3 Wrist Articulations Radiocarpal joint Radius with scaphoid, lunate, and triquetrumCondyloid jointSagittal plane motions (i.e., flexion, extension, and hyperextension)Frontal plane motions (i.e., radial deviation and ulnar deviation)Circumduction
4 Wrist Articulations (cont.) Intercarpal jointsGliding jointsMinimal contribution to wrist movementDistal radioulnar jointImmediately adjacent to radiocarpal jointTFCC – stabilizerscaphoid, lunate, capitate, triquetrum, and pisiform-- exhibit significant nonplanar motions, with the axis of rotation for each bone shifting with direction of wrist movement-- individual motions and interactions among these proximal carpal bones become particularly complex during the combined wrist motions such as extension and pronationdistal carpal row bones-- function as a single unit-- separated by gliding joints that contribute little to wrist motion-- directly linked to the motion of the third metacarpaldistal radioulnar joint-- triangular fibrocartilage (TFC): cartilaginous disc overlying the distal ulnar head, between it and the ulnar carpal column (i.e., lunate and triquetral bones)-- makes up a portion of the triangular fibrocartilage complex (TFCC)-- volar radiocarpal, dorsal radiocarpal, radial collateral, and ulnar collateral ligaments reinforce the radiocarpal joint capsule-- close-packed position is in extension with radial deviationTFCC-- acts as a stabilizer of the distal radioulnar joint-- ulnar continuation of the radius; provides an articular surface for the carpal condyle
5 Hand Articulations Carpometacarpal joints (CM) Thumb Saddle joint FingersGliding jointsIntermetacarpal joints (IM)Metacarpophalangeal joints (MP)Condyloid jointsInterphalangeal joints (IP)PIP and DIP hinge jointsCM joint of thumb-- capsule surrounding the joint serves to restrict motion-- flexion-extension axis and abduction-adduction axis at the joint are not perpendicular to each other or to the bones and do not intersectCM and IM joints of the fingers are mutually surrounded by joint capsules that are reinforced by the dorsal, volar, and two interosseous CM ligaments; V-shaped interosseous ligaments are the strongest.MP joints-- the knuckles-- rounded distal heads of metacarpals articulate with concave proximal ends of the phalanges-- each is enclosed in a capsule reinforced by strong collateral ligaments-- close-packed positions: MP joints in the fingers: full flexion; thumb: oppositionPIP and DIP joints of the fingers, and single IP joint of the thumb-- hinge joints-- articular capsule joined by volar and collateral ligaments surrounds each IP joint-- close-packed position of full extensionflexor retinaculum-- protects extrinsic flexor tendons and median nerve as they pass into the hand through the carpal tunnel on the palmar sideextensor retinaculum-- protects extrinsic extensor tendons on the dorsal side of the wrist
9 Muscles (cont.) Tendon sheaths Level of the metacarpal heads – point where flexor tendons enter a flexor tendon sheathAnnular pulleysKeep flexor tendons and sheath closely applied to phalangesCruciate pulleysCollapse to allow full digital flexiontendon sheaths-- a double-walled hollow tube sealed at both ends-- provides low-friction gliding and nutrition for the flexor tendons-- annular pulleys or cruciform pulleys – series of retinacular thickenings
10 Nerves Median nerve Radial nerve Ulnar nerve median nerve -- majority of flexors of wrist and hand, as well as intrinsic flexors on the radial side of the palm-- cutaneous sensation – lateral two-thirds of palm and dorsum of 2nd and 3rd fingersulnar nerve-- flexor carpi ulnaris and ulnar portion of flexor digitorum profundus and most intrinsic muscles-- cutaneous sensation to 5th and half of 4th finger on both dorsal and palmar sidesradial nerve-- divides into superficial and deep branches distal to the lateral epicondyle of the elbow-- superficial branch: skin on the dorsum of the hand; deep branch: most of extensor muscles of forearm
11 Blood Vessels Radial artery Ulnar artery Numerous divisions -- muscles on the radial side of the forearm, as well as the thumb and index fingerulnar artery-- divides into anterior and posterior interosseous arteries, which supply the deep flexor muscles and extensor muscles of forearm, respectively-- in palm, radial and ulnar arteries merge to form the superficial and deep palmar arches-- digital arteries branch from the palmar arches to supply the fingers, and branches from the carpal arch run distally along the metacarpal bones-- radial artery is superficial on the anterior aspect of wrist; pulse is readily palpable
12 Kinematics Wrist movements Flexion Extension/ hyperextension Radial deviationUlnar deviationCircumductionmajor flexor muscles of the wrist-- flexor carpi radialis and flexor carpi ulnaris-- palmaris longus, which is often absent in one or both forearms, contributes to flexion-- flexor digitorum superficialis and flexor digitorum profundus assist with flexion at the wrist when the fingers are completely extended, but when the fingers are in flexion, these muscles cannot develop sufficient tension to assistmajor extensor muscles of the wrist-- extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris-- extensor pollicis longus, extensor indicis, extensor digiti minimi, and extensor digitorum assist with extension movements, particularly when the fingers are in flexionFlexor and extensor muscles of the wrist cooperatively develop tension to produce radial and ulnar deviation of the hand at the wrist.-- radial deviation - flexor carpi radialis and extensor carpi radialis-- ulnar deviation - flexor carpi ulnaris and extensor carpi ulnaris
13 Kinematics (cont.) CM Thumb – flexion, extension, abduction, adduction MP – fingersFingers – minimal motionFlexionExtensionAbductionAdductionCM joint of the thumb allows a large range of movement, comparable to that of a ball-and-socket joint; 5th CM joint permits significantly less range of motion and only a very small amount of motion is allowed at the 2nd to 4th carpometacarpal joints, due to the presence of restrictive ligaments.
