1. Wrist Anatomy Bones Quiz - What bones comprise the wrist? Joints
Quiz - What joints comprise the wrist?

2. Carpal Bones and Articulations
Proximal Row
Where can you palpate these?
Scaphoid
Lunate
Triquetrum
Pisiform
Radiocarpal joint
Ulnocarpal joint
Intercarpal joints
Distal Row
Where can you palpate these?
Trapezium
Trapezoid
Capitate
Hamate
Intercarpal joints
Carpometacarpal joints (related to hand)

3. Articulations and ROM Distal Radioulnar joint
Supination and Pronation – 80-90o
Ulna moves posteriorly and laterally with pronation
Radiocarpal joint (and Ulnocarpal joint)
Flexion (80-90o) and Extension (75-85o)
Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints
Gliding

4. 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

5. Soft tissue of Wrist Ligaments Dorsal – limits flexion
Dorsal Radiocarpal
Palmar - limit extension
Transverse carpal ligament
Palmar radiocarpal
Multiple divisions
Palmar ulnocarpal ligament

6. 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

8. Muscle Tissue of Wrist Extensor muscles Flexor Muscles
Extensor Retinaculum
What’s its function?
Muscles innervated by radial nerve
There are 8
Name them…
Flexor Muscles
Flexor retinaculum (aka transverse carpal ligament)
Two compartments
Superficial – 4
Deep – 3
Name them…
Innervated by median and ulnar nerve

9. EXTENSORS
FLEXORS

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

12. Wrist Injuries Strains Wrist Ganglion
Onset usually acute – FOOSH or Overexertion
S/S: Active ROM limited
Wrist Ganglion
Herniation of the joint capsule or synovial sheath of a tendon.
Tx: Bible Therapy

13. Wrist Injuries deQuervain’s Disease - thumb/wrist
stenosing tenosynovitis of the extensor pollicis
brevis and abductor pollicis longus.
S/S: crepitation, tenderness, strength loss.
Special Test: = Finkelstein’s test
Tx: RICE, NSAIDs

14. 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
S/S: Laxity, pain, swelling, limited ROM
Pain is usually with overstretching
Special Tests: Varus/Valgus, Carpal Glide
PRICE, Rehabilitation, Taping for prevention

15. 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

16. 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: Tinel’s sign
and Phalen’s
Tx: Conservative (PRICE, NSAIDs) and Surgical

17. Neural Injuries Biker’s Palsy Drop Wrist Syndrome
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

18. 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

19. Wrist Injuries Wrist Fractures Distal Radius/Ulna Colles’ Fracture
MOI: hyperextension-fall on outstretched
S/S: “silver fork deformity” - radius & ulna posteriorly
Smith’s Fracture (Reverse Colles)
MOI: hyperflexed
S/S: “garden spade deformity” - radius & ulna anteriorly

20. 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 non-union fractures
Preiser’s Disease
Surgery may be necessary

21. 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 (Murphy’s sign), Paresthesia of middle finger, weak finger flexion
Risk: Untreated or repeated trauma
Kienbock’s Disease
Decreased grip, pain with ulnar deviation, weak extension, pain with passive 3rd finger extension
Immobilization – 6-8 weeks; Surgery may be necessary

22. Wrist Injury Prevention
Good technique!
But…these help

23. Hand and Fingers
Pathology

24. Lumbricals 1 2 3 4 Dorsal Interossei Palmar Interossei
Flexor tendon arrangement
Lumbricals 1 2 3 4
Dorsal Interossei
Palmar Interossei

25. Extensor Hood, Long extensor tendon, and lateral bands
Finger flexor tendons
Unique finger
Look at pulley
system

26. Observation Relaxed position of hand Skin and Nail health
Fingers slightly flexed
Relative shortness of finger flexors
Skin and Nail health
Discoloration, texture, hair patterns
Finger alignment
Tips of fingers should align with finger flexion
Hand abnormalities
Finger and metacarpal positioning
Muscle atrophy
Range of motion

27. Range of Motion Carpometacarpal Metacarpophalangeal
Flexion (70-80o)/Extension
Abduction (70-80o)/Adduction
Opposition
Metacarpophalangeal
Flexion (85-105o)/Extension (20-35o)
Abduction/Adduction (20-25o)
Interphangeal joints
Thumb flexion (80-90o)
PIP flexion ( o)
DIP flexion (80-90o)

28. Palpation Metacarpals and joints Phalanges and joints
Collateral ligaments of MCPs
Phalanges and joints
Collateral ligaments of PIPs and DIPs
Thenar compartment
muscles
Thenar webspace
Central compartment
Palmar fascia and muscles
Hypothenar compartment

29. Pathology Tendon pathology Joint pathology Bony pathology
Dupuytren’s Contracture
Tendon pathology
Trigger Finger/Thumb
Mallet Finger
Boutonniere Deformity
Jersey Finger
Dupuytren’s Contracture
Swan Neck Deformity
Joint pathology
Sprains
Bony pathology
Fractures
Dislocations
Swan Neck Deformity

