Wrist & Hand Lecture

7/27/2019 Wrist & Hand Lecture

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Wrist Anatomy

Bones

Quiz - Whatbones comprisethe wrist?

Joints

Quiz - What jointscomprise the

wrist?


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Carpal Bones and

ArticulationsProximal Row Where can you

palpate these? Scaphoid

Lunate

Triquetrum

Pisiform

Radiocarpal joint Ulnocarpal joint

Intercarpal joints

Distal Row Where can you

palpate these? Trapezium

Trapezoid

Capitate

Hamate

Intercarpal joints Carpometacarpal

joints (related tohand)


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Articulations and ROM

Distal Radioulnar joint

Supination and Pronation 80-90o

Ulna moves posteriorly and laterally with pronationRadiocarpal joint (and Ulnocarpal joint)

Flexion (80-90o) and Extension (75-85o)

Radial (20o) and Ulnar (35o) Deviation

Intercarpal joints

Gliding


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Soft tissue of Wrist

Ligaments

Covered by a fibrous

capsule

Radial and ulnarcollateral

limit ulnar and radial

deviation; collectively

limits flexion and

extension

Intercarpal and

Carpometacarpal


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Ligaments Dorsal limits flexion

Dorsal Radiocarpal

Palmar - limitextension Transverse carpal

ligament

Palmar radiocarpal

Multiple divisions

Palmar ulnocarpalligament

Multiple divisions


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Cartilage Triangular Fibrocartilage

Complex TFCC

Meniscus betweenulna and triquetrum

Ulnar collateral ligamentand palmar ulnocarpalligaments haveattachments

Compressed withPronation andExtension

Compressed with Ulnardeviation


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Muscle Tissue of Wrist

Extensor muscles

Extensor

Retinaculum Whats its function?

Muscles innervated

by radial nerve

There are 8 Name them

Flexor Muscles Flexor retinaculum

(aka transverse

carpal ligament)

Two compartments Superficial 4

Deep 3

Name them Innervated by

median and ulnarnerve


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FLEXORSEXTENSORS


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Wrist and Hand Anatomy

Nerves/Vessels Radial & ulnar artery and veins

Radial, ulnar, & median nerves

Carpal Tunnel -

Flexor Tendons - 9 Median Nerve


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Wrist Injuries

Strains Onset usually acute FOOSH or Overexertion

S/S: Active ROM limited

Wrist Ganglion Herniation of the joint capsule or synovial sheath

of a tendon.

Tx: Bible Therapy


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Wrist Injuries

deQuervains Disease - thumb/wrist

stenosing tenosynovitis of the extensor

pollicis

brevis and abductor pollicis longus.

S/S: crepitation, tenderness, strength loss.

Special Test: = Finkelsteins test

Tx: RICE, NSAIDs


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Wrist Injuries

Sprains

Onset is usually acute FOOSH or overexertion

Often diagnosed when other injuries are ruled out Both active and passive ROM are effected

S/S: Laxity, pain, swelling, limited ROM

Pain is usually with overstretching

Special Tests: Varus/Valgus, Carpal Glide PRICE, Rehabilitation, Taping for prevention


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Wrist Injuries

Triangular Fibrocartilage Injuries - TFCC

Onset is usually acute

MOI: Forced hyperextension of wrist with loading S/S: Pain with pronation/extension and/or ulnar

deviation; Pain with loading; Point tenderness;

Swelling; Altered joint mechanics

Special Test: Valgus test elicits pain but no laxityand Varus test compresses and causes pain

Immobilization and Surgery are often necessary


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Neural Injuries

Carpal Tunnel Syndrome Compression of median nerve

Fibrosis of the synovium of flexor tendons secondary totenosynovitis

MOI: Insidious onset with repetitive wrist movement (andfinger movement); Acute onset with trauma; Progressivedegeneration

S/S: numbness palmar thumb, index,

middle fingers, dull ache, weak finger

flexion (grip). May worsen with sleep. Poor posture may predispose.

Special Tests: Tinels sign

and Phalens

Tx: Conservative (PRICE, NSAIDs) and Surgical


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Neural InjuriesBikers Palsy Ulnar nerve compression

Ulnar nerve passes through tunnel of Guyon between

pisiform and hamate.

MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar

deviation

Tx: Padding (Gloves), Ice, NSAIDs

Drop Wrist Syndrome Radial nerve compression at elbow

Inability to extend wrist and fingers


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Wrist Injuries

Wrist Fractures

Distal Radius/Ulna and Forearm Fractures

Onset is acute MOI: Hyperextension or hyperflexion combined

with rotatory motion FOOSH

S/S: Deformity felt and observed; Crepitus

Evaluated Neurovascular status Tx: Splint, Ice, Referral


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Wrist InjuriesWrist Fractures

Distal Radius/Ulna

Colles Fracture

MOI: hyperextension-fall on outstretched

S/S: silver fork deformity - radius & ulna posteriorly Smiths Fracture (Reverse Colles)

MOI: hyperflexed

S/S: garden spade deformity - radius

& ulna anteriorly


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Wrist Injuries

Wrist Fractures Scaphoid - most common carpal

MOI: fall on outstretched hand

S/S: wrist aches, pain in anatomical

snuff box,

painful handshake or withoverpressure

Tx: Splint, Referral, Ice

Plain X-rays may not be enough

Immobilization (long and/or short)

12 weeks

Risk: aseptic necrosis and non-

union fractures

Preisers Disease

Surgery may be necessary


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Wrist Injuries

Wrist Dislocations Radius or Ulna

Lunate is very common

MOI: force hyperextension

Dorsal displacement = perilunate dislocation Palmar displacement (total rupture) = lunate

dislocation

S/S: Deformity, 3rd Knuckle is lower(Murphyssign), Paresthesia of middle finger, weak fingerflexion

Risk: Untreated or repeated trauma Kienbocks Disease

Decreased grip, pain with ulnar deviation,weak extension, pain with passive 3rdfinger extension

Immobilization 6-8 weeks; Surgery may be

necessary


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Wrist Injury Prevention

Good technique!

Butthese help


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Lumbricals

123

4PalmarInterossei

DorsalInterossei

Flexortendonarrangement


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Extensor Hood, Long extensor

tendon, and lateral bands

Finger flexortendons

Unique fingerLook at pulley

system


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Observation

Relaxed position of hand Fingers slightly flexed

Relative shortness of finger flexors

Skin and Nail health Discoloration, texture, hair patterns

Finger alignment Tips of fingers should align with finger flexion

Hand abnormalities Finger and metacarpal positioning

Muscle atrophy

Range of motion


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Range of Motion

Carpometacarpal Flexion (70-80o)/Extension

Abduction (70-80o)/Adduction

OppositionMetacarpophalangeal Flexion (85-105o)/Extension (20-35o)

Abduction/Adduction (20-25o)

Interphangeal joints Thumb flexion (80-90o)

PIP flexion (110-120o)

DIP flexion (80-90o)


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Palpation

Metacarpals and joints

Collateral ligaments of MCPs

Phalanges and joints Collateral ligaments of PIPs and DIPs

Thenar compartment

muscles

Thenar webspace

musclesCentral compartment

Palmar fascia and muscles

Hypothenar compartment

muscles


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Pathology

Tendon pathology

Trigger Finger/Thumb

Mallet Finger

Boutonniere Deformity Jersey Finger

Dupuytrens Contracture

Swan Neck Deformity

Joint pathology Sprains

Bony pathology

Fractures

Dislocations


Swan Neck Deformity


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Tendon pathology

Trigger Finger or Thumb Etiology

Repeated motion of fingers may cause irritation, producingtenosynovitis

Inflammation of tendon sheath (flexortendons of wrist, fingers andthumb, abductor pollicis) Thickening forming a nodule that does not slide easily

Signs and Symptoms Resistance to re-extension, produces snapping that is palpable,

audible and painful

Palpation produces pain and lump can be felt w/in tendon sheath

Management Immobilization, rest, cryotherapy and NSAIDs

Ultrasound and ice are also beneficial

Injection


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Tendon pathology

Mallet Finger (baseball or basketball finger) Etiology

Caused by a blow that contacts tip of finger

avulsing extensor tendon from insertion Avulses extensor digitorum at distal phalanx

Signs and Symptoms Unable to extend distal end of finger (carrying at 30

degree angle)

Point tenderness at sight of injury X-ray shows avulsed bone on dorsal proximal distal

phalanx

Management RICE and splinting in hyperextension for 6-8

weeks


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Tendon pathology

Boutonniere Deformity Etiology

Rupture ofextensor tendon dorsalto the middle

phalanx bone passes through central slip Forces DIP joint into extension and PIP into

flexion

Signs and Symptoms Severe pain, obvious deformity and inability to

extend DIP joint Swelling, point tenderness

Management Cold application, followed by splinting in PIP

extension and DIP flexion

Splinting must be continued for 5-8 weeks


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Tendon pathology

Jersey Finger Etiology

Rupture offlexor digitorum profundus tendon

from insertion on distal phalanx Often occurs w/ ring finger when athlete tries to

grab a jersey

Signs and Symptoms DIP can not be flexed, finger remains extended

Pain and point tenderness over distal phalanx Management

Must be surgically repaired

Rehab requires 12 weeks and there is often poorgliding of tendon, w/ possibility of re-rupture