16 Kinetics Wrist flexors of hand are 2× stronger than extensor muscles GripsPowerPrecisionLateral pinch; fencingMaximum grip strength – exerted with wrist in ulnar deviation and slight hyperextensionExtrinsic flexor muscles of the hand are more than twice as strong as the extrinsic extensor muscles; the flexor muscles of the hand are used extensively in everyday activities involving gripping, grasping, or pinching movements, while the extensor muscles rarely exert much force.power grip-- typified by the baseball bat grip-- the fingers and thumb are used to clamp the grip of the bat against the palm of the hand; wrist is held in a position of ulnar deviation and slight hyperextension to increase the tension in the flexor tendonsprecision grip-- exemplified by the baseball grip-- involves use of the semiflexed fingers and thumb to pinch the ball against the palm, with the wrist in slight hyperextension.lateral pinch; fencing grip-- grip on the foil is essentially a power grip, but with the thumb aligned along the long axis of the foil handle, it enables precise control of the direction of force application
17 Prevention of Injuries Protective equipmentPads and glovesPhysical conditioningStrength and flexibilityExercises for wrist and elbowProper skill techniqueInstruction on fallingA skill technique that can prevent injury of the wrist and hand is proper instruction on the shoulder-roll method of falling; the force of impact is dispersed over a wider area, lessening the risk for injury from direct axial loading on the extended wrist.
18 Contusions and Skin Wounds Always important to consider an underlying fractureContusion S&S: pain & discolorationSkin wounds – typically abrasions and lacerationsManagementStandard acute for closed wound & open woundDirect impact to the hand by any object may lead to abrasions, lacerations, and puncture wounds. Although many are minor, it is always important to be alert for an underlying fracture
19 SprainsWristMechanism: axial loading on proximal palm during fall on outstretched handS&SStandard – sprainSpecificPoint tenderness on dorsum of radiocarpal joint↑ Pain with active or passive extensionNeed to rule out fracture, especially scaphoid fxManagement: standard acute; NSAIDsSprains in wrist and hand are the result either of a single episode of trauma or of repetitive stress.When due to a single episode, the severity of injury is dependent on:-- characteristics of the injury force (i.e., point of application, magnitude, rate, and direction)-- position of the hand at impact-- relative strength of the carpal bones and ligamentsMost injuries result from a compressive load applied while the hand is in some degree of extension, although hyperflexion or rotation may also lead to injury.Sprains-- gymnasts – high incidence of dorsal wrist pain when excessive forces are exerted on the wrist, producing combined hyperextension, ulnar deviation, and intercarpal supination; occur during vaulting, floor exercise, or during pommel horse routines
20 Sprains (cont.) Gamekeeper’s thumb Tear of the UCL of the MP joint Mechanism: MP in extension and forceful abductionS&SPalmar aspect of joint – pain; swelling+ abduction stressManagement: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repairIntegrity of the ulnar collateral ligament at the MP joint is critical for normal hand function because it stabilizes the joint as the thumb is pushed against the index and middle fingers while performing many pinching, grasping, and gripping motions.Gamekeeper’s thumb-- common in football, baseball/softball, hockey, and skiing (falls on the ski pole [skier’s thumb])-- partial tears: only moderate laxity is present and a definite end feel is present-- severe cases: laxity greater than 35° and the absence of an end feel indicate total rupture of the ulnar collateral ligament-- no instability: treatment involves early mobilization accompanied by cryotherapy, contrast baths, ultrasound, and NSAIDs-- joint instability: a thumb spica cast may be applied for 3 to 6 weeks, followed by further taping for another 3 to 6 weeks during risk activities
21 Sprains (cont.) IP sprains Excessive valgus and varus: collateral ligamentsHyperextension stress: volar plateS&SRapid swelling; masks conditionX-ray: rule out fracture and dislocationManagement: standard acute; “buddy” tapingIP Collateral Ligament Sprains-- ligament failure usually occurs at its attachment to the proximal phalanx or, less frequently, in the mid-portionS&S-- obvious deformity may not be present, unless there is a fracture or total rupture of the supporting tissues that causes a dorsal dislocation
22 Dislocations Distal radioulnar joint (DRUJ) Isolated or with radial fractureMechanism: hyperextensionWith hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocationDislocations are often caused by a fall on the outstretched hand or from traumatic hyperflexion, hyperextension, or rotary movement.DRUJ dislocation-- triangular fibrocartilage complex (TFCC) functions as a sling to support the ulnar border of the wrist and connects the distal ulna to the ulnar side of the radius – dislocation can result in damage to some portion of this complex or to its attachments-- clinical appearance can vary significantly depending on the presence or absence of an associated fracture-- prognosis and rehabilitation program depend on the extent of tissue damage and instability; simple DRUJ dislocations may be stabilized after the internal fixation of associated fractures and immobilized in an above-the-elbow cast
23 Dislocations (cont.) S&S Pain; deformity; extensive swelling Dorsal dislocation – ulnar head prominent dorsally; volar dislocation – wrist appears narrow (result of overlap of the distal radius and ulna)elbow flexion and extension – normal unless fracture present; pronation and supination of forearm – limitedManagement: immobilization of limb in vacuum splint; immediate transportation to physician
