1. Chapter 24: The Forearm, Wrist, Hand and Fingers
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Anatomy of the Forearm
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Figure 24-1
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Figure 24-2
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Figure 24-2
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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
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7. 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?
Any previous injury to your forearm?
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Observation
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
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9. 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
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10. 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
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11. Recognition and Management of Injuries to the Forearm
Contusion
Etiology
Ulnar side receives majority of blows due to arm blocks
Can be acute or chronic
Result of direct contact or blow
Signs and Symptoms
Pain, swelling and hematoma
If repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematoma
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Contusion (continued)
Management
Proper care in acute stage involves RICE and followed up w/ additional cryotherapy
Protection is critical - full-length sponge rubber pad can be used to provide protective covering
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Forearm Splints
Etiology
Forearm strain - most come from severe static contraction
Signs and Symptoms
Dull ache between extensors which cross posterior aspect of forearm
Weakness and pain w/ contraction
Point tenderness in interosseus membrane
Management
Treat symptomatically
Patient should focus on strengthening forearm
Treat w/ cryotherapy, wraps, or heat if condition persists
Can develop compartment syndrome in forearm as well and should be treated like lower extremity
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Forearm Fractures
Etiology
Common in youth due to falls and direct blows
Ulna and radius generally fracture individually
Fracture in upper third may result in abduction deformity due pull of pronator teres
Fracture in lower portion will remain relatively neutral
Older patients may experience greater soft tissue damage and greater chance of paralysis due to Volkmann's contracture
Signs and Symptoms
Audible pop or crack followed by moderate to severe pain, swelling, and disability
Edema, ecchymosis w/ possible crepitus
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Management
Initially RICE followed by splinting until definitive care is available
Long term casting followed by rehab plan
Figure 24-3
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Colles’ Fracture
Etiology
Occurs in lower end of radius or ulna
MOI is fall on outstretched hand, forcing radius and ulna into hyperextension
Less common is the reverse Colles’ fracture (Smith fracture)
Anterior displacement of distal fragment
Intraarticular fracture is referred to as a Barton fracture
Figure 24-4
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Signs and Symptoms
Forward displacement of radius causing visible deformity (silver fork deformity)
When no deformity is present, injury can be passed off as bad sprain
Extensive bleeding and swelling
Tendons may be torn/avulsed and there may be median nerve damage
Management
Cold compress, splint wrist and refer to physician
X-ray and immobilization
Severe sprains should be treated as fractures
In children, injury may cause lower epiphyseal separation
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Madelung Deformity
Etiology
Developmental deformity of the wrist
Associated with changes in radius, ulna and carpal bone  results in palmar and ulnar wrist subluxations
Common in females
Carpals become wedged between radius and ulna following epiphyseal plate changes
Signs and Symptoms
Bowing of radius and ulna evident on X-ray
Wrist pain and loss of forearm rotation
Palmar subluxation with prominence of radius and ulnar styloid processes
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Madelung Deformity (continued)
Management
Therapeutic modalities and NSAID’s for pain
Wrist can be taped or braced to prevent wrist extension
Typically corrected surgically in patients with chronic pain and disability
Figure 24-5
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20. Anatomy of the Wrist, Hand and Fingers
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Figure 24-6
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Figure 24-7
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Figure 24-8
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Figure 24-9 A & B
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Figure 24-9 C
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Figure 24-10
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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)
Figure 24-11
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28. 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?
