The Forearm, Wrist, Hand, and Fingers

The Forearm, Wrist, Hand, and Fingers
Chapter 18 The Forearm, Wrist, Hand, and Fingers 5/3/2016 Sports Medicine - Mr. Cronin

Objectives When you finish with this chapter you should be able to:
Review the structural and functional anatomy of the forearm, wrist, hand and fingers. Outline the process of assessment for injuries to the forearm, wrist, hand and fingers. Incorporate management techniques for dealing with injuries to the forearm, wrist, hand, and fingers. Implement the appropriate rehabilitation techniques for dealing with injuries to the forearm, wrist, hand, and fingers. 5/3/2016 Sports Medicine - Mr. Cronin

Anterior Radius and Ulna
Parts to know: Radius: Head of the radius Neck of the radius Radial tuberosity Shaft of the radius Ulnar notch of the radius Styloid process of the radius Ulna Trochlear notch of the ulna Coronoid process of the ulna Ulnar tuberosity Radial notch of the ulna Styloid process of the ulna Olecranon process of the ulna Head of the ulna Shaft of the Ulna Interosseous membrane Distal radioulnar joint Proximal radioulnar joint Parts to know: Radius Head of the Radius - The most proximal aspect of the radius bone. This area is mobile within the annular ligament and allows pronation and supination of the forearm. The head of the radius has a cylindrical form, and on its upper surface is a shallow cup or fovea for articulation with the capitulum of the humerus. The circumference of the head is smooth; it is broad medially where it articulates with the radial notch of the ulna, narrow in the rest of its extent, which is embraced by the annular ligament. Neck of the Radius – The narrow part of the shaft just below the head. The head is supported on a round, smooth, and constricted portion called the neck, on the back of which is a slight ridge for the insertion of part of the supinator muscle. Radial Tuberosity – An oval eminence on the medial side of the radius distal to the neck where the tendon of the biceps brachii muscle inserts. Shaft of the Radius – is prismoid in form, narrower above than below, and slightly curved, so as to be convex lateralward. It presents three borders and three surfaces. The volar border (margo volaris; anterior border) extends from the lower part of the tuberosity above to the anterior part of the base of the styloid process below, and separates the volar from the lateral surface. Its upper third is prominent, and from its oblique direction has received the name of the oblique line of the radius; it gives origin to the flexor digitorum superficialis muscle (also flexor digitorum sublimis) and flexor pollicis longus muscle; the surface above the line gives insertion to part of the supinator muscle. The middle third of the volar border is indistinct and rounded. The lower fourth is prominent, and gives insertion to the pronator quadratus muscle, and attachment to the dorsal carpal ligament; it ends in a small tubercle, into which the tendon of the brachioradialis muscle is inserted. The dorsal border (margo dorsalis; posterior border) begins above at the back of the neck, and ends below at the posterior part of the base of the styloid process; it separates the posterior from the lateral surface. is indistinct above and below, but well-marked in the middle third of the bone. The interosseous crest (crista interossea; internal or interosseous border) begins above, at the back part of the tuberosity, and its upper part is rounded and indistinct; it becomes sharp and prominent as it descends, and at its lower part divides into two ridges which are continued to the anterior and posterior margins of the ulnar notch. To the posterior of the two ridges the lower part of the interosseous membrane is attached, while the triangular surface between the ridges gives insertion to part of the pronator quadratus muscle. This crest separates the volar from the dorsal surface, and gives attachment to the interosseous membrane. The connection between the two bones is actually a joint referred to as a syndesmosis joint. Ulnar Notch of the Radius - The articular surface for the ulna is called the ulnar notch (sigmoid cavity) of the radius; it is in the distal radius, and is narrow, concave, smooth, and articulates with the head of the ulna forming the distal radioulnar joint. Styloid Process of the Radius – The radial styloid process is a projection of bone on the lateral surface of the distal radius bone. It extends obliquely downward into a strong, conical projection. The tendon of the brachioradialis attaches at its base, and the radial collateral ligament of the wrist attaches at its apex. Ulna Trochlear Notch of the Ulna – The trochlear notch (also semilunar notch, or greater sigmoid cavity) is a large depression in the upper extremity of the ulna that fits the trochlea of the humerus (the bone directly above the ulna in the arm) as part of the elbow joint. It is formed by the olecranon and the coronoid process. Coronoid Process of the Ulna – The coronoid process is a triangular eminence projecting forward from the anterior proximal portion of the ulna. Its base is continuous with the body of the bone, and of considerable strength. Its apex is pointed, slightly curved upward, and in flexion of the forearm is received into the coronoid fossa of the humerus. Ulnar Tuberosity – a prominence at the lower border of the anterior surface of the coronoid process, giving attachment (insertion) to the brachialis muscle. Radial Notch of the Ulna – The radial notch of the ulna (lesser sigmoid cavity) is a narrow, oblong, articular depression on the lateral side of the coronoid process; it receives the circumferential articular surface of the head of the radius. Styloid Process of the Ulna – The styloid process of the ulna is found at distal end of the forearm, and projects from the medial and back part of the bone; it descends a little lower than the head, and its rounded end affords attachment to the ulnar collateral ligament of the wrist. Olecranon Process of the Ulna – The olecranon /oʊˈlɛkrənɒn/ from the Greek olene meaning elbow and kranon meaning head is a large, thick, curved bony eminence of the forearm that projects behind the elbow. Head of the Ulna – the small rounded distal extremity of the ulna articulating with the ulnar notch of the radius and the articular disk. Shaft of the Ulna – Part between the head at the distal end and the structures at the proximal end. Other Structures Interosseous Membrane – The interosseous membrane of the forearm (rarely middle or intermediate radioulnar joint) is a fibrous sheet that connects the radius and the ulna. It is the main part of the radio-ulnar syndesmosis, a fibrous joint between the two bones. Distal Radioulnar Joint – The distal radioulnar articulation (inferior radioulnar joint) is a joint between the two bones in the forearm; the radius and ulna. It is one of two joints between the radius and ulna. Proximal Radioulnar Joint - The proximal radioulnar articulation (superior radioulnar joint) is a synovial trochoid or pivot joint between the circumference of the head of the radius and the ring formed by the radial notch of the ulna and the annular ligament. 5/3/2016 Sports Medicine - Mr. Cronin

