Wrist Anatomy

Bones Quiz - What bones comprise the wrist? Joints Quiz - What joints comprise the wrist?

Carpal Bones and Articulations

Proximal Row

Distal Row

Where can you palpate these?

Where can you palpate these?

Scaphoid Lunate Triquetrum Pisiform

Trapezium Trapezoid Capitate Hamate

Radiocarpal joint

Ulnocarpal joint

Intercarpal joints

Intercarpal joints Carpometacarpal joints (related to hand)

Articulations and ROM

Distal Radioulnar joint

Supination and Pronation 80-90o Ulna moves posteriorly and laterally with pronation Flexion (80-90o) and Extension (75-85o) Radial (20o) and Ulnar (35o) Deviation Gliding

Radiocarpal joint (and Ulnocarpal joint)

Intercarpal joints

Soft tissue of Wrist

Ligaments

Covered by a fibrous capsule

Radial and ulnar collateral

limit ulnar and radial deviation; collectively limits flexion and extension

Intercarpal and Carpometacarpal

Soft tissue of Wrist

Ligaments

Dorsal limits flexion

Dorsal Radiocarpal

Palmar - limit extension

Transverse carpal ligament Palmar radiocarpal

Multiple divisions

Palmar ulnocarpal ligament

Multiple divisions

Soft tissue of Wrist

Cartilage

Triangular Fibrocartilage Complex TFCC

Meniscus between ulna and triquetrum Ulnar collateral ligament and palmar ulnocarpal ligaments have attachments Compressed with Pronation and Extension Compressed with Ulnar deviation

Muscle Tissue of Wrist

Extensor muscles

Flexor Muscles

Extensor Retinaculum

Whats its function?

Muscles innervated by radial nerve There are 8

Flexor retinaculum (aka transverse carpal ligament) Two compartments

Superficial 4 Deep 3 Name them

Name them

Innervated by median and ulnar nerve

EXTENSORS

FLEXORS

Wrist and Hand Anatomy

Nerves/Vessels Radial & ulnar artery and veins Radial, ulnar, & median nerves Carpal Tunnel Flexor Tendons - 9 Median Nerve

Wrist Injuries
Strains

Onset usually acute FOOSH or Overexertion S/S: Active ROM limited Herniation of the joint capsule or synovial sheath of a tendon.

Wrist Ganglion

Tx: Bible Therapy

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

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 Pain is usually with overstretching

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

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

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 laxity and Varus test compresses and causes pain Immobilization and Surgery are often necessary

Neural Injuries
Carpal Tunnel Syndrome

Compression of median nerve

Fibrosis of the synovium of flexor tendons secondary to tenosynovitis

MOI: Insidious onset with repetitive wrist movement (and finger movement); Acute onset with trauma; Progressive degeneration 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

Neural Injuries
Bikers 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

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

Wrist Injuries
Wrist Fractures Distal Radius/Ulna Colles Fracture

MOI: hyperextension-fall on outstretched S/S: silver fork deformity - radius & ulna posteriorly MOI: hyperflexed S/S: garden spade deformity - radius & ulna anteriorly

Smiths Fracture (Reverse Colles)

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 with overpressure Tx: Splint, Referral, Ice

Plain X-rays may not be enough Immobilization (long and/or short) 12 weeks

Risk: aseptic necrosis and nonunion fractures

Preisers Disease Surgery may be necessary

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 (Murphys sign), Paresthesia of middle finger, weak finger flexion Risk: Untreated or repeated trauma

Kienbocks Disease Decreased grip, pain with ulnar deviation, weak extension, pain with passive 3rd finger extension

Immobilization 6-8 weeks; Surgery may be necessary

Wrist Injury Prevention

Good technique!

Butthese help

Flexor tendon arrangement

Lumbricals

Palmar Interossei

Dorsal Interossei

Extensor Hood, Long extensor tendon, and lateral bands

Finger flexor tendons

Unique finger

Look at pulley
system

Observation
Relaxed position of hand

Fingers slightly flexed

Relative shortness of finger flexors

Skin and Nail health

Discoloration, texture, hair patterns

Tips of fingers should align with finger flexion Finger and metacarpal positioning Muscle atrophy

Finger alignment

Hand abnormalities

Range of motion

Range of Motion
Carpometacarpal

Flexion (70-80o)/Extension Abduction (70-80o)/Adduction Opposition Flexion (85-105o)/Extension (20-35o) Abduction/Adduction (20-25o) Thumb flexion (80-90o) PIP flexion (110-120o) DIP flexion (80-90o)

Metacarpophalangeal

Interphangeal joints

Palpation
Metacarpals and joints

Collateral ligaments of MCPs Collateral ligaments of PIPs and DIPs muscles muscles Palmar fascia and muscles muscles

Phalanges and joints

Thenar compartment

Thenar webspace

Central compartment

Hypothenar compartment

Pathology
Tendon pathology

Trigger Finger/Thumb Mallet Finger Boutonniere Deformity Jersey Finger Dupuytrens Contracture Swan Neck Deformity

Dupuytrens Contracture

Joint pathology

Sprains
Fractures Dislocations

Swan Neck Deformity

Bony pathology

Tendon pathology
Trigger Finger or Thumb

Etiology

Repeated motion of fingers may cause irritation, producing tenosynovitis Inflammation of tendon sheath (flexor tendons of wrist, fingers and thumb, 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 Immobilization, rest, cryotherapy and NSAIDs Ultrasound and ice are also beneficial Injection

Management

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 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 RICE and splinting in hyperextension for 6-8 weeks