24 Dislocations (cont.) Lunate Axial loading displaces in volar direction S&SPoint tenderness – dorsum of hand just distal to radiusThickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal)Passive and active motion may not be painfulCaution: bone into carpal tunnel – compression of median nerveManagement: immobilization of limb in vacuum splint; immediate transportation to physicianlunate dislocation-- shape of the lunate and its position between the large capitate and lower end of the radius; particularly prone to dislocation-- as force initially impacts the carpals, the distal row is displaced away from lunate, resulting in lunate resting dorsally relative to other carpals (perilunate dislocation); if force continues to extend wrist, dorsal ligaments rupture, relocating the carpals and rotating the lunate; lunate then rests volarly relative to other carpals (lunate dislocation)-- compression of median nerve – pain, numbness, and tingling in 1st & 2nd fingers-- following reduction, the wrist is immobilized in moderate flexion with a silicone cast for 3 to 4 weeks; the wrist is then placed into a neutral position and protected from any wrist extension, particularly during sport participation-- condition is often overlooked until complications (e.g., flexor tendon contractures and median nerve palsies) arise from chronic dislocations-- repeated trauma to lunate can lead to vascular compromise, resulting in degeneration or osteochondritis of lunate - Kienböck’s disease
26 Dislocations (cont.) Fingers Can involve collateral ligaments and volar plateMCPRare, but easily recognizableHyperextension or shearPIPHyperextension and axial loading (e.g., ball striking extended finger)DIPUsually occur dorsallyIndividual often reduces injury on their ownMCP joint dislocations-- hyperextension or a shearing force causes the anterior capsule to tear, allowing the proximal phalanx to move backward over the metacarpal and stand at a 90° angle to the metacarpalPIP joint-- because digital nerves and vessels run along the sides of the fingers and thumb, these dislocations are potentially seriousDIP jointMCP joint dislocations,S&S-- pain will be present at the joint line and will increase when the mechanism is reproducedManagement-- stable MCP joint injury: protection with buddy taping for 2-3 weeks is usually sufficient-- uncomplicated dislocation of the PIP joint: finger may be splinted in about 30° of flexion with active motion started at 10 to 14 days-- volar displaced PIP dislocations with suspected central slip injury: PIP joint splinted in complete extension for 6 full weeks.-- if inadequately managed, dislocations at the PIP joint can result in a painful, stiff finger with a fixed flexion deformity called a “coach’s finger”-- if volar plate is trapped in the joint, the deformity may result in the PIP joint being held in flexion and the DIP joint in hyperextension (a pseudo-boutonnière deformity)-- DIP joint dislocation: splint the DIP joint with a volar splint for approximately 3 weeks
29 StrainsJersey fingerRupture of flexor digitorum profundus from distal phalanxMechanism: rapid extension (from active flexion)S&SUnable to flex the DIPPalpate tendon in proximal aspect of fingerHematoma formation along the entire flexor tendon sheathManagement: standard acute; physician referralJersey finger (profundus tendon rupture)-- injury typically occurs when gripping an opponent’s jersey while opponent simultaneously twists and turns to get away; jerking motion may force the fingers to rapidly extend-- ring finger is most commonly involved, because this finger assumes a position of slight extension relative to the other, more flexed fingers during grip-- if a portion of bone is also avulsed, it may become trapped distal to the A4 pulley over the middle phalanx or distal to the A2 pulley, or it may retract all the way into the palmManagement-- in cases where the tendon has retracted into the palm, surgical reattachment of the tendon must be performed within 7 to 10 days
30 Strains (cont.) Mallet finger Rupture of extensor tendon from distal phalanxMechanism: forceful flexion of PIPS&SPain, swellingLack of extension at DIPManagement: standard acute; physician referralmallet finger, or baseball finger-- an object hits the end of the finger while the extensor tendon is taut, such as when catching a ball; resulting forceful flexion can avulse the lateral bands of the extensor mechanism from its distal attachment-- treatment usually involves splinting the DIP joint in complete extension for 6 to 8 weeks
31 Strains (cont.) Boutonnière deformity Rupture of central slip of extensor tendon at the middle phalanxMechanism: rapid forceful flexion of PIPResult: hyperextension at MCP, flexion of PIP, hyperextension of DIPS&SNo active extensionDeformity usually not present immediately, but develops over 2-3 weeksManagement: standard acute; injury that limits PIP extension to <30º: immediate physician referralBoutonnière deformity-- caused by blunt trauma to dorsal aspect of PIP joint, or by rapid, forceful flexion of the joint against resistance-- deformity develops over 2-3 weeks as the lateral slips move in a palmar direction and cause hyperextension at the MCP joint, flexion at the PIP joint, and hyperextension at the DIP joint-- pseudo-boutonnière deformity – injury to volar plate leads to a flexion deformity of the PIP joint (resembles a boutonnière deformity), but central slip of extensor tendon is not involved-- injury that limits PIP extension to 30° or less and produces dorsal tenderness over the base of the middle phalanx should be treated as an acute tendon rupture and immediately referred to a physician; initial treatment involves splinting the PIP joint in complete extension for 5-6 weeks with the DIP joint free to move