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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 nail beds
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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
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31. Palpation: Soft Tissue
Triangular fibrocartilage
Ligaments of the carpals
Carpometacarpal joints and ligaments
Metacarpophalangeal joints and ligaments
Proximal and distal interphalangeal 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
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32. 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
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Special Tests
Finklestein’s Test
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
Figure 24-12
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Special Tests
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
Figure 24-13
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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
Figure 24-14
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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
Figure 24-15
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Lunotriquetral Ballottement 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
Figure 24-16
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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
Patient is instructed to clench fist 3-4 times, holding it on the final time
Pressure applied to ulnar and radial arteries
Patient 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)
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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
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40. Recognition and Management of Injuries to the Wrist, Hand and Fingers
Wrist Sprains
Etiology
Most common wrist injury
Arises from any abnormal, forced movement
Falling on hyperextended wrist, violent flexion or torsion
Multiple incidents may disrupt blood supply
Signs and Symptoms
Pain, swelling and difficulty w/ movement
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Management
Refer to physician for X-ray if severe
RICE, splint and analgesics
Have patient begin strengthening soon after injury
Tape for support can benefit healing and prevent further injury
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Triangular Fibrocartilage Complex (TFCC) Injury
Etiology
Occurs through forced hyperextension, falling on outstretched hand
Violent twist or torque of the wrist
Often associated w/ sprain of UCL
Signs and Symptoms
Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clicking
Swelling is possible, not much initially
Patient may not report injury immediately
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Management
Referred to physician for treatment
Treatment will require immobilization initially for 4 weeks
Immobilization should be followed by period of strengthening and ROM activities
Surgical intervention may be required if conservative treatments fail
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Tenosynovitis
Etiology
Cause of repetitive wrist accelerations and decelerations
Repetitive overuse of wrist tendons and sheaths
Signs and Symptoms
Pain w/ use or pain in passive stretching
Tenderness and swelling over tendon
Management
Acute pain and inflammation treated w/ ice massage 4x daily for first hours, NSAID’s and rest
When swelling has subsided, ROM is promoted
Ultrasound and phonophoresis can be used
PRE can be instituted once swelling and pain subsided
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Tendinitis
Etiology
Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris; repetitive pressure on palms (cycling) can cause irritation of flexor digitorum
Primary cause is overuse of the wrist
Signs and Symptoms
Pain on active use or passive stretching
Isometric resistance to involved tendon produces pain, weakness or both
Management
Acute pain and inflammation treated w/ ice massage 4x daily for first hours, NSAID’s and rest
When swelling has subsided, ROM is promoted w/ contrast bath
PRE can be instituted once swelling and pain subsided (high rep, low resistance)
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Nerve Compression, Entrapment, Palsy
Etiology
Median and ulnar nerve compression
Result of direct trauma to nerves
Signs and Symptoms
Sharp or burning pain associated w/ skin sensitivity or paresthesia
May result in benediction/ bishop’s deformity
(damage to the ulnar nerve) or claw hand deformity (damage to both nerves)
Palsy of radial nerve produces drop wrist deformity caused by paralysis of extensor muscles
Palsy of median nerve can cause ape hand (thumb pulled back in line w/ other fingers)
Management
Chronic entrapment may cause irreversible damage
Surgical decompression may be necessary
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47. Figures 24-19 to 22 Bishop or Benediction Hand Drop Wrist Ape Hand
Claw Hand
Figures to 22
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Carpal Tunnel Syndrome
Etiology
Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel
Result of repeated wrist flexion or direct trauma to anterior aspect of wrist
Signs and Symptoms
Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb
Management
Conservative treatment - rest, immobilization, NSAID’s
If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament
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de Quervain’s Disease (Hoffman’s disease)
Etiology
Stenosing tenosynovitis in thumb (extensor pollicis brevis and abductor pollicis longus
Constant wrist movement can be a source of irritation
Signs and Symptoms
Aching pain, which may radiate into hand or forearm
Positive Finklestein’s test
Point tenderness and weakness during thumb extension and abduction; painful catching and snapping
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de Quervain’s Disease (Hoffman’s disease)
Management
Immobilization, rest, cryotherapy and NSAID’s
Ultrasound and ice are also beneficial
Joint mobilizations have been recommended to maintain ROM
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Dislocation of Lunate Bone
Etiology
Forceful hyperextension or fall on outstretched hand
Signs and Symptoms
Pain, swelling, and difficulty executing wrist and finger flexion
Numbness/paralysis of flexor muscles due to pressure on median nerve
Management
Treat as acute, and sent to physician for reduction
If not recognized, bone deterioration could occur, requiring surgical removal
Usual recovery is 1-2 months
Figure 24-24
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Kienböck's Disease
Etiology
Loss of blood supply to lunate bone resulting in osteonecrosis
Signs and Symptoms
Pain, swelling, with decreases in ROM
Decreased grip strength
Tenderness over the bone (middle of the dorsum of the wrist)
Management
Early treatment involves immobilization and NSAID’s
Operative treatment may be required if conservative treatment fails
May involve wrist bone fusion or bone removal
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Scaphoid Fracture
Etiology
Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones
Often fails to heal due to poor blood supply
Signs and Symptoms
Swelling, severe pain in anatomical snuff box
Presents like wrist sprain
Pain w/ radial flexion
Figure 24-25
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Scaphoid Fracture
Management
Must be splinted and referred for X-ray prior to casting
Immobilization lasts 6 weeks and is followed by strengthening and protective tape
Wrist requires protection against impact loading for 3 additional months
Figure 24-25
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55. © 2011 McGraw-Hill Higher Education. All rights reserved.
