Chapter 24: The Forearm, Wrist, Hand and Fingers

1. Chapter 24: The Forearm, Wrist, Hand and Fingers © 2011 McGraw-Hill Higher Education. All rights reserved.

2. Anatomy of the Forearm © 2011 McGraw-Hill Higher Education. All rights reserved.

3. Figure 24-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

4. Figure 24-2 © 2011 McGraw-Hill Higher Education. All rights reserved.

5. Figure 24-2 © 2011 McGraw-Hill Higher Education. All rights reserved.

6. Blood and Nerve Supply Most of the flexors are supplied by the median nerve Most of the extensor are controlled by the radial nerve Blood is supplied by the radial and ulnar arteries © 2011 McGraw-Hill Higher Education. All rights reserved.

7. Assessment of the Forearm History What was the cause? What were the symptoms at the time of injury, did they occur later, were they localized or diffuse? Was there swelling and discoloration? What treatment was given and how does it feel now? Any previous injury to your forearm? © 2011 McGraw-Hill Higher Education. All rights reserved.

8. Observation Visually inspect for deformities, swelling and skin defects Range of motion Pain w/ motion Palpation Palpated at distant sites and at point of injury Can reveal tenderness, edema, fracture, deformity, changes in skin temperature, a false joint, bone fragments or lack of bone continuity © 2011 McGraw-Hill Higher Education. All rights reserved.

9. Palpation: Bony and Soft Tissue Proximal head of radius Olecranon process Radial shaft Ulnar shaft Distal radius and ulna Radial styloid Ulnar head Ulnar styloid Distal radioulnar joint Radiocarpal joint Extensor retinaculum Flexor retinaculum Extensor carpi radialis longus and brevis Extensor carpi ulnaris Brachioradialis Extensor pollicis longus and brevis © 2011 McGraw-Hill Higher Education. All rights reserved.

10. Palpation (continued) Abductor pollicis longus Extensor indicus supinator Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Pronator teres © 2011 McGraw-Hill Higher Education. All rights reserved.

11. Recognition and Management of Injuries to the Forearm Contusion Etiology Ulnar side receives majority of blows due to arm blocks Can be acute or chronic Result of direct contact or blow Signs and Symptoms Pain, swelling and hematoma If repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematoma © 2011 McGraw-Hill Higher Education. All rights reserved.

12. Contusion (continued) Management Proper care in acute stage involves RICE and followed up w/ additional cryotherapy Protection is critical - full-length sponge rubber pad can be used to provide protective covering © 2011 McGraw-Hill Higher Education. All rights reserved.

13. Forearm Splints Etiology Forearm strain - most come from severe static contraction Signs and Symptoms Dull ache between extensors which cross posterior aspect of forearm Weakness and pain w/ contraction Point tenderness in interosseus membrane Management Treat symptomatically Patient should focus on strengthening forearm Treat w/ cryotherapy, wraps, or heat if condition persists Can develop compartment syndrome in forearm as well and should be treated like lower extremity © 2011 McGraw-Hill Higher Education. All rights reserved.

14. Forearm Fractures Etiology Common in youth due to falls and direct blows Ulna and radius generally fracture individually Fracture in upper third may result in abduction deformity due pull of pronator teres Fracture in lower portion will remain relatively neutral Older patients may experience greater soft tissue damage and greater chance of paralysis due to Volkmann's contracture Signs and Symptoms Audible pop or crack followed by moderate to severe pain, swelling, and disability Edema, ecchymosis w/ possible crepitus © 2011 McGraw-Hill Higher Education. All rights reserved.

15. Management Initially RICE followed by splinting until definitive care is available Long term casting followed by rehab plan Figure 24-3 © 2011 McGraw-Hill Higher Education. All rights reserved.

16. Colles’ Fracture Etiology Occurs in lower end of radius or ulna MOI is fall on outstretched hand, forcing radius and ulna into hyperextension Less common is the reverse Colles’ fracture (Smith fracture) Anterior displacement of distal fragment Intraarticular fracture is referred to as a Barton fracture Figure 24-4 © 2011 McGraw-Hill Higher Education. All rights reserved.

17. Signs and Symptoms Forward displacement of radius causing visible deformity (silver fork deformity) When no deformity is present, injury can be passed off as bad sprain Extensive bleeding and swelling Tendons may be torn/avulsed and there may be median nerve damage Management Cold compress, splint wrist and refer to physician X-ray and immobilization Severe sprains should be treated as fractures In children, injury may cause lower epiphyseal separation © 2011 McGraw-Hill Higher Education. All rights reserved.