33 Strains (cont.) Tendinopathies tendinopathies -- strenuous and repetitive training often inflames tendons and tendon sheaths in the wrist and hand-- macrotraumatic, involving acute tissue destruction, or microtraumatic, from chronic loading-- overuse can lead to derangement of both the mechanic and physiologic components of the normal tendon and is clinically referred to as tendinitis-- tendons most at risk for injury when tension is applied rapidly at an oblique angle
34 Strains (cont.) Tendinopathies Trigger finger Finger flexors contract but are unable to re-extendDue to a nodule within tendon sheath or sheath too constricted to allow free motionS&SLocking usually occurs when wakening from sleepPainful popping sensation when PIP joint is passively returned to extensionManagement: NSAIDs, resting finger; splinting when necessary; possible cortisone injections into the sheathtrigger finger-- may be present in individuals who have multiple, severe trauma to the palmar aspect of the hand or who perform repeated movement and clenching of the fingers-- most commonly occurs to the middle or ring finger, but may occur at the thumb and other fingers-- additional palpable crepitus may indicate an underlying systemic disease (e.g., systemic sclerosis, rheumatoid arthritis, granulomatous infection)-- treatment – often, an incision proximal to the palpable nodule is necessary to cut the annular ligament and allow the tendon to slide freely
36 Strains (cont.) de Quervain's tenosynovitis Stenosing tenosynovitis of APL and EPBA forceful grasp, combined with repetitive use of thumb and ulnar deviationS&SPain over radial styloid process ↑ with thumb and wrist motionPoint tenderness over the tendonsPain with RROM thumb abduction+ Finkelstein’s testManagement: standard acute; NSAIDSde Quervain’s tenosynovitis-- sports such as racquet sports, golf, fly fishing, and javelin and discus throwing place a high demand on the abductor pollicis longus (APL) and extensor pollicis brevis (EPB)-- tendons share a single synovial tendon sheath that travels through a bony groove over the radiostyloid process, then turns sharply as much as 105° to enter the thumb when the wrist is in radial deviation-- tenosynovitis results from friction between the tendons, the stenosing sheath, and the bony process; tendons slide within the sheath not only during movements of the thumb, but also in movements of the wrist with the thumb fixed, as in bowling and throwing-- if symptoms are not relieved, steroid injections or immobilization with a thumb spica for 3 weeks, or both, may be helpful; in severe cases, surgical decompression may be necessary
38 Strains (cont.) Intersection syndrome Tendinitis or friction tendinitis in 1st and 2nd dorsal compartments of wristOveruse of radial extensors by excessive curlingS&SPoint tenderness on the dorsum of the forearm, 2-3 finger breadths proximal to the wrist jointCrepitus with AROM or PROMManagement: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activitiesintersection syndrome-- has been described in rowers, indoor racket players, canoeists, and weight lifters-- muscle and tendons of these two compartments traverse each other at a 60° angle, two to three finger breadths proximal to the wrist joint on the dorsal aspect (4-6 cm proximal to Lister’s tubercle)-- treatment: corticosteroid injection may be necessary to relieve acute symptoms
39 Strains (cont.) Dupuytren’s contracture Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformityS&SFixed flexion deformity is visibleFinger cannot be extendedManagement: surgical repairDupuytren’s contracture-- rare, but can impact normal function of the fingers-- occurs more frequently on the ring finger or little finger
40 Strains (cont.) Gymnast’s wrist Stress fracture to distal radial epiphyseal plateMechanism: compression (maximum dorsiflexion)S&S:Diffuse tenderness – dorsum of midcarpal area↑ pain with extreme motionManagement: splinting; NSAIDs; activity modificationgymnast’s wrist-- repetitive performance on the pommel horse and uneven bars causes excessive wrist loading, leading to pain over the dorsum of the wrists-- maximum dorsiflexion, as occurs in vaulting, tumbling, and beam work-- treatment: complete resolution of symptoms may require up to 3-6 months; dorsal block splint may be beneficial for practice and competition to avoid extremes of wrist extension
41 Strains (cont.) Ganglion cysts Benign tumor mass on dorsal aspect of wristAssociated with tissue sheath degenerationTreatment: symptomaticganglion cysts-- cyst itself contains a jelly-like, colorless fluid of mucin, and is freely mobile and palpable-- occurring spontaneously, cysts seldom cause any pain or loss of motion; as the ganglion increases in size, discomfort from the pressure may occur-- treatment: aspiration, injection, and rupture of the cyst have not proven successful because the condition may recur; surgical excision remains the treatment of choice
42 Finger Tip Injuries Subungual hematoma Blood under fingernail Due to direct traumaNeed to rule out fractureManagementSoak in ice water for minutesIf pain does not diminish, may need to be drained under supervision of a physicianRefer to Application Strategy 16.1subungual hematomaIncreasing pressure can lead to throbbing pain.If the pain diminishes, it may not be necessary to drain the hematoma. This is preferable, as draining the hematoma opens an avenue for infection.If discomfort interferes with the ability to perform physical activities, the hematoma should be drained under the direction of a physician. This is performed by cutting a hole through the nail with a rotary drill or a no. 11 surgical blade, or melting a hole through the nail with the end of a paper clip heated to a bright red color.Refer to Field Strategy 15.1
