Presentation is loading. Please wait.

Presentation is loading. Please wait.

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16.

Similar presentations


Presentation on theme: "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16."— Presentation transcript:

1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16

2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy

3 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist Articulations Radiocarpal joint –Radius with scaphoid, lunate, and triquetrum –Condyloid joint –Sagittal plane motions (i.e., flexion, extension, and hyperextension) –Frontal plane motions (i.e., radial deviation and ulnar deviation) –Circumduction

4 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist Articulations (cont.) Intercarpal joints –Gliding joints –Minimal contribution to wrist movement Distal radioulnar joint –Immediately adjacent to radiocarpal joint –TFCC – stabilizer

5 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hand Articulations Carpometacarpal joints (CM) –Thumb Saddle joint –Fingers Gliding joints Intermetacarpal joints (IM) Metacarpophalangeal joints (MP) –Condyloid joints Interphalangeal joints (IP) –PIP and DIP hinge joints

6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles

7 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles (cont.)

8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles (cont.)

9 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscles (cont.) Tendon sheaths –Level of the metacarpal heads – point where flexor tendons enter a flexor tendon sheath –Annular pulleys Keep flexor tendons and sheath closely applied to phalanges –Cruciate pulleys Collapse to allow full digital flexion

10 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerves Median nerve Radial nerve Ulnar nerve

11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Blood Vessels Radial artery Ulnar artery Numerous divisions

12 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics Wrist movements –Flexion –Extension/ hyperextension –Radial deviation –Ulnar deviation –Circumduction

13 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) CM –Thumb – flexion, extension, abduction, adduction MP – fingers –Fingers – minimal motion –Flexion –Extension –Abduction –Adduction

14 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) MP – thumb –Flexion –Extension IP –Flexion –Extension

15 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (Cont’d)

16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics Wrist flexors of hand are 2× stronger than extensor muscles Grips –Power –Precision –Lateral pinch; fencing –Maximum grip strength – exerted with wrist in ulnar deviation and slight hyperextension

17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Injuries Protective equipment –Pads and gloves Physical conditioning –Strength and flexibility –Exercises for wrist and elbow Proper skill technique –Instruction on falling

18 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions and Skin Wounds Always important to consider an underlying fracture Contusion S&S: pain & discoloration Skin wounds – typically abrasions and lacerations Management –Standard acute for closed wound & open wound

19 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains Wrist –Mechanism: axial loading on proximal palm during fall on outstretched hand –S&S Standard – sprain Specific  Point tenderness on dorsum of radiocarpal joint  ↑ Pain with active or passive extension –Need to rule out fracture, especially scaphoid fx –Management: standard acute; NSAIDs

20 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains (cont.) Gamekeeper’s thumb –Tear of the UCL of the MP joint –Mechanism: MP in extension and forceful abduction –S&S Palmar aspect of joint – pain; swelling + abduction stress –Management: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repair

21 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains (cont.) IP sprains –Excessive valgus and varus: collateral ligaments –Hyperextension stress: volar plate –S&S Rapid swelling; masks condition –X-ray: rule out fracture and dislocation –Management: standard acute; “buddy” taping

22 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocations Distal radioulnar joint (DRUJ) –Isolated or with radial fracture –Mechanism: hyperextension With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation

23 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 – limited –Management: immobilization of limb in vacuum splint; immediate transportation to physician

24 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocations (cont.) Lunate –Axial loading displaces in volar direction –S&S Point tenderness – dorsum of hand just distal to radius Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal) Passive and active motion may not be painful –Caution: bone into carpal tunnel – compression of median nerve –Management: immobilization of limb in vacuum splint; immediate transportation to physician

25 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

26 Dislocations (cont.) Fingers –Can involve collateral ligaments and volar plate –MCP Rare, but easily recognizable Hyperextension or shear –PIP Hyperextension and axial loading (e.g., ball striking extended finger) –DIP Usually occur dorsally Individual often reduces injury on their own

27 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocations (cont.) –S&S: swollen, painful finger –Management: immobilization; ice; immediate physician referral

28 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocations (cont.)

