Wrist and Hand Conditions

Wrist and Hand Conditions
Chapter 16

Anatomy

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

Wrist Articulations (cont.)
Intercarpal joints Gliding joints Minimal contribution to wrist movement Distal radioulnar joint Immediately adjacent to radiocarpal joint TFCC – stabilizer scaphoid, 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 pronation distal 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 metacarpal distal 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 deviation TFCC -- acts as a stabilizer of the distal radioulnar joint -- ulnar continuation of the radius; provides an articular surface for the carpal condyle

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 CM 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 intersect CM 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: opposition PIP 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 extension flexor retinaculum -- protects extrinsic flexor tendons and median nerve as they pass into the hand through the carpal tunnel on the palmar side extensor retinaculum -- protects extrinsic extensor tendons on the dorsal side of the wrist

Muscles

Muscles (cont.)

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 tendon 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

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 fingers ulnar 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 sides radial 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

Blood Vessels Radial artery Ulnar artery Numerous divisions
-- muscles on the radial side of the forearm, as well as the thumb and index finger ulnar 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

Kinematics Wrist movements Flexion Extension/ hyperextension
Radial deviation Ulnar deviation Circumduction major 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 assist major 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 flexion Flexor 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

Kinematics (cont.) CM Thumb – flexion, extension, abduction, adduction
MP – fingers Fingers – minimal motion Flexion Extension Abduction Adduction CM 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.

Kinematics (cont.) MP – thumb Flexion Extension IP

Kinematics (Cont’d)

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 Extrinsic 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 tendons precision 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

Prevention of Injuries
Protective equipment Pads and gloves Physical conditioning Strength and flexibility Exercises for wrist and elbow Proper skill technique Instruction on falling A 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.

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 Direct 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

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 Sprains 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 ligaments Most 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

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 Integrity 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

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 IP Collateral Ligament Sprains -- ligament failure usually occurs at its attachment to the proximal phalanx or, less frequently, in the mid-portion S&S -- obvious deformity may not be present, unless there is a fracture or total rupture of the supporting tissues that causes a dorsal dislocation

Dislocations Distal radioulnar joint (DRUJ)
Isolated or with radial fracture Mechanism: hyperextension With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation Dislocations 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

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

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 lunate 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

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 MCP 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 metacarpal PIP joint -- because digital nerves and vessels run along the sides of the fingers and thumb, these dislocations are potentially serious DIP joint MCP joint dislocations, S&S -- pain will be present at the joint line and will increase when the mechanism is reproduced Management -- 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

Dislocations (cont.) S&S: swollen, painful finger
Management: immobilization; ice; immediate physician referral

Dislocations (cont.)

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 Jersey 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 palm Management -- in cases where the tendon has retracted into the palm, surgical reattachment of the tendon must be performed within 7 to 10 days

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 mallet 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

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 Boutonnière 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

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

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 trigger 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

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 de 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

Strains (cont.) de Quervain's tenosynovitis

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 intersection 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

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 Dupuytren’s contracture -- rare, but can impact normal function of the fingers -- occurs more frequently on the ring finger or little finger

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 gymnast’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

Strains (cont.) Ganglion cysts
Benign tumor mass on dorsal aspect of wrist Associated with tissue sheath degeneration Treatment: symptomatic ganglion 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

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 subungual hematoma Increasing 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

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 Paronychia commonly seen with a hangnail and in individuals whose hands are frequently immersed in water condition is treated with warm water soaks and germicide more severe cases, the physician may recommend systemic antibiotics and drainage of localized pus, or may perform a partial-nail resection

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 nerve entrapment -- susceptible due to narrow spaces nerves must pass through -- mechanism: repetitive compression, contusion, or traction

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 median nerve entrapment median 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 lumbricales anterior 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 players carpal 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 conduction Management -- 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

Carpal tunnel

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 Ulnar Nerve Entrapment The 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 swing S&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

Ulnar nerve entrapment

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 bowler’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

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 Radial 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

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

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 distal radial and ulnar fractures -- in many instances, open reduction and internal fixation with rigid plates and screws are necessary to restore function

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

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.

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 scaphoid 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

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.

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 lunate 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 extension hamate 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

Fractures (cont.) S&S Tenderness – hypothenar mass
Painful RROM abduction of the small finger ↓ grip strength Management: standard acute; splint; physician referral

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 triquetrum 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 excision metacarpal 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

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

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 Bennett’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 present Preferred 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.

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_

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 Rolando 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

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 boxer’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

Boxer’s fracture. These fractures usually involve the fourth and fifth metacarpals.