44 Finger Tip Injuries (cont.) ParonychiaInfection along nail foldFold is red, swollen, and painful; can produce purulent drainageManagementWarm water soaks and germicide.More severe cases, physician referralParonychiacommonly seen with a hangnail and in individuals whose hands are frequently immersed in watercondition is treated with warm water soaks and germicidemore severe cases, the physician may recommend systemic antibiotics and drainage of localized pus, or may perform a partial-nail resection
45 Nerve Entrapment Syndromes Median nerveAnterior interosseous nerve syndromeFollowing set of strenuous or repetitive elbow motion exercisesAffects motor but not sensationS&SAcute – sudden loss of use of flexor pollicis longus index finger profundus tendonsGradual – weakness becomes apparent during heavy activity+ pinch grip testManagement: splint extremity; avoid heavy activitynerve entrapment-- susceptible due to narrow spaces nerves must pass through-- mechanism: repetitive compression, contusion, or traction
46 Nerve Entrapment Syndromes (cont.) Carpal tunnel syndromeMedian nerve, finger flexors, and flexor pollicis longusDue to direct trauma, repetitive overuse, or anatomic anomaliesS&SAwakening pain in middle of night; often relieved by “shaking out their hands”Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger+ Phalen’s maneuver; + Tinel’s signWeak thumb abductionManagement: physician referralmedian nerve entrapmentmedian nerve-- lies medial to brachial artery in the cubital fossa and passes distally between the two heads of the pronator teres-- divides at distal margin to form the anterior interosseous nerve to supply the flexor pollicis longus, flexor digitorum superficialis to index and middle digits, and pronator quadratus-- main trunk continues distally beneath the fibrous arch of the flexor digitorum superficialis-- palmar cutaneous branch supplies sensation to the volar wrist, thenar eminence, and palm; continues through the carpal tunnel beneath the flexor retinaculum to supply sensation to the palm and the radial three and one-half digits-- deep motor branch supplies abductor pollicis brevis, opponens pollicis, superficial head of flexor pollicis brevis, and two lateral lumbricalesanterior interosseous nerve (AIN) syndrome-- may be compression of nerve by fibrous bands from deep head of pronator teres or flexor digitorum superficialis, affecting any or all of muscles innervated by the nerve; no sensory cutaneous portion of the nerve, there will be no sensory changes-- has been reported in “junk” baseball pitchers, weight lifters, gymnasts, tennis players, swimmers, and football playerscarpal tunnel syndrome (CTS)-- most common compression syndrome of wrist and hand, but not commonly seen in the physically active population-- typically seen in dominant extremity-- sporting activities with predisposition: activities that involve repetitive or continuous flexion and extension of the wrist, such as cycling, throwing sports, racquet sports, archery, and gymnastics-- etiologies other than traumatic causes include: infectious origin (e.g., diphtheria, mumps, influenza, pneumonia, meningitis, malaria, syphilis, typhoid, dysentery, tuberculosis, gonococcus); metabolic causes (e.g., hypothyroidism, diabetes, rheumatoid arthritis, gout, vitamin deficiency, heavy metals poisoning, and carbon monoxide poisoning)S&S-- relieved by “shaking out their hands”; + “flick”-- generally, only one extremity is affected-- grip strength and pinch strength may be limited-- common complaint is difficulty manipulating coins-- diminished sensitivity to pain and weak thumb abduction are more predictive of abnormal nerve conductionManagement-- immobilization in slight wrist extension with a dorsal splint is used to rest the wrist for up to 3-5 weeks, particularly at night when symptoms occur-- ice cup or ice bag, NSAIDs, or in some situations, diuretics, can initially reduce swelling and pain in the area caused by tenosynovitis-- compression wrap should be avoided-- in cases that do not respond well to conservative treatment, surgical decompression or carpal tunnel release can be performed
48 Nerve Entrapment Syndromes (cont.) Ulnar nerve entrapmentUlnar tunnel syndromeDue to repetitive compressive trauma to the palmar aspect of the handS&SNumbness in the ulnar nerve distribution (especially little finger)+ Froment’s signSlight weakness in grip strength+ Tinel’s signManagement: splinting, NSAIDs; activity modificationUlnar Nerve EntrapmentThe ulnar nerve passes through the ulnar groove posterior to the medial epicondyle, to enter the cubital tunnel formed by the aponeurosis and two heads of the flexor carpi ulnaris. The nerve continues distally between the flexor digitorum profundus dorsally and the flexor carpi ulnaris palmarly. The palmar cutaneous nerve arises in the midforearm to supply the proximal hypothenar eminence. The dorsal cutaneous nerve arises 5 to 8 cm proximal to the ulnar styloid and supplies the dorsum of the ulnar side of the hand. In the wrist, the nerve courses between the hook of the hamate and pisiform, then passes through Guyon’s canal to move distally into the fingers.The superficial branch supplies the overlying palmaris brevis, then becomes entirely sensory to supply the hypothenar eminence and ring and small fingers. The deep branch curves around the hook of the hamate to supply the ulnar intrinsics, ending its terminal branch in the first dorsal interossei.ulnar tunnel syndrome-- may occur as the nerve enters the ulnar tunnel, or as the deep branch curves around the hook of the hamate and traverses the palm-- frequently seen in cycling, racquet sports, and in baseball/softball catchers, hockey goalies, and handball players-- distal ulnar nerve palsy may also be seen as a push-up palsy, following fractures of the hook of the hamate, or caused by a missed golf shot or baseball swingS&S-- may present with motor, sensory, or mixed symptoms-- coincident involvement of the median nerve is common-- atrophy of the hypothenar mass may also be present-- Tinel’s sign: tapping just distal to the pisiform bone-- management: if symptoms do not disappear within 6 months of conservative treatment, surgical decompression of Guyon’s canal may be necessary