29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains Jersey finger –Rupture of flexor digitorum profundus from distal phalanx –Mechanism: rapid extension (from active flexion) –S&S Unable to flex the DIP Palpate tendon in proximal aspect of finger Hematoma formation along the entire flexor tendon sheath –Management: standard acute; physician referral

30 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Mallet finger –Rupture of extensor tendon from distal phalanx –Mechanism: forceful flexion of PIP –S&S Pain, swelling Lack of extension at DIP –Management: standard acute; physician referral

31 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Boutonnière deformity –Rupture of central slip of extensor tendon at the middle phalanx –Mechanism: rapid forceful flexion of PIP –Result: hyperextension at MCP, flexion of PIP, hyperextension of DIP –S&S No active extension Deformity usually not present immediately, but develops over 2-3 weeks –Management: standard acute; injury that limits PIP extension to <30º: immediate physician referral

32 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

33 Strains (cont.) Tendinopathies

34 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Tendinopathies –Trigger finger Finger flexors contract but are unable to re-extend Due to a nodule within tendon sheath or sheath too constricted to allow free motion S&S  Locking usually occurs when wakening from sleep  Painful popping sensation when PIP joint is passively returned to extension Management: NSAIDs, resting finger; splinting when necessary; possible cortisone injections into the sheath

35 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

36 Strains (cont.) –de Quervain's tenosynovitis Stenosing tenosynovitis of APL and EPB A forceful grasp, combined with repetitive use of thumb and ulnar deviation S&S  Pain over radial styloid process ↑ with thumb and wrist motion  Point tenderness over the tendons  Pain with RROM thumb abduction  + Finkelstein’s test Management: standard acute; NSAIDS

37 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) –de Quervain's tenosynovitis

38 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Intersection syndrome –Tendinitis or friction tendinitis in 1st and 2nd dorsal compartments of wrist –Overuse of radial extensors by excessive curling –S&S Point tenderness on the dorsum of the forearm, 2-3 finger breadths proximal to the wrist joint Crepitus with AROM or PROM –Management: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activities

39 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Dupuytren’s contracture –Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformity –S&S Fixed flexion deformity is visible Finger cannot be extended –Management: surgical repair

40 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Gymnast’s wrist –Stress fracture to distal radial epiphyseal plate –Mechanism: compression (maximum dorsiflexion) –S&S: Diffuse tenderness – dorsum of midcarpal area ↑ pain with extreme motion –Management: splinting; NSAIDs; activity modification

41 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont.) Ganglion cysts –Benign tumor mass on dorsal aspect of wrist –Associated with tissue sheath degeneration –Treatment: symptomatic

42 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Finger Tip Injuries Subungual hematoma –Blood under fingernail –Due to direct trauma –Need to rule out fracture –Management Soak in ice water for minutes If pain does not diminish, may need to be drained under supervision of a physician Refer to Application Strategy 16.1

43 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

44 Finger Tip Injuries (cont.) Paronychia –Infection along nail fold –Fold is red, swollen, and painful; can produce purulent drainage –Management Warm water soaks and germicide. More severe cases, physician referral

45 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes Median nerve –Anterior interosseous nerve syndrome Following set of strenuous or repetitive elbow motion exercises Affects motor but not sensation S&S Acute – sudden loss of use of flexor pollicis longus index finger profundus tendons Gradual – weakness becomes apparent during heavy activity + pinch grip test Management: splint extremity; avoid heavy activity

46 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) –Carpal tunnel syndrome Median nerve, finger flexors, and flexor pollicis longus Due to direct trauma, repetitive overuse, or anatomic anomalies S&S  Awakening 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 sign  Weak thumb abduction Management: physician referral

47 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) Carpal tunnel

48 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) Ulnar nerve entrapment –Ulnar tunnel syndrome Due to repetitive compressive trauma to the palmar aspect of the hand S&S  Numbness in the ulnar nerve distribution (especially little finger)  + Froment’s sign  Slight weakness in grip strength  + Tinel’s sign Management: splinting, NSAIDs; activity modification

49 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) Ulnar nerve entrapment

50 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) –Cyclist's palsy Due to leaning on handlebar for extended period; leads to swelling in hypothenar area Symptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of ride Key: proper padding; varying hand position –Bowler’s thumb Compression of ulnar digital sensory nerve S&S  Numbness, tingling, or pain – medial aspect of thumb Management: standard acute; NSAIDs; immobilization

51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) Radial nerve entrapment –Distal posterior interosseous nerve syndrome Due to compression associated with repetitive and forceful wrist dorsiflexion S&S Deep, dull ache in wrist, reproduced with:  Forceful wrist extension  Deep palpation of forearm with wrist in flexion Management: standard acute; activity modification

52 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont.) –Superficial radial nerve entrapment Compressed at the wrist  Aggravated by repeated pronation and supination  Tight wrist straps S&S  Burning pain and sensory changes in dorsoradial aspect of wrist, hand, dorsal thumb, and index finger  + Tinel’s sign Management: standard acute; activity modification

53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures Distal radius/ulna fracture –Mechanism: axial loading; fall on outstretched hand –Monteggia’s Distal ulna with associated dislocation of radial head –Galeazzi's Distal radius with associated dislocation or subluxation of distal radioulnar joint –Colles’ Distal metaphysis of radius, with displacement of distal fragment dorsally

54 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Distal radius/ulna fracture (cont.) –Smith’s Distal radius, with displacement of distal fragment toward palmar aspect –S&S: normal fracture –Concerns: Circulatory impairment Nerve damage –Management: immobilization in a vacuum splint; immediate physician referral