18. Madelung Deformity Etiology Developmental deformity of the wrist Associated with changes in radius, ulna and carpal bone  results in palmar and ulnar wrist subluxations Common in females Carpals become wedged between radius and ulna following epiphyseal plate changes Signs and Symptoms Bowing of radius and ulna evident on X-ray Wrist pain and loss of forearm rotation Palmar subluxation with prominence of radius and ulnar styloid processes © 2011 McGraw-Hill Higher Education. All rights reserved.

19. Madelung Deformity (continued) Management Therapeutic modalities and NSAID’s for pain Wrist can be taped or braced to prevent wrist extension Typically corrected surgically in patients with chronic pain and disability Figure 24-5 © 2011 McGraw-Hill Higher Education. All rights reserved.

20. Anatomy of the Wrist, Hand and Fingers © 2011 McGraw-Hill Higher Education. All rights reserved.

21. Figure 24-6 © 2011 McGraw-Hill Higher Education. All rights reserved.

22. Figure 24-7 © 2011 McGraw-Hill Higher Education. All rights reserved.

23. Figure 24-8 © 2011 McGraw-Hill Higher Education. All rights reserved.

24. Figure 24-9 A & B © 2011 McGraw-Hill Higher Education. All rights reserved.

25. Figure 24-9 C © 2011 McGraw-Hill Higher Education. All rights reserved.

26. Figure 24-10 © 2011 McGraw-Hill Higher Education. All rights reserved.

27. Blood and Nerve Supply Three major nerves Ulnar, median and radial Ulnar and radial arteries supply the hand Two arterial arches (superficial and deep palmar arches) Figure 24-11 © 2011 McGraw-Hill Higher Education. All rights reserved.

28. Assessment of the Wrist, Hand and Fingers History Past history Mechanism of injury When does it hurt? Type of, quality of, duration of, pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments? © 2011 McGraw-Hill Higher Education. All rights reserved.

29. Observation Postural deviations Is the part held still, stiff or protected? Wrist or hand swollen or discolored? General attitude What movements can be performed fully and rhythmically? Thumb to finger touching Color of nail beds © 2011 McGraw-Hill Higher Education. All rights reserved.

30. Palpation: Bony Scaphoid Trapezoid Trapezium Lunate Capitate Triquetral Pisiform Hamate (hook) Metacarpals 1-5 Proximal, middle and distal phalanges of the fingers Proximal and distal phalanges of the thumb © 2011 McGraw-Hill Higher Education. All rights reserved.

31. Palpation: Soft Tissue Triangular fibrocartilage Ligaments of the carpals Carpometacarpal joints and ligaments Metacarpophalangeal joints and ligaments Proximal and distal interphalangeal joints and ligaments Flexor carpi radialis Flexor carpi ulnaris Lumbricale muscles Flexor digitorum superficialis and profundus Palmer interossi Flexor pollicis longus and brevis Abductor pollicis brevis Opponens pollicis Opponens digiti minimi © 2011 McGraw-Hill Higher Education. All rights reserved.

32. Palpation: Soft Tissue Extensor carpi radialis longus and brevis Extensor carpi ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Dorsal interossi Extensor pollicis brevis and longusAbductor pollicis longus © 2011 McGraw-Hill Higher Education. All rights reserved.

33. Special Tests Finklestein’s Test Test for de Quervain’s syndrome Athlete makes a fist w/ thumb tucked inside Wrist is ulnarly deviated Positive sign is pain indicating stenosising tenosynovitis Pain over carpal tunnel could indicate carpal tunnel syndrome Figure 24-12 © 2011 McGraw-Hill Higher Education. All rights reserved.

34. Special Tests Tinel’s Sign Produced by tapping over transverse carpal ligament Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome Figure 24-13 © 2011 McGraw-Hill Higher Education. All rights reserved.

35. Phalen’s Test Test for carpal tunnel syndrome Position is held for approximately one minute If test is positive, pain will be produced in region of carpal tunnel Figure 24-14 © 2011 McGraw-Hill Higher Education. All rights reserved.

36. Valgus/Varus and Glide Stress Tests Tests used to assess ligamentous integrity of joints in hands and fingers Valgus and varus tests are used to test collateral ligaments Anterior and posterior glides are used to assess the joint capsule Figure 24-15 © 2011 McGraw-Hill Higher Education. All rights reserved.

37. Lunotriquetral Ballottement Test Stabilize lunate while sliding the triquetral anteriorly and posteriorly Assessing laxity, pain and crepitus Positive test indicates instability that often results in dislocation of the lunate Figure 24-16 © 2011 McGraw-Hill Higher Education. All rights reserved.