50 Nerve Entrapment Syndromes (cont.) Cyclist's palsyDue to leaning on handlebar for extended period; leads to swelling in hypothenar areaSymptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of rideKey: proper padding; varying hand positionBowler’s thumbCompression of ulnar digital sensory nerveS&SNumbness, tingling, or pain – medial aspect of thumbManagement: standard acute; NSAIDs; immobilizationbowler’s thumb-- compression of the ulnar digital sensory nerve, on the medial aspect of the thumb in the web space, while gripping the ball; constant pressure on this spot can lead to scarring in the area-- radial digital nerve of the index finger is similarly at risk in racquet sports-- athletic trainers develop similar symptoms from excessive use of dull scissors or added pressure on the thumb as one cuts through thick tape-- no true motor involvement; grip strength may be decreased secondary to pain-- management: depends on the stage of injury; since the predominant cause is inflammatory in nature, treatment is directed at reducing inflammation; cryotherapy, immobilization with a molded plastic thumb guard, NSAIDs, and corticosteroid injection, if needed, are usually successful in relieving symptoms
51 Nerve Entrapment Syndromes (cont.) Radial nerve entrapmentDistal posterior interosseous nerve syndromeDue to compression associated with repetitive and forceful wrist dorsiflexionS&SDeep, dull ache in wrist, reproduced with:Forceful wrist extensionDeep palpation of forearm with wrist in flexionManagement: standard acute; activity modificationRadial nerve entrapment-- radial nerve bifurcates near the radiocapitellar joint to become the posterior interosseous and superficial radial nerves-- posterior interosseous nerve travels between the two heads of the supinator, around the proximal radius, and under the forearm extensors to supply terminal articular branches to wrist-- superficial radial nerve travels underneath the brachioradialis to become subcutaneous in the distal forearm and supply sensation to the dorsoradial portion of the hand, including the first web space and the proximal phalanges of the first three digits distal posterior interosseous nerve syndrome- compression of the distal posterior interosseous nerve occurs as it passes dorsally over the distal radius and enters the wrist capsule- gymnasts are particularly prone
52 Nerve Entrapment Syndromes (cont.) Superficial radial nerve entrapmentCompressed at the wristAggravated by repeated pronation and supinationTight wrist strapsS&SBurning pain and sensory changes in dorsoradial aspect of wrist, hand, dorsal thumb, and index finger+ Tinel’s signManagement: standard acute; activity modification
53 Fractures Distal radius/ulna fracture Mechanism: axial loading; fall on outstretched handMonteggia’sDistal ulna with associated dislocation of radial headGaleazzi'sDistal radius with associated dislocation or subluxation of distal radioulnar jointColles’Distal metaphysis of radius, with displacement of distal fragment dorsallydistal radial and ulnar fractures-- in many instances, open reduction and internal fixation with rigid plates and screws are necessary to restore function
54 Fractures (cont.) Distal radius/ulna fracture (cont.) Smith’s Distal radius, with displacement of distal fragment toward palmar aspectS&S: normal fractureConcerns:Circulatory impairmentNerve damageManagement: immobilization in a vacuum splint; immediate physician referral
55 Fractures (cont.) Forearm fractures Forearm fractures. A, Colles’ fracture. The extra-articular distal radial fracture is associated with a fracture of the base of the ulnar styloid. B, Smith’s fracture. This fracture is characterized by a transverse fracture of the distal radius with volar and proximal displacement of the distal radial fragment. C, Monteggia fracture. This type of fracture is characterized by a fracture of the proximal one-third of the ulna accompanied by a dislocation of the radial head. D, Galeazzi’s fracture. The distal radioulnar dislocation is secondary to the marked shortening of the radius caused by the severe ulnar displacement and dorsal angulation of the distal radial fragment.
56 Fractures (cont.) Scaphoid fracture S&S History of falling on an outstretched handPoint tenderness in anatomic snuff boxPain with inward pressure along long axis↑ pain with wrist extension and radial deviationManagement: standard acute; splint; physician referralConcern: aseptic necrosisscaphoid fractures-- most common wrist bone fracture in physically active individuals-- peak incidence years of age-- in many cases, the individual will fall on the wrist, have normal radiographs, and be discharged with a diagnosis of a wrist sprain without further care; several months later, the individual will continue to experience persistent wrist pain; radiographs at this time may reveal an established nonunion fracture of the scaphoid-- common complication: aseptic necrosis because of a poor blood supply to the area-- nondisplaced fracture: immobilized in a thumb spica cast, with wrist in slight radial deviation-- follow-up radiographs are taken at 3- to 4-week intervals to monitor healing and detect signs of delayed union, nonunion, malunion, or avascular necrosis; some fractures may take several weeks or months to heal-- displaced fracture: secured with internal fixation
57 Scaphoid fracture. A, Radiograph of a scaphoid fracture Scaphoid fracture. A, Radiograph of a scaphoid fracture. Nonunion fractures occur when the area has a poor blood supply. B, The scaphoid forms the floor of the anatomical snuff box. It is bounded by the extensor pollicis brevis medially and by the extensor pollicis longus laterally. Increased pain during palpation in this region indicates a possible fracture to the scaphoid bone.