Hamate Fracture
Etiology
Occurs as a result of a fall or more commonly from contact while athlete is holding an implement
Signs and Symptoms
Wrist pain and weakness, along w/ point tenderness
Pull of muscular attachment can cause non-union
Management
Casting wrist and thumb is treatment of choice
Hook of hamate can be protected w/ doughnut pad to take pressure off area
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Hamate Fracture
Management
Casting wrist and thumb is treatment of choice
Hook of hamate can be protected w/ doughnut pad to take pressure off area
Figure 24-26
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Wrist Ganglion
Etiology
Synovial cyst (herniation of joint capsule or synovial sheath of tendon)
Generally appears following wrist strain
Signs and Symptoms
Appear on back of wrist generally
Occasional pain w/ lump at site
Pain increases w/ use
May feel soft, rubbery or very hard
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Wrist Ganglion
Management
Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing
New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad
Ultrasound can be used to reduce size
Surgical removal is most effective treatment method
Figure 24-27
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59. © 2011 McGraw-Hill Higher Education. All rights reserved.
Contusion and Pressure Injuries of Hand and Fingers
Etiology
Result of blow or compression of bones w/in hand and fingers
Signs and Symptoms
Pain and swelling of soft tissue
Management
Cold compression until hemorrhaging has ceased
Follow w/ gradual warming - soreness may still be present -- padding may also be necessary
Bruising of distal phalanx can result in subungual hematoma - extremely painful due to build-up of pressure under nail
Pressure must be released once hemorrhaging has ceased
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Figure 24-28
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Trigger Finger or Thumb
Etiology
Repeated motion of fingers may cause irritation, producing tenosynovitis
Inflammation of tendon sheath (extensor tendons of wrist, fingers and thumb, abductor pollicis)
Thickening occurs w/in the sheath, forming a nodule that does not slide easily
Signs and Symptoms
Resistance to re-extension, produces snapping that is palpable, audible and painful
Palpation produces pain and lump can be felt w/in tendon sheath
Management
Same treatment as de Quervain’s disease -- if unsuccessful, injection and splinting are last options
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Extensor Tendon Avulsion (Mallet Finger)
Etiology
Caused by a blow to tip of finger avulsing extensor tendon from insertion
Also referred to as baseball or basketball finger
Signs and Symptoms
Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx
Unable to extend distal end of finger (carrying at 30 degree angle)
Point tenderness at sight of injury
Management
RICE and splinting for 6-8 weeks
Figure 24-29
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Boutonniere Deformity
Etiology
Rupture of extensor expansion dorsal to the middle phalanx
Tendon slides below axis of PIP joint Forces DIP joint into extension and PIP into flexion
Signs and Symptoms
Severe pain, obvious deformity and inability to extend DIP joint
Swelling, point tenderness
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Boutonniere Deformity
Management
Cold application, followed by splinting
Splinting must be continued for 5-8 weeks
Athlete is encouraged to flex distal phalanx
Figure 24-30
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Flexor Digitorum Profundus Rupture (Jersey Finger)
Etiology
Rupture of flexor digitorum profundus tendon from insertion on distal phalanx
Often occurs w/ ring finger when athlete tries to grab a jersey
Signs and Symptoms
DIP can not be flexed, finger remains extended
Pain and point tenderness over distal phalanx
Management
Must be surgically repaired
Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture
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Dupuytren’s Contracture
Etiology
Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity
Signs and Symptoms
Often develops in 4th or 5th finger (flexion deformity)
Management
Tissue nodules must be removed as they can ultimately interfere w/ normal hand function
Figure 24-32
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67. © 2011 McGraw-Hill Higher Education. All rights reserved.
Gamekeeper’s Thumb
Etiology
Sprain of UCL of MCP joint of the thumb
Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextension
Signs and Symptoms
Pain over UCL in addition to weak and painful pinch
Figure 24-33
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Management
Immediate follow-up must occur
If instability exists, athlete should be referred to orthopedist
If stable, X-ray should be performed to rule out fracture
Thumb splint should be applied for protection for 3 weeks or until pain free
Splint should extend from wrist to end of thumb in neutral position
Thumb spica should be used following splinting for support
If a complete tear occurs, surgical repair is necessary to allow normal function to return
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Sprains of Interphalangeal Joints
Etiology
Can include collateral ligament, volar plate, extensor expansion tears
Occurs w/ axial loading or valgus/varus stresses
Signs and Symptoms
Pain, swelling, point tenderness, instability
Valgus and varus tests may be positive
Management
RICE, X-ray examination and possible splinting
Splint at degrees of flexion for 10 days
If sprain is to the DIP, splinting for a few days in full extension may assist healing process
Taping can be used for support
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Swan Neck Deformity and PsuedoBoutonniere Deformity
Etiology
Distal tear of volar plate may cause Swan Neck deformity; proximal tear may cause PsuedoBoutonniere deformity
Signs and Symptoms
Pain, swelling w/ varying degrees of hyperextension
Tenderness over volar plate of PIP
Indication of volar plate tear = passive hyperextension
Management
RICE and analgesics
Splint in degrees of flexion for 3 weeks; followed by buddy taping and then PRE