55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Forearm fractures

56 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Scaphoid fracture –S&S History of falling on an outstretched hand Point tenderness in anatomic snuff box Pain with inward pressure along long axis ↑ pain with wrist extension and radial deviation –Management: standard acute; splint; physician referral –Concern: aseptic necrosis

57 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

58 Fractures (cont.) Lunate fracture –Rare in sports –S&S: dorsal wrist pain, swelling, and weakness of wrist associated with use –Concern: Kienböck’s disease –Management: standard acute; splint; physician referral Hamate fracture –Direct impact; when striking a stationary object with a racquet or club in full swing

59 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) –S&S Tenderness – hypothenar mass Painful RROM abduction of the small finger ↓ grip strength –Management: standard acute; splint; physician referral

60 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Triquetrum fracture –Caused by impingement of ulnar styloid into dorsum of triquetrum –S&S History of acute wrist dorsiflexion injury or direct trauma Pain – dorsal wrist over triquetrum –Management: standard acute; splint; physician referral Metacarpal fracture (typical) –Mechanism: axial compression

61 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) –S&S: ↑ pain and palpable – palm, directly over involved metacarpal ↑ pain with percussion and compression –Management: immobilize in position of function; ice without compression; immediate physician referral

62 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Bennett’s fracture –Articular fracture – proximal end of first metacarpal –Mechanism: axial compression –Pull of APL tendon displaces shaft proximally; deep volar ligament holds small medial fragment in place → fracture-dislocation –S&S Localized pain and swelling; ↑ pain with inward pressure long axis –Management: standard acute; splint; immediate physician referral

63 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

64 Fractures (cont.) Rolando fracture –Similar to Bennett’s fracture –Intra-articular fracture – proximal end of first metacarpal; tends to be more comminuted –S&S: same as Bennett’s, but ↑ deformity –Management: standard acute; splint; immediate physician referral

65 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Boxer’s fracture –Distal metaphysis or neck of fourth or fifth metacarpals –Inherently unstable –S&S Sudden pain, inability to grip, rapid swelling, and deformity Point tenderness; crepitus ↑ pain with axial compression and percussion –Management: standard acute; splint; immediate physician referral

66 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

67 Fractures (cont.) Phalangeal fracture –Mechanism: compression; hyperextension –S&S: ↑ pain with circulative compression of phalanx ↑ pain with percussion and compression (long axis) –Management: standard acute; splint; immediate physician referral

68 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 hand –Proximal to distal Physical examination tests

70 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Motion (ROM) Active range of motion (AROM) –Forearm pronation/supination –Wrist Flexion/extension Radial deviation/ulnar deviation –Fingers and thumb Flexion/extension Abduction/adduction Opposition of thumb and little finger Passive range of motion (PROM) –Normal end feel – tissue stretch

71 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Normal ranges –Supination: 90° –Pronation: 90° –Wrist flexion: 80-90° –Wrist extension: 70-90° –Radial deviation: 15° –Ulnar deviation: 30-45°

72 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Resisted range of motion (RROM) –Supination –Pronation –Wrist flexion –Wrist extension –Ulnar deviation –Radial deviation –Finger flexion/extension –Finger abduction/adduction –Thumb flexion/extension –Thumb abduction/adduction –Opposition

73 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

74 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

75 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Tests Wrist ligamentous instability tests –Varus and valgus Finger ligamentous instability tests –Varus and valgus –Anterior/posterior glide

76 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests Finkelstein’s test for de Quervain’s tenosynovitis

77 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Flexor digitorum superficialis (test for rupture of FDS) Flexor digitorum profundus Extensor tendon rupture

78 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Carpal tunnel compression test

79 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Phalen’s wrist flexion test Tinel’s sign

80 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Pinch-grip test for anterior interosseous nerve entrapment

81 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Froment’s sign for ulnar nerve paralysis Allen test for circulation

82 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fracture Assessment

83 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests Myotomes –Scapular elevation - C4 –Shoulder abduction - C5 –Elbow flexion and/or wrist extension - C6 –Elbow extension and/or wrist flexion - C7 –Thumb extension and/or ulnar deviation - C8 –Abduction and/or adduction of fingers - T1 Reflexes –Biceps - C5-C6 –Brachioradialis - C6 –Triceps – C7

84 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Dermatomes

85 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Restoration of motion –Concern: joint contractures and stiffness – begin AROM ASAP –Use of opposite hand to supply load Restoration of proprioception and balance –Closed-chain exercises Muscular strength, endurance, and power –Open-chain exercises –PNF-resisted exercises Cardiovascular fitness


Download ppt "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Conditions Chapter 16."

Similar presentations


Ads by Google