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Tendon pathology


Etiology

Nodules develop in palmer aponeurosis,limiting finger extension - ultimately causing

flexion deformity

Signs and Symptoms

Often develops in 4th or 5th finger (flexiondeformity)

Management

Tissue nodules must be removed as they can

ultimately interfere w/ normal hand function



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Tendon pathology

Swan Neck Deformity Etiology Distal tear of volar plate or finger trauma may cause

Swan Neck deformity

Flexed MCP, extended PIP, and flexed DIP

Signs and Symptoms

Pain, swelling w/ varying degrees of hyperextension

Tenderness over volar plate of PIP

Indication of volar plate tear = passivehyperextension

Management

RICE and analgesics

Splint in PIP 20-30 degrees of flexion/DIP extension

for 3 weeks; followed by buddy taping


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Joint pathology

Sprains Phalanges Etiology

Phalanges are prone to sprains caused bydirect blows or twisting

Signs and Symptoms Recognition primarily occurs through history

Sprain symptoms - pain, severe swelling and

hemorrhaging


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Joint pathology

Gamekeepers Thumb Etiology

Sprain of UCL of MCP joint of the thumb

Mechanism is forceful abduction of proximal phalanx occasionally

combined w/ hyperextension

Signs and Symptoms Pain over UCL in addition to weak and painful pinch

Management Immediate follow-up must occur

If instability exists, athlete should be referred to orthopedist If stable, X-ray should be performed to rule out fracture

Thumb splint should be applied for protection for 3 weeks or untilpain free

Splint should extend from wrist to end of thumb in neutral position

Thumb spica should be used following splinting for support


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Joint pathology

Sprains of Interphalangeal Joints of Fingers

Etiology Can include collateral ligament, volar plate, extensor slip tears

Occurs w/ axial loading or valgus/varus stresses

Signs and Symptoms Pain, swelling, point tenderness, instability

Valgus and varus tests may be possible

Management RICE, X-ray examination and possible splinting

Splint at 30-40 degrees of flexion for 10 days

If sprain is to the DIP, splinting for a few days in full extension mayassist healing process

Taping can be used for support


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Joint pathology

PIP Dorsal Dislocation Etiology

Hyperextension thatdisrupts volar plate atmiddle phalanx

Signs and Symptoms Pain and swelling over PIP

Obvious deformity,disability and possibleavulsion

Management Treated w/ RICE, splinting

and analgesics followed byreduction

After reduction, finger issplinted at 20-30 degreesof flexion for 3 weeks --followed by buddy taping

PIP Palmar Dislocation Etiology

Caused by twist while it issemiflexed

Signs and Symptoms Pain and swelling over PIP;

point tenderness overdorsal side

Finger displays angular orrotational deformity

Management Treat w/ RICE, splinting

and analgesics followed byreduction

Splint in full extension for4-5 weeks after which it isprotected for 6-8 weeksduring activity


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Open Dislocation


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Joint pathology

MCP Dislocation

Etiology

Caused by twisting or shearing force Signs and Symptoms

Pain, swelling and stiffness at MCP joint

Proximal phalanx is angulated at 60-90

degrees Management

RICE, following reduction splinting in slightflexion (3 weeks)

