Wrist and Hand Unit

Anatomy, Injuries, Evaluations,

Treatments, and Rehabilitation

Anatomy of wristBones: carpals and metacarpalsJoints: radiocarpal, carpal, metacarpal, and phalangeal jointsLigaments: “many at each joint in the hand”Musculature: “many intrinsic and extrinsic muscles”Blood and Nerve Supply: ulnar, median, radial nerve and radial and ulnar superficial and deep palmar arch arteries

Wrist and hand jointsRadiocarpal joints:condyloid jt.Permits flex/ext, abd/add, circum.Carpal joints:gliding jts.Stabilized by ant/post interosseous lig.Metacarpal joints: 5 bones forming the MCP jtCondyloid jt. But the thumb is a saddle jt.Phalangeal joints: interphalangeal is a hinge jt. Ext/flex only

Wrist ligaments:Radius=radial collateral lig attaches the radial styloid to the scaphoidUlna=ulnar collateral lig. Attaches the ulnar styloid to thepisiform and triquetral boneTransverse carpal lig. = roof of the carpal tunnelPhalangeal ligaments:PIP/DIP joint same ligaments as the wrist.Volar plate on the palmar surface of the phalangeExtensor expansion= sheath that expands over the dorsal surface of the phalange.

Assessment of Wrist, Hand, and Finger Injuries

HistoryObservationPalpationSpecial Tests: Finklestein’s test, Tinel’s Sign, Phalen’s test, valgus and varus stress test, Glide test, Lunotriquetral Ballotment testCirculatory and Neurological Evaluation

Allen testFunctional Evaluation

Carpal Tunnel Syndrome

Carpal tunnel syndromeEtiology: transverse carpal lig. Is the roof of the tunnel, 8 long flexor tendons and median N pass through this. Over use of wrist flexion and sometimes a direct blow can cause this. Signs and symptoms: tingling, numbness over the thumb, 2-3 phalanges, and palm of the hand. Also thumb weaknessManagement: rest, immobilization, NSAID’s then surgery to relieve the compression by cutting the transverse carpal lig.

Carpal Tunnel

Carpal Tunnel

Injuries of the wristWrist Sprain

Etiology: Falling on hyperextended wrist most common but you can fall on a flexed wristSigns and Symptoms: pain, swelling, limited ROMManagement: Severe sprain go for x-ray. For mod/minor injury RICE and start exercise ASAP

Triangular Fibrocartilage Complex Injury (TFCC)

Etiology: fall on an outstretched hand in hyperextension that compresses the TFCC between radioulnar jt and carpals. UCL involved Signs and Symptoms: pain along the ulnar side of the wrist, swelling and pain in wrist extensionManagement: referred to physician. If not properly managed, permanent loss of motion and disability can occur.

TenosynovitisEtiology: occurs to extensor carpi rad. Longus/brevis mainly in wt. Lifters and rowers chronic injury of repetitive useSigns and Symptoms: pain in passive stretching and swelling and tendernessManagement: RICE and NSAID’s, along with increase ROM exercises in contrast baths. US

TendinitisEtiology: common flexor carpi rad./ulnaris= overuseSigns and Symptoms:pain in active/passive stretchingManagement: Same as above

Nerve Compression, Entrapment, Palsy

Etiology:direct blow- median/ulnar nerve is involved. Median N is compressed in the carpal tunnel. Unlar N is compressed in the tunnel of Guyon (pisiform and hook of the hamateSigns and Symptoms: sharp, burning pain with possibility of numbness. Ulanr N= Bishops/Benediction hand 4/5th finger is flexedUlnar/median n= claw hand distal phalanx flexed, median N= drop wrist or ape hand 2-5 distal phalanx flexed and thumb extendedManagement: RICE, NSAID’s or surgery for decompression

Fractured wrist

Dislocation of the Lunate Bone

Etiology: Most common of the carpals. Fall on an outstretched hand. Dislocated anteriorly (palmar side)Signs and Symptoms: pain, swelling, difficult to flex fingers/wristManagement: send to Dr. to reduce dislocation, 1-2 months recovery.

Scaphoid Fracture

Etiology: most frequent fx. Force on the outstretched hand.Signs and Symptoms: swelling, pt. Tender over anatomical snuffbox. Pain in radial flexion.Management: Ice, splint, and early immobilization. If not aseptic necrosis might occur because of very poor blood supply.

