The Forearm, Wrist, Hand, and FingersChapter 24

Forearm AnatomyRadius and Ulna: ElbowJoints: radioulnar joint (superior, middle, and distal)Bone: proximal radial head, olecranon process, radial shaft, ulnar shaft, distal radius, radial styloid process, ulnar head, ulnar styloid

Musculature: flexors& pronators (lie anteriorly. ulnar side), extensors & supinators (lie posteriorly, medial side)Nerve/Blood Supply: median and radial nerve and brachial, radial, and ulnar artery

Forearm AssessmentHistoryObservationVisually inspect, including wrsit and elbowIf no deformity present, observe while they supinate and pronatePalpationSpecial Tests

Recognition and Management of Forearm InjuriesContusionEtiology:direct blowWhy more common to ulna?Signs and SymptomsManagementForearm SplintsEtiology: repeated severe static contractionSigns and Symptoms:dull ache between extensors, interosseous membraneManagement: early season vs late in season?Note: Acute / Chronic exertional compartment syndrome: deep compartment most common and associated with avulsions, distal radius fracture, or crushing injuries; management same as in lower leg

Colles fractureEtiology: FOA, forces radius and ulna back and up = hyperextensionSigns and Symptoms (posterior displacement)ManagementReverse Colles = fall on back of handForearm FracturesEtiologySigns and Symptoms: more common for radius and ulna to fracture simultaneouslyManagement

Wrist, Hand, and Finger AnatomyBones: carpals and metacarpalsJoints: radiocarpal, carpal, metacarpal, and phalangeal jointsLigaments: many at each joint in the handTFCC (triangular fibrocartilage complex); b/t head of ulna and triquetrial boneMusculature: many intrinsic and extrinsic musclesBlood and Nerve Supply: ulnar, median, radial nerve and radial and ulnar superficial and deep palmar arch arteries.

Assessment of Wrist, Hand, and Finger Injuries

HistoryObservationPalpationSpecial Tests: Finklesteins test, Tinels Sign, Phalens test, valgus and varus stress test, Circulatory and Neurological EvaluationAllen testFunctional Evaluation

Special TestsFinklesteins TestDe Quervains (tenosynovitis)Thumb tucked inside fist with ulnar deviationTinels SignTap over transverse carpal ligamentPain numbness and tingling indicates median nerve disruption and presence of carpal tunnelPhalens TestCarpal tunnelBilateral wrist flexion and press them together; pain is positive signValgus/varus at wrist, MCP, and IP jointsCirculatory / neurological evaluationsAllen's test: test function of radial and ulnar arteriesAthlete makes fist 4-5 times; while holding final fist, evaluator pinches off both arteries; hand should be blanchedRelease arties individually

Recognition and Management of Wrist, Hand, and Finger InjuriesWrist SprainEtiologySigns and SymptomsManagementTriangular Fibrocartilage Complex InjuryEtiology:forced hyperextension or compression of radioulnar joint and proximal row of carpalsSigns and SymptomsManagement

TenosynovitisEtiology: repeated wrist acceleration and decelerationSigns and Symptoms: pain w/ passive stretchingManagement: may need splinting and strengtheningTendinitisEtiology: repetitive pulling motions and pressure on palm of handSigns and Symptoms:pain with AROM and passive stretchingManagementNerve Compression, Entrapment, PalsyEtiology: median (carpal tunnel) and ulnar (pisiform and hamate)Signs and Symptoms:deformities(bishops, claw and drop wrist)Management: if chronic, may require surgical decompression

Carpal Tunnel SyndromeTunnel = pinkBones = whiteLigament = blue

Carpal tunnel syndromeEtiology: repeated flexionSigns and Symptoms: sensory and motor impairmentManagement

Recognition and Management of Wrist, Hand, and Finger InjuriesDislocation of the Lunate BoneEtiology:forced hyperextension of wristSigns and Symptoms:difficulty with wrist and finger flexion; may have impaired nervesManagement: referral for reductionHamate FractureEtiology: contact while holding something(racket)Signs and SymptomsManagementWrist Ganglion(synovial cyst)Etiology:herniation of joint capsule or tendonSigns and SymptomsManagement

