Presentation on theme: "Wrist Anatomy Bones Quiz - What bones comprise the wrist? Joints"— Presentation transcript:
1 Wrist Anatomy Bones Quiz - What bones comprise the wrist? Joints Quiz - What joints comprise the wrist?
2 Carpal Bones and Articulations Proximal RowWhere can you palpate these?ScaphoidLunateTriquetrumPisiformRadiocarpal jointUlnocarpal jointIntercarpal jointsDistal RowWhere can you palpate these?TrapeziumTrapezoidCapitateHamateIntercarpal jointsCarpometacarpal joints (related to hand)
3 Articulations and ROM Distal Radioulnar joint Supination and Pronation – 80-90oUlna moves posteriorly and laterally with pronationRadiocarpal joint (and Ulnocarpal joint)Flexion (80-90o) and Extension (75-85o)Radial (20o) and Ulnar (35o) DeviationIntercarpal jointsGliding
4 Soft tissue of Wrist Ligaments Covered by a fibrous capsule Radial and ulnar collaterallimit ulnar and radial deviation; collectively limits flexion and extensionIntercarpal and Carpometacarpal
6 Soft tissue of Wrist Cartilage Triangular Fibrocartilage Complex – TFCC“Meniscus” between ulna and triquetrumUlnar collateral ligament and palmar ulnocarpal ligaments have attachmentsCompressed with Pronation and ExtensionCompressed with Ulnar deviation
12 Wrist Injuries Strains Wrist Ganglion Onset usually acute – FOOSH or OverexertionS/S: Active ROM limitedWrist GanglionHerniation 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 pollicisbrevis and abductor pollicis longus.S/S: crepitation, tenderness, strength loss.Special Test: = Finkelstein’s testTx: RICE, NSAIDs
14 Wrist Injuries Sprains Onset is usually acute – FOOSH or overexertion Often diagnosed when other injuries are ruled outBoth active and passive ROM are effectedS/S: Laxity, pain, swelling, limited ROMPain is usually with overstretchingSpecial Tests: Varus/Valgus, Carpal GlidePRICE, Rehabilitation, Taping for prevention
15 Wrist Injuries Triangular Fibrocartilage Injuries - TFCC Onset is usually acuteMOI: Forced hyperextension of wrist with loadingS/S: Pain with pronation/extension and/or ulnar deviation; Pain with loading; Point tenderness; Swelling; Altered joint mechanicsSpecial Test: Valgus test elicits pain but no laxity and Varus test compresses and causes painImmobilization and Surgery are often necessary
16 Neural Injuries Carpal Tunnel Syndrome Compression of median nerve Fibrosis of the synovium of flexor tendons secondary to tenosynovitisMOI: Insidious onset with repetitive wrist movement (and finger movement); Acute onset with trauma; Progressive degenerationS/S: numbness palmar thumb, index,middle fingers, dull ache, weak fingerflexion (grip). May worsen with sleep.Poor posture may predispose.Special Tests: Tinel’s signand Phalen’sTx: Conservative (PRICE, NSAIDs) and Surgical
17 Neural Injuries Biker’s Palsy Drop Wrist Syndrome Ulnar nerve compressionUlnar nerve passes through tunnel of Guyon between pisiform and hamate.MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar deviationTx: Padding (Gloves), Ice, NSAIDsDrop Wrist SyndromeRadial nerve compression at elbowInability to extend wrist and fingers
18 Wrist Injuries Wrist Fractures Distal Radius/Ulna and Forearm FracturesOnset is acuteMOI: Hyperextension or hyperflexion combined with rotatory motion – FOOSHS/S: Deformity felt and observed; CrepitusEvaluated Neurovascular statusTx: Splint, Ice, Referral
20 Wrist Injuries Wrist Fractures Scaphoid - most common carpal MOI: fall on outstretched handS/S: wrist aches, pain in anatomical snuff box,painful handshake or with overpressureTx: Splint, Referral, IcePlain X-rays may not be enoughImmobilization (long and/or short) – 12 weeksRisk: aseptic necrosis and non-union fracturesPreiser’s DiseaseSurgery may be necessary
21 Wrist Injuries Wrist Dislocations Radius or Ulna Lunate is very common MOI: force hyperextensionDorsal displacement = perilunate dislocationPalmar displacement (total rupture) = lunate dislocationS/S: Deformity, 3rd Knuckle is lower (Murphy’s sign), Paresthesia of middle finger, weak finger flexionRisk: Untreated or repeated traumaKienbock’s DiseaseDecreased grip, pain with ulnar deviation, weak extension, pain with passive 3rd finger extensionImmobilization – 6-8 weeks; Surgery may be necessary
22 Wrist Injury Prevention Good technique!But…these help
