1. The Forearm, Wrist, Hand and Finger

2. ANTERIOR
POSTERIOR

4. Trapezoid Hamate Capitate Trapezium Triquetral Scaphoid Pisiform
THUMB
PINKY
Trapezoid
Hamate
Trapezium
Capitate
Triquetral
Scaphoid
Pisiform
Lunate

5. "So Long To Pinky, Here Comes The Thumb" · Proximal row, lateral-to-medial, then distal row, medial-to-medial: Scaphoid Lunate Triquetral Pisiform Hamate Capate Trapezoid Trapezium
Since there are three T's in the carpal bone mnemonic sentences, need to know which T is where:
TrapeziUM is by the thUMb,
TrapezoID is insIDe.
TrIquetral is by the pInky
Triquetral after all (after all the other fingers is the pinky)

7. 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?

8. 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

9. 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

10. Special Tests Fracture Tests Range of Motion
___________, ____________, _____________
Range of Motion
Active
Passive or Resistive

11. 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?

12. Assessment of the Forearm
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

14. Elbow Flexors Brachioradialis Brachialis Origin Insertion
Lateral condyle of humerus
Insertion
Styloid process of the radius
Actions
Elbow flexion
Brachialis
Origin
Distal Humerus
Insertion
Ulnar Tuberosity and Coronoid
Action
flex the elbow

15. Muscles of the Thumb Flexor pollicis longus Origin
Middle anterior surface of the radius
Insertion
Base of the distal phalanx of the thumb
Actions
Flexion of the thumb
Flexion of the wrist

16. Flexors Flexor digitorum superficialis Flexor carpi radialis - Origin
Medial Epicondyle
Insertion
Anterior phalanges 2-5
Actions
Flexion of fingers
Flexor carpi radialis
- Origin
Medial epicondyle
- Insertion
Base of the 2nd and 3rd metacarpals
- Actions
Flexion of the wrist
Radial deviation of the wrist

17. Flexors Flexor carpi ulnaris Origin Insertion Actions
Medial epicondyle of the humerus
Insertion
Base of the 5th metacarpal
Pisiform and hook of hamate
Actions
Flexion of the wrist
Ulnar deviation (adduction) of the wrist

18. Pronator quadratus Pronator teres Origin
Lower quater of the anterior surface of the ulna
Insertion
Lower quarter of the anterior side of the radius
Actions
Pronation
Pronator teres
Origin
Medial epicondyle
Medial side of the coronoid process of the ulna
Insertion
Middle 1/3 of the outer surface of the radius
Actions
Pronation
Elbow flexion

19. Palmaris Longus Origin Supinator Insertion Action Origin
Medial epicondyle of humerus
Insertion
Metacarpals 2-5
Action
Flexes hand (at wrist)
Supinator
Origin
Lateral epicondyle
Posterior part of the ulna
Insertion
Outer surface of the upper third of the radius
Actions
Supination

20. Extensors Extensor digitorum superficialis Extensor carpi radialis
Origin
Lateral Epicondyle
Insertion
Posterior phalanges 2-5
Actions
Extension of fingers
Extensor carpi radialis
Origin
Lateral Epicondyle
Insertion
Base of the 2nd metacarpal (dorsal side)
Actions
Extension of the wrist
Radial deviation (abduction) of the wrist

21. Extensors Extensor carpi ulnaris Origin
Lateral epicondyle of the humerus
Insertion
Base of the 5th metacarpal (dorsal side)
Actions
Extension of the wrist
Ulnar deviation (adduction) of the wrist

22. Muscles of the Thumb Abductor pollicis longus Extensor pollicis longus
Origin
Posterior surfaces of ulna, radius
Insertion
Base of 1st metacarpal
Action
Abducts thumb
Extends wrist
Extensor pollicis longus
Origin
middle 1/3 of ulna
Insertion
distal phalanx of thumb
Action
Extends thumb

24. 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)

27. Elbow Injuries Strains Sprains Management
Acute mechanism (fall, hit, etc)
Pain with motion
Point tenderness
Sprains
Pain with angular motion
Management
Immediate
RICE
Long Term
Bracing
Strengthening

28. Elbow Injuries Bursitis Epicondylitis Management
Mostly seen as an overuse injury, but can be acute
Swelling
Pain
Point Tenderness
Epicondylitis
Due to repetitive trauma
Aching pain during and after activity
Point Tenderness
Management
RICE - Chopat brace - Rehab

29. Elbow Injuries Tennis Elbow (Lateral Epicondylitis)
Athlete extends hand with elbow flexed and wrist pronated
Clinician resists motion while palpating lateral epicondyle
+ pain with this activity
Pitcher’s Elbow (Medial Epicondylitis)
Athlete flexes hand with elbow flexed and wrist supinated
Clinician resists motion while palpating medial epicondyle