38. Circulatory and Neurological Evaluation Hands should be felt for temperature Cold hands indicate decreased circulation Pinching fingernails can also help detect circulatory problems (capillary refill) Allen’s test can also be used Patient is instructed to clench fist 3-4 times, holding it on the final time Pressure applied to ulnar and radial arteries Patient then opens hand (palm should be blanched) One artery is released and should fill immediately (both should be checked) Hand’s neurological functioning should also be tested (sensation and motor functioning) © 2011 McGraw-Hill Higher Education. All rights reserved.

39. Functional Evaluation Range of motion in all movements of wrist and fingers should be assessed Active, resistive and passive motions should be assessed and compared bilaterally Wrist - flexion, extension, radial and ulnar deviation MCP joint - flexion and extension PIP and DIP joints - flexion and extension Fingers - abduction and adduction MCP, PIP and DIP of thumb - flexion and extension Thumb - abduction, adduction and opposition 5th finger - opposition © 2011 McGraw-Hill Higher Education. All rights reserved.

40. Recognition and Management of Injuries to the Wrist, Hand and Fingers Wrist Sprains Etiology Most common wrist injury Arises from any abnormal, forced movement Falling on hyperextended wrist, violent flexion or torsion Multiple incidents may disrupt blood supply Signs and Symptoms Pain, swelling and difficulty w/ movement © 2011 McGraw-Hill Higher Education. All rights reserved.

41. Management Refer to physician for X-ray if severe RICE, splint and analgesics Have patient begin strengthening soon after injury Tape for support can benefit healing and prevent further injury © 2011 McGraw-Hill Higher Education. All rights reserved.

42. Triangular Fibrocartilage Complex (TFCC) Injury Etiology Occurs through forced hyperextension, falling on outstretched hand Violent twist or torque of the wrist Often associated w/ sprain of UCL Signs and Symptoms Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clicking Swelling is possible, not much initially Patient may not report injury immediately © 2011 McGraw-Hill Higher Education. All rights reserved.

43. Management Referred to physician for treatment Treatment will require immobilization initially for 4 weeks Immobilization should be followed by period of strengthening and ROM activities Surgical intervention may be required if conservative treatments fail © 2011 McGraw-Hill Higher Education. All rights reserved.

44. Tenosynovitis Etiology Cause of repetitive wrist accelerations and decelerations Repetitive overuse of wrist tendons and sheaths Signs and Symptoms Pain w/ use or pain in passive stretching Tenderness and swelling over tendon Management Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and rest When swelling has subsided, ROM is promoted Ultrasound and phonophoresis can be used PRE can be instituted once swelling and pain subsided © 2011 McGraw-Hill Higher Education. All rights reserved.

45. Tendinitis Etiology Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris; repetitive pressure on palms (cycling) can cause irritation of flexor digitorum Primary cause is overuse of the wrist Signs and Symptoms Pain on active use or passive stretching Isometric resistance to involved tendon produces pain, weakness or both Management Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and rest When swelling has subsided, ROM is promoted w/ contrast bath PRE can be instituted once swelling and pain subsided (high rep, low resistance) © 2011 McGraw-Hill Higher Education. All rights reserved.

46. Nerve Compression, Entrapment, Palsy Etiology Median and ulnar nerve compression Result of direct trauma to nerves Signs and Symptoms Sharp or burning pain associated w/ skin sensitivity or paresthesia May result in benediction/ bishop’s deformity (damage to the ulnar nerve) or claw hand deformity (damage to both nerves) Palsy of radial nerve produces drop wrist deformity caused by paralysis of extensor muscles Palsy of median nerve can cause ape hand (thumb pulled back in line w/ other fingers) Management Chronic entrapment may cause irreversible damage Surgical decompression may be necessary © 2011 McGraw-Hill Higher Education. All rights reserved.

47. Bishop or Benediction Hand Drop Wrist Ape Hand Claw Hand Figures 24-19 to 22 © 2011 McGraw-Hill Higher Education. All rights reserved.

48. Carpal Tunnel Syndrome Etiology Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel Result of repeated wrist flexion or direct trauma to anterior aspect of wrist Signs and Symptoms Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb Management Conservative treatment - rest, immobilization, NSAID’s If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament © 2011 McGraw-Hill Higher Education. All rights reserved.

49. de Quervain’s Disease (Hoffman’s disease) Etiology Stenosing tenosynovitis in thumb (extensor pollicis brevis and abductor pollicis longus Constant wrist movement can be a source of irritation Signs and Symptoms Aching pain, which may radiate into hand or forearm Positive Finklestein’s test Point tenderness and weakness during thumb extension and abduction; painful catching and snapping © 2011 McGraw-Hill Higher Education. All rights reserved.

50. de Quervain’s Disease (Hoffman’s disease) Management Immobilization, rest, cryotherapy and NSAID’s Ultrasound and ice are also beneficial Joint mobilizations have been recommended to maintain ROM © 2011 McGraw-Hill Higher Education. All rights reserved.