Buddy taping following splinting


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Bony Pathology

Metacarpal Fracture

Etiology

Direct axial force or compressive force

Fractures of the 5th metacarpal = BoxersFracture

Signs and Symptoms

Pain and swelling; possible angular or rotational

deformity Management

RICE, analgesics are given followed by X-rayexaminations

Deformity is reduced, followed by splinting - 4

weeks of splinting after which therapy starts


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Bony pathology

Bennetts Fracture Etiology

Occurs at carpometacarpal joint of the thumb as

a result of an axial and abduction force to the thumb Signs and Symptoms

CMC may appeared to be deformed - X-ray willindicate fracture

Athlete will complain of pain and swelling over the

base of the thumb Management

Structurally unstable and must be referred to anorthopedic surgeon

Surgery and immobilization season ending


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Bony pathology

Distal Phalangeal Fracture

Etiology

Crushing force Signs and Symptoms

Complaint of pain and swelling of distal phalanx

Subungual hematoma is often seen in this

condition Management

RICE and analgesics are given

Protective splint is applied as a means for pain

relief


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Bony pathology

Middle Phalangeal Fracture

Etiology

Occurs from direct trauma or twist Signs and Symptoms

Pain and swelling w/ tenderness over middle

phalanx

Possible deformity; X-ray will show bone

displacement

Management

RICE and analgesics

No deformity - buddy tape w/ splint for activity

Deformit - immobilization for 3-4 weeks and a


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Bony pathology

Proximal Phalangeal Fracture

Etiology

May be spiral or angular Signs and Symptoms

Complaint of pain, swelling, deformity

Inspection reveals varying degrees of deformity

Management RICE and analgesics are given as needed

Fracture stability is maintained byimmobilization of the wrist in slight

extension, MCP in 70 degrees of flexion andbudd ta in


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Lacerations

Superficial location of tendons and

nerves predisposes athletes to damage

form shallow lacerations.Any laceration to the fascia below the

cutaneous layer should receive a

referral R/O trauma to tendons and nerves

Prevent infection

Suture to ensure minimal scarring


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Finger Nail Pathology

Subungual Hematoma

MOI: finger caught between two surfaces

Presents with bleeding under nail bed

Draining Drill or Cauterize

Paronychia

Infection around fingernail beds

S/S: Redness, pain, drainage

Warm soaks (Betadine), Antibiotic, Referral

Changes in normal appearance - indicative of a number of

different diseases Scaling or ridging = psoriasis

Ridging and poor development = hyperthyroidism

Clubbing and cyanosis = congenital heart disorders or chronicrespiratory disease

Spooning or depression = chronic alcoholism or vitamin deficiency


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Prevention of Hand

InjuriesProtection

Gloves, Grips, Braces

Proper Technique Sport and Ergonomics

Physical Conditioning

Reps and Sets for muscles of Hand Theraputty, Wrist curls/extensions, Fist pumps


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Problem Solving

Putting it together withCase studies


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History What is the cause of pain? Mechanism of injury?

Previous history?

Location, duration and intensity of pain?

Creptitus, numbness, distortion in temperature?

Sounds or sensations?

Technique changes?

Weakness or fatigue?

What provides relief?


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Observation

Functional Evaluation Range of motion in all movements of wrist should

be assessed

Active, resistive and passive motions should beassessed and compared bilaterally

Wrist - flexion, extension, radial and ulnar deviation

Wrist attitude How do the carpals and metacarpals align with the distal

radius and ulna?

Is there symmetry? How are those tendons looking?

Is there a palmaris longus? - 10% of population it isabsent

Become a palm reader?


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Palpation

Bony and Soft Tissue PalpationAre they where they should be?

Do they feel like they should feel?

Circulatory and Neurological Evaluation Hands should be felt for temperature

Cold hands indicate decreased circulation

Take pulse radial artery

Pinching fingernails can also help detectcirculatory problems (capillary refill)

Hands neurological functioning should also betested (sensation and motor functioning)


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Is it nerve?

What test is this?

What other test is

common for nerve

injury?

How else can you

detect a neural injury?


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Is it the ligaments or

joints?

Which tests are these?

What are some distinguishing

characteristics of a ligament or joint

injury?


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Is it muscle or tendon?

What test assesses

these structures?

What are some distinguishing

characteristics of a muscleinjury?

How do you assess the function

of a muscle?


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Is it bone?

What is are distinguishing signs of a potential fractures?


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Case study #1

A 28 year old woman complains of painin the right hand over the last 3 months.

She reports numerous FOOSHincidents and currently works as acashier at a grocery store. The painawakens her at night and is relieved

only by vigorous rubbing of her handand motion of the fingers and wrist.There is some tingling in the index andmiddle fingers. What is your

assessment plan?


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Case study #2

A 18 year old boy reports with wrist pain andswelling on the dorsum of his wrist and hand.He notes the pain is more near the base of

the thumb. He is an active weightlifter. Hesays he tripped and experienced a FOOSHwhile playing recreational football. He statesthat after the injury the wrist hurt, he rested 2

days and iced, the pain decreased, but thenwith weightlifting the swelling has developedthe last 5 days. Now it is very swollen andpainful. What is your assessment plan?


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Case study #3

A 22 year old golfer comes to you with pain

along his right medial wrist. He reports that

while on spring break he went skiing and had

a FOOSH. The wrist was achy but didnt

bother after a few hours especially since he

put snow on it for 20 minutes. Now that he

has returned to school and golf practice he ishaving trouble controlling his drives and long

iron shots because of pain in his wrist at the

top of the swing. What is your assessment

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Wrist & Hand Lecture