31. Elbow Injuries Dislocation Complications Management
Fall on hyper-extended elbow
Rupturing and tearing most stabilizing ligamentous tissue
Deformity
Severe pain
Complications
Hemorrhage
Injury to the major nerves and arteries
Myositis ossificans
Radial head fracture
Management
RICE - Strengthening of wrist
Splint and hand
Refer for X-rays - NO STRETCHING

32. Contusion Cause Signs and Symptoms Management 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
Management
Proper care in acute stage involves RICE for at least one hour and followed up w/ additional cryotherapy
Protection is critical - full-length sponge rubber pad can be used to provide protective covering

34. Forearm Fractures Cause Signs and Symptoms
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 athlete may experience greater soft tissue damage and greater chance of paralysis due to Volkman’s contracture
Signs and Symptoms
Audible pop or crack followed by moderate to severe pain, swelling, and disability
Edema, ecchymosis w/ possible crepitus

35. Management
Initially RICE followed by splinting until definitive care is available
Long term casting followed by rehab plan

36. Colles’ Fracture Cause Signs and Symptoms Management
Occurs in lower end of radius or ulna
FOOSH, forcing radius and ulna into
hyperextension
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
Without complications a Colles’ fracture will keep an athlete out for 1-2 months
In children, injury may cause lower epiphyseal separation

37. Recognition and Management of Injuries
Wrist Sprains
Cause
any abnormal, forced movement
Signs and Symptoms
Pain, swelling and difficulty w/ movement
Management
Refer to physician for X-ray if severe
RICE, splint and analgesics
Have athlete begin strengthening soon after injury
Tape for support can benefit healing and prevent further injury

38. Tendinitis Cause Signs and Symptoms Management
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)

39. Nerve Compression, Entrapment, Palsy
Cause
Median and ulnar nerve compression
Result of direct trauma to nerves
Signs and Symptoms
Sharp or burning pain associated w/ skin sensitivity or paresthesia
(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

40. Carpal Tunnel Syndrome
Cause
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
Tingling, numbness and burning or prickling sensation; weakness in thumb and index finger
Management
Conservative treatment - rest, immobilization, NSAID’s
If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament

41. Special Tests Tinel’s Sign Phalen’s Test
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 approx.
one minute
If test is positive, pain will be
produced in region of carpal tunnel

42. Dislocation of Lunate Bone
Cause
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

43. 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

44. Scaphoid Fracture Cause Signs and Symptoms Management
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
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

45. Hamate Fracture Cause Signs and Symptoms Management
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

46. Wrist Ganglion Cause Signs and Symptoms Management
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
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

47. Contusion and Pressure Injuries of Hand and Fingers
Cause
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

48. Mallet Finger (baseball or basketball finger)
Cause
Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion
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

50. Boutonniere Deformity
Cause
Rupture of extensor tendon dorsal to the middle phalanx 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
Management
Ice
Splinting must be continued for 5-8 weeks
Athlete is encouraged to flex distal phalanx

51. Swan Neck Deformity and PsuedoBoutonniere Deformity
Cause
Distal tear of volar plate may cause Swan Neck deformity; proximal tear may cause Psuedo Boutonniere deformity
Signs and Symptoms
Pain, swelling w/ varying degrees of hyperextension
Tenderness over volar plate of PIP
passive hyperextension
Management
RICE
Splint in degrees of
flexion for 3 weeks; followed by
buddy taping and then PRE

52. Jersey Finger Cause Signs and Symptoms Management
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

53. Sprains, Dislocations and Fractures of Phalanges
Cause
Phalanges are prone to sprains caused by direct blows or twisting
MOI is also similar to that which causes fractures and dislocations
Signs and Symptoms
Recognition primarily occurs through history
Sprain symptoms - pain, severe swelling and hematoma

54. 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

55. Gamekeeper’s Thumb Cause Signs and Symptoms Management
Sprain of Ulnar Collateral Ligament (UCL) of MCP joint of the thumb
Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextension
Signs and Symptoms
Pain over UCL
weak and painful pinch
Management
X-ray should be performed to rule out fracture
Thumb splint until pain free
Splint should extend from wrist
to end of thumb in neutral position
Thumb spica should be used
following splinting for support

56. Gamekeeper’s Thumb

57. Sprains of Interphalangeal Joints of Fingers
Cause
Can include collateral ligament, volar plate, extensor slip 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

58. Metacarpal Phalangeal Joint Dislocation
Carpo-metacarpal dislocation
Metacarpal Phalangeal Joint Dislocation

59. MCP Dislocation Cause Signs and Symptoms Management
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

60. PIP Fractures and Dislocation
Cause
Combination of fracture and dislocation is the result of “jamming” a partially flexed finger
Signs and Symptoms
Pain and swelling at the joint
Localized tenderness over the joint
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