1. HuP 191B – Advanced Assessment of Upper Extremity Injuries Wrist, Hand and Finger Evaluation and Pathologies

2. History

3. History • Location of pain • Mechanism of injury/etiology • Unusual sounds/sensations • Onset/duration and description of symptoms • Prior history/general health concerns

4. Location of Pain • Generally, local injury represented by local symptoms – sometimes difficult to identify specific structure/s • Must be aware of possible referred pain from cervical, shoulder and/or elbow pathologies

5. Mechanism of Injury • Direct trauma • Hyperextension/hyperflexion injuries of wrist and/or fingers • Insiduous onset increases likelihood of chronic conditions • Identify factors which increase or decrease symptoms

6. Unusual Sounds or Sensations • Numbness/tingling indicative of neurological pathology – must establish if local or referred • Fractures, dislocations and tendon ruptures often accompanied by “popping” sensation • Some overuse conditions (tendonitis) may present with “snapping” sensation

7. Onset/Duration and Description of Symptoms • Type of pain (ache, throb, etc.) • Intensity of pain (objectify) • Immediate vs. gradual onset of symptoms • Changes in symptoms (better, worse)

8. Prior History and General Health Concerns • Any previous injury, especially if neurological in nature, may have lasting effect on function, etc. • Hand is typically first part of body to be affected by: • Arthritis • Peripheral vascular disease (PVD) • Insufficient vascular structures to provide adequate circulation • Raynaud’s phenomenon • Reaction to cold temps – alternating bouts of pallor and cyanosis (vascular responses)

9. Inspection/Observation

10. Inspection/Observation • General inspection • Inspection of wrist and hand • Inspection of thumb and fingers

11. General Inspection • Hand posture • Relaxed normal hand is slightly flexed with subtle palmar arch • Gross deformity • Associated with fractures and/or dislocations • Palmar creases • May not be visible if severe swelling • Cuts, scars, lacerations • Superficial nature of neurovascular structures makes them susceptible to injury even with superficial wounds

12. Inspection of Wrist and Hand • Distal radioulnar continuity • Carpal and metacarpal continuity/contour • MP joint alignment • Depressed knuckle = Boxer’s fracture • Wrist and hand posturing • Neurovascular conditions may prompt abnormalities (drop wrist, Volkmann’s ischemic contracture)

13. Inspection of Wrist and Hand • Ganglion cyst • Defined as benign collection of thick fluid within a tendinous sheath or joint capsule • Most commonly found in wrist and hand • Painful with motions that impinge upon when symptomatic

14. Inspection of Thumb and Fingers • Skin and fingernails • Subungual hematoma • Paronychia – infection at nail periphery • Felon – infection/abscess at or distal to DIP • Finger alignment and deformity • If finger out of alignment, may be spiral fracture of phalanx/metacarpal • Secondary to fracture, dislocation or tendon injury

15. Skin and Fingernail Conditions

16. Palpation

17. Palpation • Wrist and finger flexors • Wrist and finger extensors • Bony anatomy • Non-carpal bones • Carpal bones • Ligamentous and intrinsic muscular structures

18. Wrist and Finger Flexors • Flexor carpi ulnaris tendon • Flexor carpi radialis tendon • Tendons of finger flexors • Superficialis vs. profundus • Palmaris longus tendon

19. Wrist and Finger Extensors • Extensor digitorum tendons • Anatomical snuffbox • Extensor pollicis longus – medial (ulnar) border • Abductor pollicis longus and extensor pollicis brevis – lateral (radial) border • Scaphoid - floor

20. Anatomic Snuffbox

21. Non-Carpal Bony Anatomy • Distal radius/radial styloid process • Lister’s tubercle (dorsal and distal radius) • Ulnar head/ulnar styloid process • Metacarpals • Phalanges

22. Carpal Bony Anatomy • Scaphoid • Floor of snuffbox, easier with ulnar deviation • Lunate • Typically aligned with 3rd metacarpal, distal to Lister’s tubercle and flex wrist • Triquetrum • Just distal to ulnar styloid process • Pisiform • Small, rounded prominence at proximal aspect of hypothenar eminence in palm

23. Carpal Bony Anatomy • Trapezium • Between scaphoid and 1st metacarpal • Trapezoid • Base of 2nd metacarpal • Capitate • Move toward thumb from hamate, base of 3rd metacarpal • Hamate • “hook” of hamate is large prominence at distal hypothenar eminence on palm

24. Ligamentous and Intrinsic Muscular Anatomy • Radial collateral ligaments • Radiocarpal joint, MP/IP/PIP/DIP joints • Ulnar collateral ligaments • Ulnocarpal joint, MP/IP/PIP/DIP joints • Carpal tunnel (transverse carpal ligament) • Thenar eminence • Hypothenar eminence