58 Fractures (cont.) Lunate fracture Rare in sports S&S: dorsal wrist pain, swelling, and weakness of wrist associated with useConcern: Kienböck’s diseaseManagement: standard acute; splint; physician referralHamate fractureDirect impact; when striking a stationary object with a racquet or club in full swinglunate fracture/Kienböck’s disease-- difficult to identify and diagnose-- because a large portion of the lunate is cartilage and cancellous bone, minimal pain is present-- Kienböck’s disease can result in loss chronic tenderness, pain, and swelling over the lunate, decreased grip strength, and weakness during wrist extensionhamate fracture-- nonunion fracture; once fractured, the ligamentous insertions of the transverse carpal ligament, the pisohamate ligament, the short flexor, and the opponens digiti minimi act to displace the fragment and prevent union-- care is usually symptomatic, with a protective orthoses worn for 4-6 weeks until tenderness subsides; may be 2-3 months before a racquet or bat will feel comfortable in the hand again
59 Fractures (cont.) S&S Tenderness – hypothenar mass Painful RROM abduction of the small finger↓ grip strengthManagement: standard acute; splint; physician referral
60 Fractures (cont.) Triquetrum fracture Caused by impingement of ulnar styloid into dorsum of triquetrumS&SHistory of acute wrist dorsiflexion injury or direct traumaPain – dorsal wrist over triquetrumManagement: standard acute; splint; physician referralMetacarpal fracture (typical)Mechanism: axial compressiontriquetrum fractures-- ulna tends to shear a portion of bone away from the triquetrum (i.e., chip fracture)-- immobilization in a short-arm cast with mild extension of the wrist for 4-6 weeks-- some fractures may become nonunion and require surgical excisionmetacarpal fractures-- axial compression on the hand can lead to a fracture-dislocation of the proximal end of the metacarpal-- can often go undetected because edema obscures the extent of injury-- management: position of function – palm face down and fingers slightly flexed; an elastic compression bandage should not be applied to a swollen hand, as it may lead to increased distal swelling in the finger
61 Fractures (cont.)S&S:↑ pain and palpable – palm, directly over involved metacarpal↑ pain with percussion and compressionManagement: immobilize in position of function; ice without compression; immediate physician referral
62 Fractures (cont.) Bennett’s fracture Articular fracture – proximal end of first metacarpalMechanism: axial compressionPull of APL tendon displaces shaft proximally; deep volar ligament holds small medial fragment in place → fracture-dislocationS&SLocalized pain and swelling; ↑ pain with inward pressure long axisManagement: standard acute; splint; immediate physician referralBennett’s fracture-- axial compression (e.g., punch is thrown with a closed fist; falling on a closed fist)S&S-- pain and swelling localized over the proximal end of 1st metacarpal-- deformity may or may not be presentPreferred treatment for this fracture is closed reduction and percutaneous pinning for less than 3 mm of fracture displacement, and open reduction and fixation for greater displacements.
63 Bennett fracture. A Bennett fracture usually is associated with a dislocation of the metacarpophalangeal joint of the thumb. An avulsion fracture, however, occurs when a segment of the metacarpal is held in place by the deep volar ligament.Anderson_
64 Fractures (cont.) Rolando fracture Similar to Bennett’s fracture Intra-articular fracture – proximal end of first metacarpal; tends to be more comminutedS&S: same as Bennett’s, but ↑ deformityManagement: standard acute; splint; immediate physician referralRolando fracture-- similar to Bennett’s fracture, a Rolando fracture is an intra-articular fracture of the first metacarpal-- tends to be more comminuted, and the potential for serious complications significantly increases-- open reduction and internal fixation with multiple Kirschner wires may be necessary
65 Fractures (cont.) Boxer’s fracture Distal metaphysis or neck of fourth or fifth metacarpalsInherently unstableS&SSudden pain, inability to grip, rapid swelling, and deformityPoint tenderness; crepitus↑ pain with axial compression and percussionManagement: standard acute; splint; immediate physician referralboxer’s fracture-- typically has an apex dorsal angulation; inherently unstable secondary to the deforming muscle forces and the frequent volar comminution-- closed reduction is followed by immobilization in a splint for 4-6 weeks
66 Boxer’s fracture. These fractures usually involve the fourth and fifth metacarpals.
67 Fractures (cont.) Phalangeal fracture Mechanism: compression; hyperextensionS&S:↑ pain with circulative compression of phalanx↑ pain with percussion and compression (long axis)Management: standard acute; splint; immediate physician referralphalangeal fractures-- caused by having the fingers stepped on or impinged between two hard objects such as a football helmet and the ground, or by hyperextension that may lead to a fracture-dislocationS&S-- particular attention should be given to middle and proximal phalanges; these fractures tend to have marked deformity due to the strong pull of the flexor and extensor tendons; four fingers move as a unit; failure to maintain the longitudinal and rotational alignments of the fingers can lead to long-term disability in grasping or manipulating small objects in the palm of the handManagement-- while the hand is immobilized in a full wrist splint, gauze pads or a gauze roll are placed under the fingers to produce about 30° of finger flexion and reduce the pull of the flexor tendons; immobilization will depend on type of fracture and its location; may vary from 2-4 weeks
68 Phalangeal fracture. This fracture demonstrates a shearing pattern in the diaphysis
69 Assessment History Observation/inspection Expose entire arm Palpation Pain, unable or unwilling to move wrist or hand; determine the possibility of a fracture or dislocation before moving the wrist or handProximal to distalPhysical examination tests
70 Range of Motion (ROM) Active range of motion (AROM) Forearm pronation/supinationWristFlexion/extensionRadial deviation/ulnar deviationFingers and thumbAbduction/adductionOpposition of thumb and little fingerPassive range of motion (PROM)Normal end feel – tissue stretch
71 ROM (cont.) Normal ranges Supination: 90° Pronation: 90° Wrist flexion: 80-90°Wrist extension: 70-90°Radial deviation: 15°Ulnar deviation: 30-45°Goniometry measurement. A, Wrist flexion and extension. The fulcrum is centered over the lateral aspect of the wrist close to the triquetrum. Align the proximal arm along the lateral aspect of the ulna using the olecranon process as a reference. Then, align the distal arm along the midline of the fifth metacarpal. B, Radial and ulnar deviation. Center the fulcrum over the middle of the dorsum of the wrist close to the capitate. Align the proximal arm with the midline of the forearm using the lateral epicondyle as a reference. Then, align the distal arm along the midline of the third metacarpal.
72 ROM (cont.) Resisted range of motion (RROM) Supination Pronation Wrist flexionWrist extensionUlnar deviationRadial deviationFinger flexion/extensionFinger abduction/adductionThumb flexion/extensionThumb abduction/adductionOpposition
73 ROM (cont.)Resisted manual muscle testing. A, Forearm supination and pronation. B, Wrist flexion and extension. C, Ulnar and radial deviation. D, Finger flexion and extension. E, Finger abduction and adduction. F, Thumb flexion and extension.
