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Wrist and Hand

Wrist and Hand

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Wrist and Hand

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  1. Wrist and Hand

  2. Wrist and Hand Bones • Wrist (Carpals) • Scaphoid (Navicular) • Lunate • Triquetral • Pisiform • Trapezium • Trapezoid • Capitate • Hamate • Hand • Phalanges • Thumb • Proximal and distal • Fingers • DIP • PIP • MIP

  3. Wrist Joints/Ligaments • Radial Carpal Joint • Radius and carpal bones • Triangular Fibrocartilage • Medial side • Ulnar Collateral Ligament • Medial side • Radial Collateral Ligament • Lateral side • Intercarpal joints • Between the wrist bones • Carpal Metacarpal Joint of Thumb

  4. Finger Ligaments • Collateral Ligaments • At each joint of the finger

  5. Muscles Palmar muscles Palmar muscles • Lumbricales • Origin: tendon of flexor digitorumprofundus • Insertion: Tendons of the extensor digitorumcommunis • Action • flexes the metacarpophalangeal joints • Extends the interphanlangeal joints • Dorsal Interossei (4) • Origin: Adjacent sides of all the metacarpals • Insertion:Proximal phalanx of 2nd, 3rd and 4th fingers • Action • Abducts the fingers from the middle finger • Palmar Interossei (3) • Origin: medial side of the 2nd metacarpal and lateral side of the 4th and 5th metacarpals • Insertion: Proximal phalanx of the same finger • Action • Adducts the fingers toward the middle finger

  6. Muscles Thenar muscles Thenar Muscles • Abductor PollicisBrevis • Origin: scaphoid and trapezium • Insertion: proximal phalanx of the thumb • Action • Abducts the thumb • OpponensPollicis • Origin: trapezium • Insertion: latearl border of the metacarpal of the thumb • Action • Pulls the thumb in front of the palm to meet the little finger • Flexor PollicisBrevis • Origin: trapezium and 1st metacarpal • Insertion: base of the proximal phalanx of the thumb • Action • Flexes and adducts the thumb • Adductor Pollicis • Origin: capitate and 2-3rd metacarpals • Insertion: proximal phalanx of thumb • Action • Adducts the thumb

  7. Muscles Hypothenar Muscles Hypothenar Muscles • Palmaris Brevis • Origin: Flexor retinaculum • Insertion: Skin on the ulnar border of the hand • Action • Pulls the skin toward the middle of the palm • Abductor digitiminimi • Origin: pisiform • Insertion: base of little finger • Action • Abducts the little finger • Flexor digitiminimibrevis • Origin: hamate • Insertion: base of little finger • Action • Flexes little finger • Opponensdigitiminimi • Origin: hamate • Insertion: metacarpal of little finger • Action • Brings the little finger out to meet the thumb

  8. 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)

  9. Special Tests

  10. Finklestin’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

  11. 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

  12. 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

  13. 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

  14. 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) • Hand’s neurological functioning should also be tested (sensation and motor functioning) • 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)

  15. Functional Evaluation Functional EvaluationRangeof 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

  16. Wrist/Hand/Finger Injuries

  17. Wrist Sprains • 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 • 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

  18. Triangular Fibrocartilage Complex Injury (TFCC) • 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

  19. Triangular Fibrocartilage Complex Injury (TFCC) • 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

  20. 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)

  21. 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 • Management • Chronic entrapment may cause irreversible damage • Surgical decompression may be necessary

  22. Bishop/Benediction Hand: results from injury to the ulnar nerve 2. Claw Hand: results from compression of the median and ulnar nerves 3. Drop wrist: results from palsy of the radial nerve 4. Ape Hand: results from palsy of the median nerve

  23. 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

  24. De Quervian’s Disease (Hoffman’s disease) • Etiology • Stenosing tenosynovitis in thumb • (extensor pollicisbrevis and abductor pollicislongus • 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

  25. De Quervain’s Disease • Management • Immobilization • rest • Cryotherapy • NSAID’s • Ultrasound and ice are also beneficial • Joint mobilizations have been recommended to maintain ROM

  26. Scaphoid Fracture • Etiology • Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones • Often fails to heal due to poor blood supply • Signs and Symptoms • Swelling • Severe pain in anatomical snuff box • Presents like wrist sprain • Pain w/ radial flexion • Management • Must be splinted and referred for X-ray prior to casting • Immobilization lasts 6 weeks and is followed by strengthening and protective tape • Wrist requires protection against impact loading for 3 additional months

  27. Hamate Fracture • Etiology • Occurs as a result of a fall • Signs and Symptoms • Wrist pain • Weakness • Point tenderness • Pull of muscular attachment can cause non-union • Management • Casting wrist and thumb is treatment of choice • Hook of hamate can be protected w/ doughnut

  28. Extensor Tendon Avulsion (Mallet Finger) • Etiology • Caused by a blow to tip of finger avulsing extensor tendon from insertion • Also referred to as baseball or basketball finger • Signs and Symptoms • Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx • Unable to extend distal end of finger (carrying at 30 degree angle) • Point tenderness at sight of injury • Management • RICE and splinting for 6-8 weeks

  29. Boutonniere Deformity • Etiology • Rupture of extensor expansion dorsal to the middle phalanx • Tendon slides below axis of PIP joint • Forces DIP joint into extension and PIP into flexion • Signs and Symptoms • Severe pain • obvious deformity • inability to extend DIP joint • Swelling, point tenderness • Management • Cold application, followed by splinting • Splinting must be continued for 5-8 weeks • Athlete is encouraged to flex distal phalanx

  30. Jersey Finger (Flexor DigitorumProfundus Rupture) • Etiology • Rupture of flexor digitorumprofundus tendon • 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 poor gliding of tendon, w/ possibility of re-rupture

  31. Swan Neck Deformity • (PsuedoBoutonniere) • Etiology • Distal tear of volar plate may cause Swan Neck deformity; • Proximal tear may cause PsuedoBoutonniere deformity • Signs and Symptoms • Pain, swelling w/ varying degrees of hyperextension • Tenderness over volar plate of PIP • Indication of volar plate tear = passive hyperextension • Management • RICE and analgesics • Splint in 20-30 degrees of flexion for 3 weeks; followed by buddy taping and then PRE

  32. Gamekeeper’s 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 • Weak and painful pinch

  33. Gamekeeper’s Thumb • 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 until pain free • Splint should extend from wrist to end of thumb in neutral position • Thumb spica should be used following splinting for support • If a complete tear occurs, surgical repair is necessary to allow normal function to return

  34. Sprains of IP Joints • Etiology • Can include collateral ligament, volar plate, extensor expansion tears • Occurs w/ axial loading or valgus/varus stresses • Signs and Symptoms • Pain, swelling, point tenderness, instability • Valgus and varus tests may be positive • 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 may assist healing process • Taping can be used for support

  35. Metacarpal Fracture • Etiology • Direct axial force, compressive force • Being stepped on • S/S • Pain • Swelling • Appear to be an angular or rotational deformity • Management • Rice • X-ray • Reduce • Splinting • Splint 4-6 wks

  36. Bennett’s Fracture • Etiology • 1st metacarpal just distal to the CMC joint of the thumb • Axial and abduction force to thumb • S/S • Pain • Swelling over base of thumb • Deformity • Management • Unstable and referred to orthopedic

  37. Mallet Finger

  38. Boutonniere Deformity

  39. Jersey Finger

  40. Swan Neck Deformity

  41. Bennett’s Fracture