De Quervains DiseaseEtiology: tenosynovitis of thumbSigns and SymptomsManagement

Scaphoid FractureEtiology: compression of scaphoid b/t radius and ulnaConcerns: portion of scaphoid has decreased vascular supply; improper healing can occur and result in aseptic necrosis of the scaphoid boneSigns and SymptomsAnatomical snuffbox pain Management

Finger anatomyBonesLigamentsPIP and DIP have the same designCollateral ligaments, palmar fibrocartilage, and loose posterior capsule or synovial membrane (protected by extensor expansion)

Finger anatomy

MusculaturePIP: Flex. Digitorium SuperficialisDIP: Flex. Digitorium ProfundusPIP & DIP: Exten. Digitorium Longus (becomes extensor expansion after MCP)Intrinsics:Dorsal and palmar interosseei: Lumbricals:volar surface; MCP flex., IP exten.Thenar (4 that act on thumb) & hypothenar (4 that act on 5th)

Recognition and Management of Wrist, Hand, and Finger InjuriesContusion to hand and fingersEtiologySigns and Symptoms: fingernail?ManagementBowlers ThumbEtiology: fibrosis of the ulnar digital nerve form pressure Signs and Symptoms:pain, numbness, tinglingManagement: pad area, decrease activity; surgery PRNJersey fingerEtiology:FDP rupture, grabbing jerseySigns and Symptoms:DIP cannot flexManagement:SURGERY

Trigger finger or thumbEtiology: stenosing tendon by repeated movementsSigns and Symptoms: resistance to re-extension after thumb and finger flexedManagement:possible injections; splintingDupuytrens ContractureEtiology: idiopathic development of nodules in palmer aponeurosis Signs and Symptoms:flexion deformity; cannot extendManagement: surgical removal

Boutonniere deformityEtiology:rupture of extensor tendon dorsal to middle phalanx; trauma to tip of finger causes DIP extension and PIP flexionSigns and Symptoms: cannot extendManagement:splint PIP in extension 5-8wks.

Swan neck deformityAKA PseudoboutonniereEtiology:severe hyperextension; injury to volar plateSigns and Symptoms: hyperextension of PIPManagement: splint 20-30 degrees flexion 3 wks

Mallet FingerEtiology: strike to tip of finger, jamming and avulsing extensor tendon Signs and Symptoms: unable to extend, may palpate avulsed boneManagement:extension splint 6-8 wks

Gamekeepers ThumbEtiology:UCL of thumb; forced abductions, an hyperextensionSigns and Symptoms:inability to pinch; pain with stressManagement:splint 3 weeks; protect with activity

Recognition and Management of Wrist, Hand, and Finger InjuriesSprains, Dislocations, and FracturesEtiologySigns and SymptomsManagementSprains PIP and DIP jointEtiologySigns and SymptomsManagement

PIP Doral DislocationEtiology:twist while semiflexedSigns and SymptomsManagement:splint in extPIP Dorsal dislocationEtiology:hyperext.Signs and symptoms:deformity; inability to moveManagement:reduce and splint 20-30 degrees flex

Recognition and Management of Wrist, Hand, and Finger InjuriesMCP dislocationEtiology:twist an shear forceSigns and Symptoms:prox. Phalanx dorsal 60-90 degreesManagement: reduce; splint; early ROMMetacarpal fractureEtiology:compressive axial forceSigns and Symptoms:appear angular or rotatedManagement: reduce and splintBennetts FractureEtiology:thumb CMC; axial and ABD force to thumbSigns and Symptoms:base of thumb painfulManagement:refer to surgeon due to unstable nature

Distal/Middle/Proximal phalangeal fractureEtiology:crushing force; direct trauma or twistSigns and Symptoms: subungual hematoma subungual hematomaManagement:drain and splint / buddy tape; control painFingernail deformityOccur for variety of reasons:Scaling or ridging psoriasisRidging or poor development hyperthyroidismClubbing and cyanosis-chronic respiratory disease or heart disorderSpooning or depression- chronic alcoholism and vitamin deficiencies

Rehabilitation Principles for the Forearm, Wrist, Hand, and FingersGeneral Body ConditioningJoint Mobilization:traction and mobilization help restore ROMFlexibility: full ROM is measure of good rehabStrength:equalNeuromuscular Control:great dexterity requiredReturn to Activity: Goals: full dexterity, full ROM, full strength