Posterior Radius and Ulna
Parts to know: Radius: Head of the radius Neck of the radius Shaft of the radius Ulnar notch of the radius Styloid process of the radius Ulna Radial notch of the ulna Styloid process of the ulna Olecranon process of the ulna Head of the ulna Shaft of the ulna Interosseous membrane Distal radioulnar joint Proximal radioulnar joint 5/3/2016 Sports Medicine - Mr. Cronin

Articulations of the Forearm
Proximal (Superior) Radioulnar Joint Middle Radioulnar Joint Distal (Inferior) Radioulnar Joint 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Flexor Carpi Radialis Origin Insertion Action
Medial epicondyle of the humerus. Insertion Ventral surface (palm side) of the second and third metacarpals. Action Flexes the wrist and abducts the hand (radial deviation); aids in flexion of the elbow and pronation of the forearm. Flexor Carpi Radialis – p. 87 A Origin – Medial epicondyle of the humerus. Insertion – Ventral surface (palm side) of the second and third metacarpals. Action – Flexes the wrist and abducts the hand (radial deviation); aids in flexion of the elbow and pronation of the forearm. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Palmaris Longus Origin Insertion Action
Medial epicondyle of the humerus. Insertion Palmar aponeurosis (a sheet of pearly-white fibrous tissue that takes the place of a tendon in sheet-like muscles having a wide area of attachment). Action Flexes the wrist. Palmaris Longus – p. 87 B Origin – Medial epicondyle of the humerus. Insertion – Palmar aponeurosis (a sheet of pearly-white fibrous tissue that takes the place of a tendon in sheet-like muscles having a wide area of attachment). Action – Flexes the wrist. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Flexor Carpi Ulnaris Origin Insertion Action
Medial epicondyle of the humerus, olecranon process, and the proximal two-thirds of the posterior surface of the ulna. Insertion Pisiform, hamate, and fifth metacarpal. Action Flexes the wrist and adducts the hand (ulnar deviation). Flexor Carpi Ulnaris – p. 87 C Origin – Medial epicondyle of the humerus, olecranon process, and the proximal two-thirds of the posterior surface of the ulna. Insertion – Pisiform, hamate, and fifth metacarpal. Action – Flexes the wrist and adducts the hand (ulnar deviation). 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Flexor Digitorum Superficialis Origin Insertion
Medial epicondyle of the humerus, coronoid process of the ulna, and the anterior radius. Insertion Ventral surface (palm side) of the middle phalanges of the second through fifth fingers Action Flexes the wrist and phalanges. Flexor Digitorum Superficialis – p. 87 D Origin – Medial epicondyle of the humerus, coronoid process of the ulna, and the anterior radius. Insertion – Ventral surface (palm side) of the middle phalanges of the second through fifth fingers Action – Flexes the wrist and phalanges. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Flexor Digitorum Profundus Origin Insertion Action
Medial epicondyle of the humerus, the coronoid process of the ulna, the interosseous membrane, and the ventral (anterior) side of the ulna. Insertion Ventral (palm side) of the base of the distal phalanges of the second through fifth fingers. Action Flexes the wrist and the phalanges. Flexor Digitorum Profundus – p. 87 E Origin – Medial epicondyle of the humerus, the coronoid process of the ulna, the interosseous membrane, and the ventral (anterior) side of the ulna. Insertion – Ventral (palm side) of the base of the distal phalanges of the second through fifth fingers. Action – Flexes the wrist and the phalanges. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Flexor Pollicis Longus Origin Insertion Action
Ventral surface of the radius (anterior) and the interosseous membrane. Insertion Ventral surface (palm side) of the base of the distal phalanx of the thumb. Action Flexes the thumb and aids in flexing the wrist. Flexor Pollicis Longus – p. 87 F Origin – Ventral surface of the radius (anterior) and the interosseous membrane. Insertion – Ventral surface (palm side) of the base of the distal phalanx of the thumb. Action – Flexes the thumb and aids in flexing the wrist. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Pronator Quadratus Origin Insertion Action
Distal ventral surface (anterior side) of the ulna. Insertion Distal ventral surface (anterior side) of the radius. Action Pronates the forearm and hand. Pronator Quadratus – p. 87 R Origin – Distal ventral surface (anterior side) of the ulna. Insertion – Distal ventral surface (anterior side) of the radius. Action – Pronates the forearm and hand. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Carpi Radialis Longus Origin Insertion