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 phalangeal 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-dislocation S&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 hand Management -- 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

Phalangeal fracture. This fracture demonstrates a shearing pattern in the diaphysis

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

Range of Motion (ROM) Active range of motion (AROM)
Forearm pronation/supination Wrist Flexion/extension Radial deviation/ulnar deviation Fingers and thumb Abduction/adduction Opposition of thumb and little finger Passive range of motion (PROM) Normal end feel – tissue stretch

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.

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

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.

ROM (cont.) G, Thumb abduction and adduction. H, Opposition

Stress Tests Wrist ligamentous instability tests Varus and valgus
Finger ligamentous instability tests Anterior/posterior glide Wrist Valgus 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 metacarpals Examiner applies valgus stress, radially deviating the wrist Test is + if: pain and/or increased laxity when compared bilaterally = sprain of UCL Varus stress (tests RCL) Same as valgus, except varus stress is applied, ulnarly deviating the wrist Test is + if: pain and/or increased laxity when compared bilaterally = sprain of RCL IP joints Valgus stress (tests collateral ligaments) Pt is sitting or standing; joint being tested placed in extension Examiner stabilizes phalanx proximal to joint being tested Examiner grasps the distal phalanx to the joint being tested and applies a valgus stress to the joint Test is + if: increased pain, gapping compared bilaterally = collateral ligament sprain Varus stress (tests integrity of joint capsule) Same as valgus, except varus stress is applied Anterior-posterior glide Same as valgus/varus, except anterior posterior stress is applied Test is + if: increased pain, gapping compared bilaterally = joint capsule sprain Thumb Valgus stress (tests integrity of UCL at thumbs) Pt is sitting or standing; examiner in front or to side of pt Examiner stabilizes 1st metacarpal with one hand and proximal phalanx with other hand While stabilizing 1st metacarpal with the thumb, examiner gently abducts and extends, then applies a valgus stress to the UCL Test is + if: increased laxity on ulnar aspect of 1st MCP joint compared to uninjured side = UCL sprain

Special Tests Finkelstein’s test for de Quervain’s tenosynovitis
Finkelstein’s test for de Quervain’s syndrome Pt is standing or seated; examiner in front or to side of pt Pt is instructed to make a fist, putting thumb inside and wrapping fingers around thumb Pt 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

Special Tests (cont.) Flexor digitorum superficialis (test for rupture of FDS) Flexor digitorum profundus Extensor tendon rupture Flexor digitorum superficialis (test for rupture of FDS) Pt’s hand is supported; examiner holds fingers in extension, except for finger being tested Pt is instructed to flex the affected finger at the PIP joint Test is + if: inability to flex finger at PIP joint = rupture of FDS tendon Flexor digitorum profundus Examiner isolates DIP joint of affected finger by stabilizing MCP and IP joints in extension Pt is instructed to flex finger at DIP joint Test is + if: inability to flex finger at DIP joint = rupture of FDP tendon/muscle denervated Extensor tendon rupture Pt’s forearm and hand are supported by table Affected finger flexed 90 at PIP joint over edge of table and held in this position by examiner Pt is asked to extend PIP joint while examiner palpates middle phalanx Test is + if: examiner feel little pressure from middle phalanx while the DIP joint is extending = torn extensor tendon

Special Tests (cont.) Carpal tunnel compression test
Pt is sitting or standing Using thumbs, examiner applies even pressure over carpal tunnel (30 seconds) + test = numbing or tingling into palmar aspect of thumb Indication: median nerve compression

Special Tests (cont.) Phalen’s wrist flexion test Tinel’s sign
Phalen’s test for carpal tunnel Pt is standing or seated; examiner in front of pt Pt 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 overpressure Position is held for 1 minute Test 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/extended Examiner 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)

Special Tests (cont.) Pinch-grip test for anterior interosseous nerve entrapment Pinch grip (test for nerve compression) Pt is standing or seated; examiner in front of pt Examiner instructs pt to pinch the tip of the index finger and thumb Test is + if: abnormal pulp-to-pulp pinch = indication: anterior interosseous nerve compression

Special Tests (cont.) Froment’s sign for ulnar nerve paralysis
Allen test for circulation Froment’s sign (test for ulnar nerve damage) Pt is standing or seated; examiner in front of pt Pt is instructed to grasp a piece of paper between the thumb and index finger Examiner attempts to take the paper away Test is + if: distal phalanx of the thumb flexes to hold the paper = paralysis of abductor pollicis muscle (ulnar nerve damage)

Fracture Assessment Compression Pt’s hand is supported
Examiner applies compression along the long the axis of the bone Test is + if: pain felt at the injury site = fracture Percussion Examiner applies percussion at the end of the bone Distraction Examiner applies distraction at the end of the bone Test is + if: pain is decreased = fracture

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

Neurologic Tests (cont.)
Dermatomes

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

Wrist and Hand Conditions

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