Chapter 24: The Forearm, Wrist, Hand and Finger

Anatomy of the Forearm

Blood and Nerve Supply Most of the flexors are supplied by the median nerve Most of the extensor are controlled by the radial nerve Blood is supplied by the radial and ulnar arteries

Assessment of the Forearm History What was the cause? What were the symptoms at the time of injury, did they occur later, were they localized or diffuse? Was there swelling and discoloration? What treatment was given and how does it feel now?

Observation Palpation Visually inspect for deformities, swelling and skin defects Range of motion Pain w/ motion Palpation Palpated at distant sites and at point of injury Can reveal tenderness, edema, fracture, deformity, changes in skin temperature, a false joint, bone fragments or lack of bone continuity

Palpation: Bony and Soft Tissue Proximal head of radius Olecranon process Radial shaft Ulnar shaft Distal radius and ulna Radial styloid Ulnar head Ulnar styloid Distal radioulnar joint Radiocarpal joint Extensor retinaculum Flexor retinaculum Extensor carpi radialis longus and brevis Extensor carpi ulnaris Brachioradialis Extensor pollicis longus and brevis

Palpation (continued) Abductor pollicis longus Extensor indicus supinator Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Pronator teres

Anatomy of the Wrist, Hand and Fingers

Blood and Nerve Supply Three major nerves Ulnar, median and radial Ulnar and radial arteries supply the hand Two arterial arches (superficial and deep palmar arches)

Assessment of the Wrist, Hand and Fingers History Past history Mechanism of injury When does it hurt? Type of, quality of, duration of, pain? Sounds or feelings? How long were you disabled? Swelling? Previous treatments?

Observation Postural deviations Is the part held still, stiff or protected? Wrist or hand swollen or discolored? General attitude What movements can be performed fully and rhythmically? Thumb to finger touching Color of nailbeds

Palpation: Bony Scaphoid Trapezoid Trapezium Lunate Capitate Triquetral Pisiform Hamate (hook) Metacarpals 1-5 Proximal, middle and distal phalanges of the fingers Proximal and distal phalanges of the thumb

Palpation: Soft Tissue Triangular fibrocartilage Ligaments of the carpals Carpometacarpal joints and ligaments Metacarpophylangeal joints and ligaments Proximal and distal interphylangeal joints and ligaments Flexor carpi radialis Flexor carpi ulnaris Lumbricale muscles Flexor digitorum superficialis and profundus Palmer interossi Flexor pollicis longus and brevis Abductor pollicis brevis Opponens pollicis Opponens digiti minimi

Palpation: Soft Tissue Extensor carpi radialis longus and brevis Extensor carpi ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Dorsal interossi Extensor pollicis brevis and longus Abductor pollicis longus

Special Tests Finklestein’s Test Tinel’s Sign Test for de Quervain’s syndrome Athlete makes a fist w/ thumb tucked inside Wrist is ulnarly deviated Positive sign is pain indicating stenosising tenosynovitis Pain over carpal tunnel could indicate carpal tunnel syndrome Tinel’s Sign Produced by tapping over transverse carpal ligament Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome

Phalen’s Test Test for carpal tunnel syndrome Position is held for approximately one minute If test is positive, pain will be produced in region of carpal tunnel

Valgus/Varus and Glide Stress Tests Tests used to assess ligamentous integrity of joints in hands and fingers Valgus and varus tests are used to test collateral ligaments Anterior and posterior glides are used to assess the joint capsule

Lunotriquetral Ballotment Test Stabilize lunate while sliding the triquetral anteriorly and posteriorly Assessing laxity, pain and crepitus Positive test indicates instability that often results in dislocation of the lunate

Circulatory and Neurological Evaluation Hands should be felt for temperature Cold hands indicate decreased circulation Pinching fingernails can also help detect circulatory problems (capillary refill) Allen’s test can also be used Athlete instructed to clench fist 3-4 times, holding it on the final time Pressure applied to ulnar and radial arteries Athlete then opens hand (palm should be blanched) One artery is released and should fill immediately (both should be checked) Hand’s neurological functioning should also be tested (sensation and motor functioning)

Functional Evaluation Range of motion in all movements of wrist and fingers should be assessed Active, resistive and passive motions should be assessed and compared bilaterally Wrist - flexion, extension, radial and ulnar deviation MCP joint - flexion and extension PIP and DIP joints - flexion and extension Fingers - abduction and adduction MCP, PIP and DIP of thumb - flexion and extension Thumb - abduction, adduction and opposition 5th finger - opposition