Scaphoid Fracture

Hamate Fracture

Etiology: direct contact to the wrist while holding a a sports implement: tennis racket, bat, golf club.Signs and Symptoms: wrist pain, weakness, pt. Tender over hamate.Management: cast.

Wrist Ganglion

Etiology: synovial cyst, most commonly on the back of the wristSigns and Symptoms: occasional pain, lump,Management: direct pressure, US, or surgery

Mallet Finger

Etiology: blow to the tip of the finger rupturing the extensor tendon.Signs and Symptoms: pain about the DIP jt. Unable to extend the finger.Management: RICE splinted in extension.

Mallet finger

Boutonnière Deformity

Boutonniere deformityEtiology:rupture of the extensor tendon dorsal to the middle phalanx. Direct blow to an ext. DIP/ flexed PIP jointSigns and Symptoms: inability to to extend PIP joint.Management: splint the PIP in extension. Ice applied

Boutonnière

Gamekeeper’s thumb

Etiology: sprain of the ulnar collateral lig. MCP jt. Forceful abductionSigns and Symptoms: pain over the MCP, unable to pinchManagement: refer to orthopedist, splint, ice, possible surgery.

Gamekeeper’s thumb

Collateral Lig. Sprain, volar plate rupture, central slip tear

Etiology: PIP/DIP sprains, volar plate rupture, central slip tearSigns and Symptoms: pain, loss of function, swelling, deformityManagement: RICE, x-ray, splinting, taping later

PIP Dorsal dislocation

Etiology: Hyperext. With volar plate rupture direct blow to fingerSigns and Symptoms: deformity, pain, swellingManagement: Rice, Dr for reduction, splinting of 20-30 degrees of flexion for three weeks. Then buddy taping

MCP dislocationEtiology: twisting or shear forceSigns and Symptoms: pain, swelling, and stiffness of the MCP joint and prox. Phalanx is dorsally angulated 60-90 degreesManagement: Rice, splinting, Dr. reduced, buddy taped and given early ROM

Metacarpal fractureEtiology: axial loading, fifth MC from boxingSigns and Symptoms: pain deformity, angular/rotational deformityManagement: RICE splinting, Dr. splint for 4 weeks

Bennett’s FractureEtiology: Carpometacarpal CMC jt. Of the thumb.Signs and Symptoms: pain swelling over the base of the thumbManagement: referred to orthopedic surgeon, ice, splint

De Quervain’s Disease( Hoffman’s disease)

Etiology: stenosing tenosynovitis in the thumb. First tunnel of the wrist narrows and inflamed synovial lining. Muscle involved would be the extensor pollicis brevis and abductor pollicis longus. Constant wrist movement can be a source of irritationSigns and Symptoms: aching pain that radiates into the hand or forearm. Movement of the wrist causes pain. (+)Finklestein test. Muscle weakness of the thumb extensors and abduction. Possible snapping/catching of the tendons during movementManagement: immobilization,rest, cryotherapy, and NSAID’s. US and Ice massage

Dupuytren’s Contracture

Etiology: Unknown how it happens. Nodules develop over the palmar aponeurosis that limit finger extension and cause a flexion deformitySigns and Symptoms: 4th/5th finger stays in flexionManagement: nodules removed surgically

Trigger finger or thumbEtiology:repeated movement of tendons causes tenosynovitis. Common areas involve the ext. carpi ulnaris, ext. pollicis longus/brevis, abductor pollicis longus.Signs and Symptoms: pain while flexing thumb or finger. In ability to extend finger or thumb produces a snapping sensation.Management: same as Dequervain’s disease, steroid injection or splinting last resort.

Trigger finger

Swan neck deformity

Etiology: The volar plate of the PIP jt. Is most commonly injured from a severe hyperextension force.Signs and Symptoms: pain, swelling at PIP jt and volar plate. More movement of hyperextension of the PIP jt compared to othersManagement: Rice, splinting at 20-30 degrees of flexion for 3 weeks

Swan neck deformity

Jersey finger

Etiology: rupture of flexor digitorum profundus. From grabbing a jersey. 4th phalange most commonly injuredSigns and Symptoms: pain, pt tenderness, unable to flex distal phalanxManagement: splint and surgery.

Fingernail deformityScaling or ridging= psoriasisRidging and poor development= hyperthyroidismClubbing and cyanosis= congenital heart disorders or chronic respiratory diseaseSpooning or depression= chronic alcoholism or vitamin deficiencies