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PIP Dorsal Dislocation
Etiology
Hyperextension that disrupts volar plate at middle phalanx
Signs and Symptoms
Pain and swelling over PIP
Obvious deformity, disability and possible avulsion
Management
Treated w/ RICE, splinting and analgesics followed by reduction
After reduction, finger is splinted at degrees of flexion for 3 weeks -- followed by buddy taping
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PIP Palmar Dislocation
Etiology
Caused by twist while digit is semiflexed
Signs and Symptoms
Pain and swelling over PIP; point tenderness over dorsal side
Finger displays angular or rotational deformity
Management
Treat w/ RICE, splinting and analgesics followed by reduction
Splint in full extension for 4-5 weeks after which it is protected for 6-8 weeks during activity
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MCP Dislocation
Etiology
Caused by twisting or shearing force
Signs and Symptoms
Pain, swelling and stiffness at MCP joint
Proximal phalanx is angulated at degrees
Management
RICE, splinting following reduction
Buddy taping and given early ROM following splinting
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Metacarpal Fracture
Etiology
Direct axial force or compressive force
Fractures of the 5th metacarpal are associated w/ boxing or martial arts (boxer’s fracture)
Signs and Symptoms
Pain and swelling; possible angular or rotational deformity
Management
RICE, analgesics are given followed by X-ray examinations
Deformity is reduced, followed by splinting - 4 weeks of splinting after which ROM is carried out
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Figure 24-36
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Bennett’s Fracture
Etiology
Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb
Signs and Symptoms
CMC may appeared to be deformed - X-ray will indicate fracture
Patient will complain of pain and swelling over the base of the thumb
Management
Structurally unstable and must be referred to an orthopedic surgeon
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Distal Phalangeal Fracture
Etiology
Crushing force
Signs and Symptoms
Complaint of pain and swelling of distal phalanx
Subungual hematoma is often seen in this condition
Management
RICE and analgesics are given
Protective splint is applied as a means for pain relief
Subungual hematoma is drained
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Middle Phalangeal Fracture
Etiology
Occurs from direct trauma or twist
Signs and Symptoms
Pain and swelling w/ tenderness over middle phalanx
Possible deformity; X-ray will show bone displacement
Management
RICE and analgesics
No deformity - buddy tape w/ thermoplastic splint for activity
Deformity - immobilization for 3-4 weeks and a protective splint for an additional 9-10 weeks during activity
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Proximal Phalangeal Fracture
Etiology
May be spiral or angular
Signs and Symptoms
Complaint of pain, swelling, deformity
Inspection reveals varying degrees of deformity
Management
RICE and analgesics are given as needed
Fracture stability is maintained by immobilization of the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping
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PIP Fractures and Dislocation
Etiology
Combination of fracture and dislocation is the result of an axial load on a partially flexed finger
Signs and Symptoms
Condition causes pain and swelling in the region of the PIP joint
Localized tenderness over the PIP
Management
RICE, analgesics, followed by reduction of the fracture
If there is a small fragment, buddy taping is used
Large fragments - splint at degrees of flexion
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Fingernail Deformities
Changes in normal appearance of the fingernail can be indicative of a number of different diseases
Scaling or ridging = psoriasis
Ridging and poor development = nutritional deficiencies
Clubbing and cyanosis = congenital heart disorders or chronic respiratory disease
Spooning or depression = thyroid problems, iron deficiency anemia
Figure 24-37
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82. Rehabilitation of the Forearm, Wrist, Hand and Fingers
General Body Conditioning
Must maintain pre-injury level of conditioning
Cardiorespiratory, strength, flexibility and neuromuscular control
Many exercise options (particularly lower extremity)
Joint Mobilizations
Wrist and hand respond to traction and mobilization techniques
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Joint Mobilization (cont.)
Can be used to increase specific ranges of motion
Figure 24-38
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Flexibility
Full pain free ROM is a major goal of rehabilitation
The program should include active assisted and active pain free stretching
Strength
Exercises should not aggravate condition or disrupt healing process
A variety of exercises are available for strength (wrist and hand)
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85. Flexibility Exercises
Figure 24-39
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86. Flexibility Exercises
Figure 24-40
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87. Neural Tension Exercises
Figure 24-41
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88. Strengthening Exercises
Figure 24-43
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Figure & 45
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Neuromuscular Control
Hand and fingers require restoration of dexterity
Pinching, fine motor activities (buttoning buttons, tying shoes, and picking up small objects)
It is important to incorporate functional activities designed to restore patient’s ability to perform daily activities
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Return to Activity
Grip strength must be equal bilaterally, full range of motion and dexterity
Thumb has unique strength requirements
A variety of customizable bracing and splinting devices are available to protect injured wrist and hand
Figure 24-46, 47, 48
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