Lateral supracondylar ridge of the humerus. Insertion Dorsal surface (posterior) of the base of the second metacarpal. Action Extends the wrist and abducts (radial deviation) the hand. Extensor Carpi Radialis Longus - p. 87 G Origin – Lateral supracondylar ridge of the humerus. Insertion – Dorsal surface (posterior) of the base of the second metacarpal. Action – Extends the wrist and abducts (radial deviation) the hand. Used when stabilizing the wrist while gripping (opening a jar), washing dishes, turning off a faucet. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Carpi Radialis Brevis Origin Insertion
Lateral epicondyle of the humerus. Insertion Dorsal surface (posterior) of the base of the third metacarpal. Action Extends the wrist and abducts (radial deviation) the hand. Extensor Carpi Radialis Brevis – p. 87 H Origin – Lateral epicondyle of the humerus. Insertion – Dorsal surface (posterior) of the base of the third metacarpal. Action – Extends the wrist and abducts (radial deviation) the hand. Used when stabilizing the wrist while gripping (opening a jar), washing dishes, turning off a faucet. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Digitorum (Communis) Origin Insertion
Extends the wrist and abducts (radial deviation) the hand. Insertion Dorsal surface (posterior) of the phalanges of the second through fifth fingers. Action Extends the fingers and wrist. Extensor Digitorum (Communis) – p. 87 I Origin – Extends the wrist and abducts (radial deviation) the hand. Insertion – Dorsal surface (posterior) of the phalanges of the second through fifth fingers. Action – Extends the fingers and wrist. Used when: Playing the piano or trumpet Holding your hand up to give the “Vulcan hand greeting” (extension of wrist and fingers) Releasing a handshake 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Digiti Minimi Origin Insertion Action
Tendon of the extensor digitorum communis. Insertion Tendon of the extensor digitorum communis on the dorsum (posterior) of the little finger. Action Extends the little finger. Extensor Digiti Minimi – p. 87 J Origin – Tendon of the extensor digitorum communis. Insertion – Tendon of the extensor digitorum communis on the dorsum (posterior) of the little finger. Action – Extends the little finger. Used when: Drinking a cup of tea with pinky extended. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Carpi Ulnaris Origin Insertion Action
Lateral epicondyle of the humerus. Insertion Base of the fifth metacarpal. Action Extends the wrist and adducts (ulnar deviation) the hand. Extensor Carpi Ulnaris – p. 87 K Origin – Lateral epicondyle of the humerus. Insertion – Base of the fifth metacarpal. Action – Extends the wrist and adducts (ulnar deviation) the hand. Used when: Shaping soft clay for an art project. Pulling a book off a shelf. Reaching into the backseat of your car. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Abductor Pollicis Longus Origin Insertion Action
Posterior surface of the middle of the radius and ulna and the interosseous membrane. Insertion Base of the first metacarpal. Action Abducts the thumb and hand (radial deviation). Abductor Pollicis Longus – p. 87 L Origin – Posterior surface of the middle of the radius and ulna and the interosseous membrane. Insertion – Base of the first metacarpal. Action – Abducts the thumb and hand (radial deviation). 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Pollicis Brevis Origin Insertion Action
Posterior surface of the middle of the radius and the interosseous membrane. Insertion Base of the first phalanx of the thumb. Action Extends thumb and wrist, abducts the hand (radial deviation). Extensor Pollicis Brevis – p. 87 M Origin – Posterior surface of the middle of the radius and the interosseous membrane. Insertion – Base of the first phalanx of the thumb. Action – Extends thumb and wrist, abducts the hand (radial deviation). 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Pollicis Longus Origin Insertion Action
Posterior surface of the middle of the ulna and the interosseous membrane. Insertion Base of the distal phalanx of the thumb. Action Extends the thumb and abducts the hand (radial deviation). Extensor Pollicis Longus – p. 87 N Origin – Posterior surface of the middle of the ulna and the interosseous membrane. Insertion – Base of the distal phalanx of the thumb. Action – Extends the thumb and abducts the hand (radial deviation). 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Musculature Extensor Indicis Origin Insertion Action
Posterior surface of the distal end of the ulna and the interosseous membrane. Insertion Tendon of the extensor digitorum communis to the index finger. Action Extends the index finger. Extensor Indicis – p. 87 O Origin – Posterior surface of the distal end of the ulna and the interosseous membrane. Insertion – Tendon of the extensor digitorum communis to the index finger. Action – Extends the index finger. 5/3/2016 Sports Medicine - Mr. Cronin