74 ROM (cont.)G, Thumb abduction and adduction. H, Opposition
75 Stress Tests Wrist ligamentous instability tests Varus and valgus Finger ligamentous instability testsAnterior/posterior glideWristValgus stress (tests UCL)Patient (pt) is seated with forearm supported; elbow flexed 90; forearm pronated; fingers relaxed (neutral/flexed)Examiner sits/stands lateral to pt; one hand grasps distal forearm; other hand across the metacarpalsExaminer applies valgus stress, radially deviating the wristTest is + if: pain and/or increased laxity when compared bilaterally = sprain of UCLVarus stress (tests RCL)Same as valgus, except varus stress is applied, ulnarly deviating the wristTest is + if: pain and/or increased laxity when compared bilaterally = sprain of RCLIP jointsValgus stress (tests collateral ligaments)Pt is sitting or standing; joint being tested placed in extensionExaminer stabilizes phalanx proximal to joint being testedExaminer grasps the distal phalanx to the joint being tested and applies a valgus stress to the jointTest is + if: increased pain, gapping compared bilaterally = collateral ligament sprainVarus stress (tests integrity of joint capsule)Same as valgus, except varus stress is appliedAnterior-posterior glideSame as valgus/varus, except anterior posterior stress is appliedTest is + if: increased pain, gapping compared bilaterally = joint capsule sprainThumbValgus stress (tests integrity of UCL at thumbs)Pt is sitting or standing; examiner in front or to side of ptExaminer stabilizes 1st metacarpal with one hand and proximal phalanx with other handWhile stabilizing 1st metacarpal with the thumb, examiner gently abducts and extends, then applies a valgus stress to the UCLTest is + if: increased laxity on ulnar aspect of 1st MCP joint compared to uninjured side = UCL sprain
76 Special Tests Finkelstein’s test for de Quervain’s tenosynovitis Finkelstein’s test for de Quervain’s syndromePt is standing or seated; examiner in front or to side of ptPt is instructed to make a fist, putting thumb inside and wrapping fingers around thumbPt is instructed to perform ulnar deviation at wrist (could also be performed passively)Test is + if: increased pain over radial styloid process and sheath of EPB and APL tendons = indication: de Quervain’s syndrome
77 Special Tests (cont.)Flexor digitorum superficialis (test for rupture of FDS)Flexor digitorum profundusExtensor tendon ruptureFlexor digitorum superficialis (test for rupture of FDS)Pt’s hand is supported; examiner holds fingers in extension, except for finger being testedPt is instructed to flex the affected finger at the PIP jointTest is + if: inability to flex finger at PIP joint = rupture of FDS tendonFlexor digitorum profundusExaminer isolates DIP joint of affected finger by stabilizing MCP and IP joints in extensionPt is instructed to flex finger at DIP jointTest is + if: inability to flex finger at DIP joint = rupture of FDP tendon/muscle denervatedExtensor tendon rupturePt’s forearm and hand are supported by tableAffected finger flexed 90 at PIP joint over edge of table and held in this position by examinerPt is asked to extend PIP joint while examiner palpates middle phalanxTest is + if: examiner feel little pressure from middle phalanx while the DIP joint is extending = torn extensor tendon
78 Special Tests (cont.) Carpal tunnel compression test Pt is sitting or standingUsing thumbs, examiner applies even pressure over carpal tunnel (30 seconds)+ test = numbing or tingling into palmar aspect of thumbIndication: median nerve compression
79 Special Tests (cont.) Phalen’s wrist flexion test Tinel’s sign Phalen’s test for carpal tunnelPt is standing or seated; examiner in front of ptPt maximally flexes wrists so that dorsal aspects of two hands are together (make sure pt doesn’t shrug shoulders) OR examiner passively flexes affected wrist, holding it with overpressurePosition is held for 1 minuteTest is + if: tingling in median nerve distribution of hand = carpal tunnel syndrome (median nerve compression)Tinel’s sign (at the wrist, nerve compression)Pt has forearm supinated and supported by table or examiner; wrist neutral/extendedExaminer taps over the carpal tunnel at the wrist (over median nerve)Test is + if: numbness, tingling, pain radiating into middle finger = carpal tunnel syndrome (median nerve compression)
80 Special Tests (cont.)Pinch-grip test for anterior interosseous nerve entrapmentPinch grip (test for nerve compression)Pt is standing or seated; examiner in front of ptExaminer instructs pt to pinch the tip of the index finger and thumbTest is + if: abnormal pulp-to-pulp pinch = indication: anterior interosseous nerve compression
81 Special Tests (cont.) Froment’s sign for ulnar nerve paralysis Allen test for circulationFroment’s sign (test for ulnar nerve damage)Pt is standing or seated; examiner in front of ptPt is instructed to grasp a piece of paper between the thumb and index fingerExaminer attempts to take the paper awayTest is + if: distal phalanx of the thumb flexes to hold the paper = paralysis of abductor pollicis muscle (ulnar nerve damage)
82 Fracture Assessment Compression Pt’s hand is supported Examiner applies compression along the long the axis of the boneTest is + if: pain felt at the injury site = fracturePercussionExaminer applies percussion at the end of the boneDistractionExaminer applies distraction at the end of the boneTest is + if: pain is decreased = fracture
85 Rehabilitation Restoration of motion Concern: joint contractures and stiffness – begin AROM ASAPUse of opposite hand to supply loadRestoration of proprioception and balanceClosed-chain exercisesMuscular strength, endurance, and powerOpen-chain exercisesPNF-resisted exercisesCardiovascular fitness
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