30. Tendon pathology Trigger Finger or Thumb Etiology Signs and Symptoms
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
Management
Immobilization, rest, cryotherapy and NSAID’s
Ultrasound and ice are also beneficial
Injection

31. 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
Signs and Symptoms
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
Management
RICE and splinting in hyperextension for 6-8 weeks

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

33. Tendon pathology Jersey Finger Etiology Signs and Symptoms Management
Rupture of flexor digitorum profundus tendon from insertion on distal phalanx
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

34. Tendon pathology Dupuytren’s Contracture Etiology Signs and Symptoms
Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity
Signs and Symptoms
Often develops in 4th or 5th finger (flexion deformity)
Management
Tissue nodules must be removed as they can ultimately interfere w/ normal hand function

35. Tendon pathology Swan Neck Deformity Etiology Signs and Symptoms
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
Management
RICE and analgesics
Splint in PIP degrees of flexion/DIP extension for 3 weeks; followed by buddy taping

36. Joint pathology Sprains Phalanges Etiology Signs and Symptoms
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

37. Joint pathology Gamekeeper’s Thumb Etiology Signs and Symptoms
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 in addition to weak and painful pinch
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

38. 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
Signs and Symptoms
Pain, swelling, point tenderness, instability
Valgus and varus tests may be possible
Management
RICE, X-ray examination and possible splinting
Splint at 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

39. Joint pathology PIP Dorsal Dislocation PIP Palmar Dislocation Etiology
Hyperextension that disrupts volar plate at middle phalanx
Signs and Symptoms
Pain and swelling over PIP
Obvious deformity, disability and possible avulsion
Management
Treated w/ RICE, splinting and analgesics followed by reduction
After reduction, finger is splinted at degrees of flexion for 3 weeks -- followed by buddy taping
PIP Palmar Dislocation
Etiology
Caused by twist while it is semiflexed
Signs and Symptoms
Pain and swelling over PIP; point tenderness over dorsal side
Finger displays angular or rotational deformity
Management
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

40. Open Dislocation

42. Joint pathology MCP Dislocation Etiology Signs and Symptoms Management
Caused by twisting or shearing force
Signs and Symptoms
Pain, swelling and stiffness at MCP joint
Proximal phalanx is angulated at degrees
Management
RICE, following reduction splinting in slight flexion (3 weeks)
Buddy taping following splinting
Therapy

43. Bony Pathology Metacarpal Fracture Etiology Signs and Symptoms
Direct axial force or compressive force
Fractures of the 5th metacarpal = Boxer’s Fracture
Signs and Symptoms
Pain and swelling; possible angular or rotational deformity
Management
RICE, analgesics are given followed by X-ray examinations
Deformity is reduced, followed by splinting - 4 weeks of splinting after which therapy starts
Unstable fracture may need to be surgically pinned

45. Bony pathology Bennett’s Fracture Etiology Signs and Symptoms
Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb
Signs and Symptoms
CMC may appeared to be deformed - X-ray will indicate fracture
Athlete will complain of pain and swelling over the base of the thumb
Management
Structurally unstable and must be referred to an orthopedic surgeon
Surgery and immobilization – season ending

46. Bony pathology Distal Phalangeal Fracture Etiology Signs and Symptoms
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
Subungual hematoma is drained

47. Bony pathology Middle Phalangeal Fracture Etiology Signs and Symptoms
Occurs from direct trauma or twist
Signs and Symptoms
Pain and swelling w/ tenderness over middle phalanx
Possible deformity; X-ray will show bone displacement
Management
RICE and analgesics
No deformity - buddy tape w/ splint for activity
Deformity - immobilization for 3-4 weeks and a protective splint for an additional 9-10 weeks during activity

48. 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

49. 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

50. Finger Nail Pathology Subungual Hematoma Paronychia
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

51. Prevention of Hand Injuries
Protection
Gloves, Grips, Braces
Proper Technique
Sport and Ergonomics
Physical Conditioning
Reps and Sets for muscles of Hand
Theraputty, Wrist curls/extensions, Fist pumps

52. Putting it together with Case studies
Problem Solving
Putting it together with
Case studies

53. H.O.P.S

54. 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?

55. 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
Wrist “attitude”
How do the carpals and metacarpals align with the distal radius and ulna?
Is there symmetry?
How are those tendons looking?
Is there a palmaris longus? - 10% of population it is absent
Become a “palm reader”?

56. 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)
Hand’s neurological functioning should also be tested (sensation and motor functioning)

57. Is it nerve? What other test is common for nerve injury?
How else can you detect a neural injury?
What test is this?

58. Is it the ligaments or joints?
Which tests are these?
What are some distinguishing characteristics of a ligament or joint injury?

59. 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?

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

61. 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?

62. 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?

63. 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 didn’t 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?