25 Extensor Hood, Long extensor tendon, and lateral bands Finger flexor tendonsUnique fingerLook at pulleysystem
26 Observation Relaxed position of hand Skin and Nail health Fingers slightly flexedRelative shortness of finger flexorsSkin and Nail healthDiscoloration, texture, hair patternsFinger alignmentTips of fingers should align with finger flexionHand abnormalitiesFinger and metacarpal positioningMuscle atrophyRange of motion
27 Range of Motion Carpometacarpal Metacarpophalangeal Flexion (70-80o)/ExtensionAbduction (70-80o)/AdductionOppositionMetacarpophalangealFlexion (85-105o)/Extension (20-35o)Abduction/Adduction (20-25o)Interphangeal jointsThumb flexion (80-90o)PIP flexion ( o)DIP flexion (80-90o)
28 Palpation Metacarpals and joints Phalanges and joints Collateral ligaments of MCPsPhalanges and jointsCollateral ligaments of PIPs and DIPsThenar compartmentmusclesThenar webspaceCentral compartmentPalmar fascia and musclesHypothenar compartment
30 Tendon pathology Trigger Finger or Thumb Etiology Signs and Symptoms Repeated motion of fingers may cause irritation, producing tenosynovitisInflammation of tendon sheath (flexor tendons of wrist, fingers and thumb, abductor pollicis)Thickening forming a nodule that does not slide easilySigns and SymptomsResistance to re-extension, produces snapping that is palpable, audible and painfulPalpation produces pain and lump can be felt w/in tendon sheathManagementImmobilization, rest, cryotherapy and NSAID’sUltrasound and ice are also beneficialInjection
31 Tendon pathology Mallet Finger (baseball or basketball finger) EtiologyCaused by a blow that contacts tip of finger avulsing extensor tendon from insertionAvulses extensor digitorum at distal phalanxSigns and SymptomsUnable to extend distal end of finger (carrying at 30 degree angle)Point tenderness at sight of injuryX-ray shows avulsed bone on dorsal proximal distal phalanxManagementRICE 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 slipForces DIP joint into extension and PIP into flexionSigns and SymptomsSevere pain, obvious deformity and inability to extend DIP jointSwelling, point tendernessManagementCold application, followed by splinting in PIP extension and DIP flexionSplinting 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 phalanxOften occurs w/ ring finger when athlete tries to grab a jerseySigns and SymptomsDIP can not be flexed, finger remains extendedPain and point tenderness over distal phalanxManagementMust be surgically repairedRehab 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 deformitySigns and SymptomsOften develops in 4th or 5th finger (flexion deformity)ManagementTissue 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 deformityFlexed MCP, extended PIP, and flexed DIPSigns and SymptomsPain, swelling w/ varying degrees of hyperextensionTenderness over volar plate of PIPIndication of volar plate tear = passive hyperextensionManagementRICE and analgesicsSplint 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 twistingSigns and SymptomsRecognition primarily occurs through historySprain symptoms - pain, severe swelling and hemorrhaging
37 Joint pathology Gamekeeper’s Thumb Etiology Signs and Symptoms Sprain of UCL of MCP joint of the thumbMechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextensionSigns and SymptomsPain over UCL in addition to weak and painful pinchManagementImmediate follow-up must occurIf instability exists, athlete should be referred to orthopedistIf stable, X-ray should be performed to rule out fractureThumb splint should be applied for protection for 3 weeks or until pain freeSplint should extend from wrist to end of thumb in neutral positionThumb 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 tearsOccurs w/ axial loading or valgus/varus stressesSigns and SymptomsPain, swelling, point tenderness, instabilityValgus and varus tests may be possibleManagementRICE, X-ray examination and possible splintingSplint at degrees of flexion for 10 daysIf sprain is to the DIP, splinting for a few days in full extension may assist healing processTaping can be used for support