Brachioradialis Origin Lateral supracondylar ridge of the humerus
Insertion Styloid process of the ulna Action Elbow flexion 87-P 1/27/2020 Sports Medicine - Mr. Cronin

Supinator Origin Lateral epicondyle of the humerus Insertion
Proximal end of the lateral surface of the shaft of the radius Action Elbow supination 87-Q 1/27/2020 Sports Medicine - Mr. Cronin

Pronator Teres Origin Medial epicondyle of the humerus and the coronoid process of the ulna Insertion Middle of the lateral surface of the shaft of the radius Action Elbow pronation 87-S 1/27/2020 Sports Medicine - Mr. Cronin

Anconeus Origin Lateral epicondyle of the humerus Insertion
Lateral surface of the olecranon process of the ulna Action Elbow extension 85-E 1/27/2020 Sports Medicine - Mr. Cronin

Muscle Groups of the Forearm
Extensors (Posterolateral) Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi Ulnaris Brachioradialis Extensor Pollicis Longus Extensor Pollicis Brevis Abductor Pollicis Longus Extensor Indicis Supinator Flexors (Anteromedial) Flexor Carpi Radialis Flexor Carpi Ulnaris Palmaris Longus Flexor Digitorum Superficialis Flexor Digitorum Profundus Flexor Pollicis Longus Pronator Quadratus Pronator Teres Before isolating the specific flexor and extensors, try determining the location of the two muscle groups. Which is medial and which is lateral? Which is posterior and which is anterior? The extensors of the hand and wrist are located on the posterior/lateral (posterolateral) side (hairy side) of the forearm. The flexors of the hand and wrist are located in the anterior/medial (anteromedial) side (hairless side) of the forearm. 5/3/2016 Sports Medicine - Mr. Cronin

