Injuries

• Subungual hematoma

– Blood under fingernail

– Due to direct trauma

– Need to rule out fracture

– Management

• Soak in ice water for 10-15 minutes

• If pain does not diminish, may need to be drained under supervision of a physician

• Refer to Application Strategy 16.1



Finger Tip Injuries (cont.)Finger Tip Injuries (cont.)

• Paronychia

– Infection along nail fold– Fold is red, swollen, and painful; can produce

purulent drainage – Management

• Warm water soaks and germicide.• More severe cases, physician referral


Nerve Entrapment SyndromesNerve Entrapment Syndromes

• Median nerve

– Anterior interosseous nerve syndrome

• Following set of strenuous or repetitive elbow motion exercises

• Affects motor but not sensation

• S&S

• Acute – sudden loss of use of flexor pollicis longus index finger profundus tendons

• Gradual – weakness becomes apparent during heavy activity

• + pinch grip test

• Management: splint extremity; avoid heavy activity


Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)– Carpal tunnel syndrome

• Median nerve, finger flexors, and flexor pollicis longus

• Due to direct trauma, repetitive overuse, or anatomic anomalies

• S&S

Awakening pain in middle of night; often relieved by “shaking out their hands”

Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger

+ Phalen’s maneuver; + Tinel’s sign

Weak thumb abduction

• Management: physician referral


Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)• Carpal tunnel


Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)• Ulnar nerve entrapment

– Ulnar tunnel syndrome

• Due to repetitive compressive trauma to the palmar aspect of the hand

• S&S

Numbness in the ulnar nerve distribution (especially little finger)

+ Froment’s sign

Slight weakness in grip strength

+ Tinel’s sign

• Management: splinting, NSAIDs; activity modification


Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)

• Ulnar nerve entrapment



– Cyclist's palsy

• Due to leaning on handlebar for extended period; leads to swelling in hypothenar area

• Symptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of ride

• Key: proper padding; varying hand position

– Bowler’s thumb

• Compression of ulnar digital sensory nerve

• S&S

Numbness, tingling, or pain – medial aspect of thumb

• Management: standard acute; NSAIDs; immobilization



• Radial nerve entrapment– Distal posterior interosseous nerve syndrome

• Due to compression associated with repetitive and forceful wrist dorsiflexion

• S&S• Deep, dull ache in wrist, reproduced with:

Forceful wrist extension Deep palpation of forearm with wrist in flexion

• Management: standard acute; activity modification



– Superficial radial nerve entrapment• Compressed at the wrist

Aggravated by repeated pronation and supination Tight wrist straps

• S&S Burning pain and sensory changes in dorsoradial

aspect of wrist, hand, dorsal thumb, and index finger + Tinel’s sign

• Management: standard acute; activity modification


FracturesFractures• Distal radius/ulna fracture

– Mechanism: axial loading; fall on outstretched hand

– Monteggia’s

• Distal ulna with associated dislocation of radial head

– Galeazzi's

• Distal radius with associated dislocation or subluxation of distal radioulnar joint

– Colles’

• Distal metaphysis of radius, with displacement of distal fragment dorsally


Fractures (cont.)Fractures (cont.)

• Distal radius/ulna fracture (cont.)

– Smith’s

• Distal radius, with displacement of distal fragment toward palmar aspect

– S&S: normal fracture

– Concerns:

• Circulatory impairment

• Nerve damage

– Management: immobilization in a vacuum splint; immediate physician referral


Fractures (cont.)Fractures (cont.)• Forearm fractures



• Scaphoid fracture

– S&S

• History of falling on an outstretched hand

• Point tenderness in anatomic snuff box

• Pain with inward pressure along long axis

• ↑ pain with wrist extension and radial deviation

– Management: standard acute; splint; physician referral

– Concern: aseptic necrosis




• Lunate fracture– Rare in sports– S&S: dorsal wrist pain, swelling, and weakness of wrist

associated with use– Concern: Kienböck’s disease – Management: standard acute; splint; physician referral

• Hamate fracture– Direct impact; when striking a stationary object with a

racquet or club in full swing



– S&S• Tenderness – hypothenar mass• Painful RROM abduction of the small finger • ↓ grip strength

– Management: standard acute; splint; physician referral



• Triquetrum fracture– Caused by impingement of ulnar styloid into dorsum of

triquetrum– S&S

• History of acute wrist dorsiflexion injury or direct trauma

• Pain – dorsal wrist over triquetrum– Management: standard acute; splint; physician referral