39 Joint pathology PIP Dorsal Dislocation PIP Palmar Dislocation Etiology Hyperextension that disrupts volar plate at middle phalanxSigns and SymptomsPain and swelling over PIPObvious deformity, disability and possible avulsionManagementTreated w/ RICE, splinting and analgesics followed by reductionAfter reduction, finger is splinted at degrees of flexion for 3 weeks -- followed by buddy tapingPIP Palmar DislocationEtiologyCaused by twist while it is semiflexedSigns and SymptomsPain and swelling over PIP; point tenderness over dorsal sideFinger displays angular or rotational deformityManagementTreat w/ RICE, splinting and analgesics followed by reductionSplint in full extension for 4-5 weeks after which it is protected for 6-8 weeks during activity
42 Joint pathology MCP Dislocation Etiology Signs and Symptoms Management Caused by twisting or shearing forceSigns and SymptomsPain, swelling and stiffness at MCP jointProximal phalanx is angulated at degreesManagementRICE, following reduction splinting in slight flexion (3 weeks)Buddy taping following splintingTherapy
43 Bony Pathology Metacarpal Fracture Etiology Signs and Symptoms Direct axial force or compressive forceFractures of the 5th metacarpal = Boxer’s FractureSigns and SymptomsPain and swelling; possible angular or rotational deformityManagementRICE, analgesics are given followed by X-ray examinationsDeformity is reduced, followed by splinting - 4 weeks of splinting after which therapy startsUnstable 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 thumbSigns and SymptomsCMC may appeared to be deformed - X-ray will indicate fractureAthlete will complain of pain and swelling over the base of the thumbManagementStructurally unstable and must be referred to an orthopedic surgeonSurgery and immobilization – season ending
46 Bony pathology Distal Phalangeal Fracture Etiology Signs and Symptoms Crushing forceSigns and SymptomsComplaint of pain and swelling of distal phalanxSubungual hematoma is often seen in this conditionManagementRICE and analgesics are givenProtective splint is applied as a means for pain reliefSubungual hematoma is drained
47 Bony pathology Middle Phalangeal Fracture Etiology Signs and Symptoms Occurs from direct trauma or twistSigns and SymptomsPain and swelling w/ tenderness over middle phalanxPossible deformity; X-ray will show bone displacementManagementRICE and analgesicsNo deformity - buddy tape w/ splint for activityDeformity - 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 angularSigns and SymptomsComplaint of pain, swelling, deformityInspection reveals varying degrees of deformityManagementRICE and analgesics are given as neededFracture stability is maintained by immobilization of the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping
49 LacerationsSuperficial location of tendons and nerves predisposes athletes to damage form shallow lacerations.Any laceration to the fascia below the cutaneous layer should receive a referralR/O trauma to tendons and nervesPrevent infectionSuture to ensure minimal scarring
50 Finger Nail Pathology Subungual Hematoma Paronychia MOI: finger caught between two surfacesPresents with bleeding under nail bedDraining – Drill or CauterizeParonychiaInfection around fingernail bedsS/S: Redness, pain, drainageWarm soaks (Betadine), Antibiotic, ReferralChanges in normal appearance - indicative of a number of different diseasesScaling or ridging = psoriasisRidging and poor development = hyperthyroidismClubbing and cyanosis = congenital heart disorders or chronic respiratory diseaseSpooning or depression = chronic alcoholism or vitamin deficiency
51 Prevention of Hand Injuries ProtectionGloves, Grips, BracesProper TechniqueSport and ErgonomicsPhysical ConditioningReps and Sets for muscles of HandTheraputty, Wrist curls/extensions, Fist pumps
52 Putting it together with Case studies Problem SolvingPutting it together withCase studies
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 assessedActive, resistive and passive motions should be assessed and compared bilaterallyWrist - flexion, extension, radial and ulnar deviationWrist “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 absentBecome 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 EvaluationHands should be felt for temperatureCold hands indicate decreased circulationTake pulse – radial arteryPinching 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 #1A 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 #2A 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 #3A 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?