Common Forearm Injuries
Forearm Splints Forearm Fractures Colles’ Fracture 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Splints Etiology Signs/Symptoms Management Etiology
-variety of activities from a static contraction; similar to MTSS; uncertain of causes—isometric contraction causes minute tears in the area of the interosseous membrane Signs/Symptoms Dull ache between the extensor muscles, which cross the back of the forearm. Weakness and extreme pain during muscle contraction. Palpation reveals an irritation of the interosseous membrane an surrounding tissue Management -sypmtomatic; concentrate on increasing the strength of the forearm through resistance exercises; if persistent rest & cryotherapy or heat an use of supportive wrap during activity -complication = compartment syndrome, although much less common than in the lower leg. 5/3/2016 Sports Medicine - Mr. Cronin

Forearm Fractures Etiology gymnastics injury Signs/Symptoms Management
Colles’ Fracture Etiology -common among active children and youths; blow or a fall on the outstretched hand; usually both bones break rather than one or the other; direct blow usually will result in ulnar fx; in older people could lead to Volkmann’s Contracture (a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. It is more common in children. Passive extension of fingers is restricted and painful). Signs/Symptoms Pop/crack; moderate to severe pain, swelling and disability; deformity/false joint; localized tenderness, edema, and ecchymosis w/ possible crepitus Management Initially RICE; splint in position found until definitive care is available. Definitive care = long-arm plaster or fiberglass cast followed by a program of rehabilitation Colles’ fracture - a fracture of the lower end of the radius in the wrist with a characteristic backward displacement of the hand. Fracture at the distal end of the radius (could be epiphyseal separation in children and youths) 5/3/2016 Sports Medicine - Mr. Cronin

Anatomy of the Wrist, Hand, and Fingers
Bones of the Wrist Carpals (8) Scaphoid Lunate Triquetral Pisiform Hamate Capitate Trapezoid Trapezium Metacarpals (5) 1st 2nd 3rd 4th 5th Phalanges (14) Proximal Intermediate Distal p. 43 Note – Pisiform should not be visible on Posterior view of the hand/wrist. Phalanges – plural Phalanx – singular Base – proximal end of the metacarpals and phalanges Shaft – middle portion of the metacarpals/phalanges Head – distal end of the metacarpals/phalanges 5/3/2016 Sports Medicine - Mr. Cronin

Articulations Radiocarpal Joint (Inter)Carpal Joints
Metacarpal Phalangeal Joints (MCP) (Inter)Phalangeal Joints Proximal Interphalangeal Joint (PIP) Distal Interphalangeal Joint (DIP) Radiocarpal Joint - a joint between the distal end of the radius and the proximal row of carpal bones Carpal Joints –the intercarpal joint between the two rows of carpal bones, the carpometacarpal joint(s) between the distal row of carpal bones and the metacarpal bone(s). Metacarpal Joints - (MCP) refer to the joints between the metacarpal bones and the phalanges of the fingers. That means the MCP joint is the knuckle between the hand and the finger. Phalangeal Joints - The interphalangeal articulations of the hand are the hinge joints between the phalanges of the hand (i.e. the finger bones). There are two sets (except in the thumb): proximal interphalangeal joints (PIP), those between the first (also called proximal) and second (intermediate) phalanges; distal interphalangeal joints (DIP), those between the second (intermediate) phalanges and the third (distal) phalanges. The thumb only has one phalangeal joint know as the interphalangeal joint (IP), between the proximal and distal phalanges. 5/3/2016 Sports Medicine - Mr. Cronin

Musculature of the Wrist, Hand, and Fingers
Palmar Muscles Lumbricales (4) Dorsal Interossei (4) Palmar Interossei (3) Thenar Muscles Abductor Pollicis Brevis Opponens Pollicis Flexor Pollicis Brevis Adductor Pollicis Hypothenar Muscles Palmaris Brevis Abductor Digiti Minimi Flexor Digiti Minimi Brevis Opponens Digiti Minimi 5/3/2016 Sports Medicine - Mr. Cronin

Lumbricals Origin – Tendons of the flexor digitorum profundus. Insertion – Tendons of the extensor digitorum communis. Action – Flexes the metacarpophalangeal joints. Not in coloring book. Looking at the anterior aspect of the hand (palmar aspect). 5/3/2016 Sports Medicine - Mr. Cronin

Dorsal Interossei (4) Origin – Adjacent sides of all of the metacarpals. Insertion – Proximal phalanx of the second, third, and fourth fingers. Action – Abducts the fingers from the middle finger. Not in coloring book. Anterior view. 5/3/2016 Sports Medicine - Mr. Cronin