Signs and Symptoms

Management

Tendon pathology
Boutonniere Deformity

Etiology

Rupture of extensor tendon dorsal to the middle phalanx bone passes through central slip Forces DIP joint into extension and PIP into flexion Severe pain, obvious deformity and inability to extend DIP joint Swelling, point tenderness Cold application, followed by splinting in PIP extension and DIP flexion Splinting must be continued for 5-8 weeks

Signs and Symptoms

Management

Tendon pathology
Jersey Finger

Etiology

Rupture of flexor digitorum profundus tendon from insertion on distal phalanx Often occurs w/ ring finger when athlete tries to grab a jersey DIP can not be flexed, finger remains extended Pain and point tenderness over distal phalanx Must be surgically repaired Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture

Signs and Symptoms

Management

Tendon pathology
Dupuytrens Contracture

Dupuytrens Contracture

Etiology

Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity Often develops in 4th or 5th finger (flexion deformity) Tissue nodules must be removed as they can ultimately interfere w/ normal hand function

Signs and Symptoms

Management

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 = passive hyperextension RICE and analgesics Splint in PIP 20-30 degrees of flexion/DIP extension for 3 weeks; followed by buddy taping

Management

Joint pathology
Sprains Phalanges

Etiology

Phalanges are prone to sprains caused by direct blows or twisting

Signs and Symptoms

Recognition primarily occurs through history Sprain symptoms - pain, severe swelling and hemorrhaging

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 Pain over UCL in addition to weak and painful pinch Immediate follow-up must occur

Signs and Symptoms

Management

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

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 Pain, swelling, point tenderness, instability Valgus and varus tests may be possible 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

Signs and Symptoms

Management

Joint pathology
PIP Dorsal Dislocation

PIP Palmar Dislocation

Etiology

Etiology

Hyperextension that disrupts volar plate at middle phalanx

Caused by twist while it is semiflexed Pain and swelling over PIP; point tenderness over dorsal side Finger displays angular or rotational deformity Treat w/ RICE, splinting and analgesics followed by reduction Splint in full extension for 4-5 weeks after which it is protected for 6-8 weeks during activity

Signs and Symptoms

Signs and Symptoms

Pain and swelling over PIP Obvious deformity, disability and possible avulsion

Management

Management

Treated w/ RICE, splinting and analgesics followed by reduction After reduction, finger is splinted at 20-30 degrees of flexion for 3 weeks -followed by buddy taping

Open Dislocation

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 slight flexion (3 weeks) Buddy taping following splinting

Bony Pathology
Metacarpal Fracture

Etiology

Direct axial force or compressive force Fractures of the 5th metacarpal = Boxers Fracture Pain and swelling; possible angular or rotational deformity RICE, analgesics are given followed by X-ray examinations Deformity is reduced, followed by splinting - 4 weeks of splinting after which therapy starts

Signs and Symptoms

Management

Bony pathology
Bennetts Fracture

Etiology

Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb CMC may appeared to be deformed - X-ray will indicate fracture Athlete will complain of pain and swelling over the base of the thumb Structurally unstable and must be referred to an orthopedic surgeon Surgery and immobilization season ending

Signs and Symptoms

Management

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

Bony pathology
Middle Phalangeal Fracture

Etiology

Occurs from direct trauma or twist Pain and swelling w/ tenderness over middle phalanx Possible deformity; X-ray will show bone displacement RICE and analgesics No deformity - buddy tape w/ splint for activity Deformity - immobilization for 3-4 weeks and a

Signs and Symptoms

Management

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 by immobilization of the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping

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

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 chronic respiratory disease Spooning or depression = chronic alcoholism or vitamin deficiency

Prevention of Hand Injuries

Protection

Gloves, Grips, Braces Sport and Ergonomics Reps and Sets for muscles of Hand

Proper Technique

Physical Conditioning

Theraputty, Wrist curls/extensions, Fist pumps

Problem Solving

Putting it together with Case studies

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?

Observation
Functional Evaluation

Range of motion in all movements of wrist should be assessed

Active, resistive and passive motions should be assessed and compared bilaterally Wrist - flexion, extension, radial and ulnar deviation How do the carpals and metacarpals align with the distal radius and ulna? Is there symmetry? Is there a palmaris longus? - 10% of population it is absent

Wrist attitude

How are those tendons looking?

Become a palm reader?

Palpation

Bony and Soft Tissue Palpation

Are 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 detect circulatory problems (capillary refill) Hands neurological functioning should also be tested (sensation and motor functioning)

Is it nerve?
What other test is common for nerve injury?

How else can you detect a neural injury?

What test is this?

Is it the ligaments or joints?

Which tests are these?

What are some distinguishing characteristics of a ligament or joint injury?

Is it muscle or tendon?
How do you assess the function of a muscle? What are some distinguishing characteristics of a muscle injury?

What test assesses these structures?

Is it bone?
What is are distinguishing signs of a potential fractures?

Case study #1
A 28 year old woman complains of pain in the right hand over the last 3 months. She reports numerous FOOSH incidents and currently works as a cashier at a grocery store. The pain awakens her at night and is relieved only by vigorous rubbing of her hand and motion of the fingers and wrist. There is some tingling in the index and middle fingers. What is your assessment plan?

Case study #2
A 18 year old boy reports with wrist pain and swelling 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. He says he tripped and experienced a FOOSH while playing recreational football. He states that after the injury the wrist hurt, he rested 2 days and iced, the pain decreased, but then with weightlifting the swelling has developed the last 5 days. Now it is very swollen and painful. What is your assessment plan?

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 is having trouble controlling his drives and long iron shots because of pain in his wrist at the top of the swing. What is your assessment plan?