25. Range of Motion

26. Range of Motion • Active/passive/resistive • Wrist • Flexion/extension, ulnar/radial deviation • Thumb (carpometacarpal joint)\ • Flexion/extension, abduction/adduction, opposition • Fingers • MP joints: flexion/extension, abduction/adduction • IP/PIP/DIP joints: flexion/extension

27. Wrist Ranges of Motion • Flexion – normally 80-90 degrees, firm end feel • Extension – normally 75-85 degrees, firm end feel • Radial deviation – normally 20 degrees, hard end feel (scaphoid on radial styloid) • Ulnar deviation – normally 35 degrees, firm end feel

28. Wrist Ranges of Motion

29. Thumb Ranges of Motion • Flexion – normally 60-70 degrees, soft end feel • Extension – 0 degrees, firm end feel • Abduction – 70-80 degrees, firm end feel • Adduction – 0 degrees, soft end feel • Opposition – flexion/adduction/rotation, touch thumb to little finger, firm end feel

30. Thumb Motions

31. Finger Ranges of Motion • MP joints • Flexion – 85-105 degrees, hard end feel (proximal phalanges on distal metacarpal) • Extension – 20-30 degrees, firm end feel • Abduction/adduction – total of 20-25 degrees, firm end feel • IP/PIP/DIP joints • Flexion – IP: 80-90 degrees, PIP: 110-120 degrees, DIP: 80-90 degrees, firm end feels except PIP is hard end feel (middle phalanges on proximal phalanges) • Extension – 0 degrees, firm end feels

32. Ligamentous/Capsular Testing

33. Ligamentous/Capsular Testing • Carpal glide tests • Attempts to elicit abnormal glide of carpal bones • Varus/valgus stress tests (do at multiple joint positions) • Wrist • UCL limits radial deviation and flexion/extension • RCL limits ulnar deviation and flexion/extension • Can also assess with glide between radius/ulna and proximal row of carpal bones • MP/IP/PIP/DIP joints • Thumb UCL is common injury site

34. Neurovascular Evaluation

35. Neurological Evaluation • Peripheral nerve distributions • Median, ulnar and radial nerve sensory and motor functions • Nerve root level distributions • Dermatomes and myotomes

36. Vascular Evaluation • Radial artery • Capillary refill • Skin temperature and color • Allen test?

37. Pathologies

38. Pathologies • Wrist injuries • Hand injuries • Finger injuries • Thumb injuries

39. Wrist Injuries • Wrist sprains • Triangular fibrocartilage complex (TFCC) injury • Carpal tunnel syndrome • Wrist fractures • Scaphoid fractures • Lunate/perilunate dislocations • Neurological injuries

40. Wrist Sprains • Most common etiology is hyperflexion or hyperextension (fall on outstretched arm) • Must rule out carpal fracture, neurological injury and TFCC injury before assessing as wrist sprain • Most common presentation involves limited ROM to all wrist movements due to pain, usually also presents with weakness – assess with radiocarpal and carpal glide tests - treated conservatively in nearly all cases

41. TFCC Injury • Sprain to ligamentous structures on dorsal and medial aspect of wrist – injury occurs acutely, but often not reported until later • Most common etiology is hyperextension with ulnar deviation • Presents with tenderness to dorsal medial wrist distal to ulna, limited ROM (especially radial and ulnar deviation), possibility of avulsion fracture • Must be referred to MD – often surgically repaired

42. TFCC Injury

43. Carpal Tunnel Syndrome • Compression of median nerve in carpal tunnel – must be able to differentiate from nerve root injury • Typically secondary to overuse conditions (tendonitis, etc.) but may be due to acute trauma • Most common presentation is neurological deficit/symptoms to median nerve distribution (sensory and motor)

44. Carpal Tunnel Syndrome • Evaluate with Tinel’s sign to carpal tunnel – positive if symptoms reproduced • Evaluate with Phalen’s test – wrist flexion for ~1 minute – positive if symptoms reproduced • Almost always treated conservatively initially with rest, splinting (night), NSAIDs • Failure of conservative measures can lead to surgery – resection of transverse carpal ligament

45. Phalen’s Test

46. Wrist Fractures • Typically occur from fall on outstretched arm – must consider neurovascular implications • Colles’ fracture • Fracture of distal radius proximal to radiocarpal joint with dorsal displacement of fracture • Smith’s fracture (reverse Colles’) • Fracture of distal radius proximal to radiocarpal joint with palmar/volar displacement of fracture

47. Colles’ Fracture

48. Smith’s Fracture

49. Scaphoid Fracture • Easily the most commonly fractured carpal bone • Most common etiology is hyperextension • Blood supply comes from distal aspect and fracture in mid-substance often compromises proximal blood supply – high incidence of non-union/malunion fractures

50. Scaphoid Fracture