• Metacarpal fracture (typical)– Mechanism: axial compression



– S&S: • ↑ pain and palpable – palm, directly over involved

metacarpal• ↑ pain with percussion and compression

– Management: immobilize in position of function; ice without compression; immediate physician referral


Fractures (cont.)Fractures (cont.)• Bennett’s fracture

– Articular fracture – proximal end of first metacarpal

– Mechanism: axial compression

– Pull of APL tendon displaces shaft proximally; deep volar ligament holds small medial fragment in place → fracture-dislocation

– S&S

• Localized pain and swelling; ↑ pain with inward pressure long axis

– Management: standard acute; splint; immediate physician referral




• Rolando fracture

– Similar to Bennett’s fracture

– Intra-articular fracture – proximal end of first metacarpal; tends to be more comminuted

– S&S: same as Bennett’s, but ↑ deformity



Fractures (cont.)Fractures (cont.)• Boxer’s fracture

– Distal metaphysis or neck of fourth or fifth metacarpals

– Inherently unstable – S&S

• Sudden pain, inability to grip, rapid swelling, and deformity

• Point tenderness; crepitus • ↑ pain with axial compression and percussion





• Phalangeal fracture

– Mechanism: compression; hyperextension

– S&S:

• ↑ pain with circulative compression of phalanx

• ↑ pain with percussion and compression (long axis)




AssessmentAssessment

• History• Observation/inspection

– Expose entire arm• Palpation

– Pain, unable or unwilling to move wrist or hand; determine the possibility of a fracture or dislocation before moving the wrist or hand

– Proximal to distal• Physical examination tests


Range of Motion (ROM)Range of Motion (ROM)• Active range of motion (AROM)

– Forearm pronation/supination

– Wrist

• Flexion/extension

• Radial deviation/ulnar deviation

– Fingers and thumb

• Flexion/extension

• Abduction/adduction

• Opposition of thumb and little finger

• Passive range of motion (PROM)

– Normal end feel – tissue stretch


ROM (cont.)ROM (cont.)• Normal ranges

– Supination: 90°

– Pronation: 90°

– Wrist flexion: 80-90°

– Wrist extension: 70-90°

– Radial deviation: 15°

– Ulnar deviation: 30-45°


ROM (cont.)ROM (cont.)• Resisted range of motion (RROM)

– Supination– Pronation– Wrist flexion– Wrist extension– Ulnar deviation– Radial deviation– Finger flexion/extension– Finger abduction/adduction– Thumb flexion/extension– Thumb abduction/adduction– Opposition


ROM (cont.)ROM (cont.)


ROM (cont.)ROM (cont.)


Stress TestsStress Tests

• Wrist ligamentous instability tests

– Varus and valgus

• Finger ligamentous instability tests

– Varus and valgus

– Anterior/posterior glide


Special TestsSpecial Tests

• Finkelstein’s test for de Quervain’s tenosynovitis


Special Tests (cont.)Special Tests (cont.)

• Flexor digitorum superficialis (test for rupture of FDS)

• Flexor digitorum profundus

• Extensor tendon rupture


Special Tests (cont.) Special Tests (cont.)

• Carpal tunnel compression test



• Phalen’s wrist flexion test

• Tinel’s sign



• Pinch-grip test for anterior interosseous nerve entrapment



• Froment’s sign for ulnar nerve paralysis

• Allen test for circulation


Fracture AssessmentFracture Assessment


Neurologic TestsNeurologic Tests• Myotomes

– Scapular elevation - C4– Shoulder abduction - C5– Elbow flexion and/or wrist extension - C6– Elbow extension and/or wrist flexion - C7– Thumb extension and/or ulnar deviation - C8– Abduction and/or adduction of fingers - T1

• Reflexes– Biceps - C5-C6– Brachioradialis - C6– Triceps – C7


Neurologic Tests (cont.)Neurologic Tests (cont.)

• Dermatomes


RehabilitationRehabilitation

• Restoration of motion

– Concern: joint contractures and stiffness – begin AROM ASAP

– Use of opposite hand to supply load

• Restoration of proprioception and balance

– Closed-chain exercises

• Muscular strength, endurance, and power

– Open-chain exercises

– PNF-resisted exercises

• Cardiovascular fitness

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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16