Palmar Interossei (3) Origin – Medial side of the second metacarpal and lateral side of the fourth and fifth metacarpals. Insertion – Proximal phalanx of the same finger. Action – Adducts the fingers toward the middle finger. Not in coloring book. 5/3/2016 Sports Medicine - Mr. Cronin

Abductor Pollicis Brevis Origin – Flexor Retinaculum, scaphoid, and trapezium. Insertion – Proximal phalanx of the thumb. Action – Abduct the thumb. Abductor pollicis brevis video Not in coloring book. 5/3/2016 Sports Medicine - Mr. Cronin

Opponens Pollicis Origin – Flexor retinaculum, and trapezium. Insertion – Lateral border of the metacarpal of the thumb. Action – Pulls the thumb in front of the palm to meet the little finger. 5/3/2016 Sports Medicine - Mr. Cronin

Flexor Pollicis Brevis Origin – Flexor retinaculum, trapezium, and first metacarpal. Insertion – Base of the proximal phalanx of the thumb. Action – Flexes and adducts the thumb. Flexor Pollicis Brevis Video 5/3/2016 Sports Medicine - Mr. Cronin

Adductor Pollicis Origin – Capitate, and second and third metacarpals. Insertion – Proximal phalanx of the thumb. Action – Adducts the thumb. Adductor Pollicis Video 5/3/2016 Sports Medicine - Mr. Cronin

Palmaris Brevis Origin – Flexor retinaculum. Insertion – Skin on the ulnar border of the hand. Action – Pulls the skin toward the middle of the palm. 5/3/2016 Sports Medicine - Mr. Cronin

Abductor Digiti Minimi Origin – Pisiform and the tendon of the flexor carpi ulnaris. Insertion – Base of the proximal phalanx of the little finger. Action – Abducts the little finger. 5/3/2016 Sports Medicine - Mr. Cronin

Flexor Digiti Minimi Brevis Origin – Flexor retinaculum and hamate. Insertion – Base of the proximal phalanx of the little finger. Action – Flexes the little finger. 5/3/2016 Sports Medicine - Mr. Cronin

Opponens Digiti Minimi Origin – Flexor retinaculum and hamate. Insertion – Metacarpal of the little finger. Action – Brings the little finger our to meet the thumb. 5/3/2016 Sports Medicine - Mr. Cronin

Joint Movements Fingers and Thumb
Finger Extension Finger Flexion Finger Abduction Finger Adduction Thumb Abduction Thumb Adduction Thumb Extension Thumb Opposition 5/3/2016 Sports Medicine - Mr. Cronin

Nerve Supply Two major nerves: (motor and sensory)
Ulnar Nerve Median Nerve Additional nerve (mostly sensory) Radial Nerve Ulnar nerve – comes to the hand by passing between the pisiform and the hook of the hamate. The nerve is the largest unprotected nerve in the human body (meaning unprotected by muscle or bone), so injury is common. This nerve is directly connected to the little finger, and the adjacent half of the ring finger, supplying the palmar side of these fingers, including both front and back of the tips, perhaps as far back as the fingernail beds. This nerve can cause an electric shock-like sensation by striking the medial epicondyle of the humerus from posteriorly, or inferiorly with the elbow flexed. The ulnar nerve is trapped between the bone and the overlying skin at this point. This is commonly referred to as bumping one's "funny bone". This name is thought to be a pun, based on the sound resemblance between the name of the bone of the upper arm, the "humerus" and the word "humorous". Alternatively, according to the Oxford English Dictionary it may refer to "the peculiar sensation experienced when it is struck". Median nerve – enters the palm of the hand through the carpal tunnel. In the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbrical muscles. It also supplies the muscles of the thenar eminence by a recurrent thenar branch. The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve. The median nerve innervates the skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers. The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases. This palmar cutaneous branch travels in a separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor retinaculum. It is therefore spared in carpal tunnel syndrome. The muscles of the hand supplied by the median nerve can be remembered using the mnemonic, "LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis. Radial nerve - The radial nerve and its branches provide motor innervation to the dorsal arm muscles (the triceps brachii and the anconeus) and the extrinsic extensors of the wrists and hands; it also provides cutaneous sensory innervation to most of the back of the hand, except for the back of the little finger and adjacent half of the ring finger (which are innervated by the ulnar nerve). 5/3/2016 Sports Medicine - Mr. Cronin

Blood Supply Radial Artery Ulnar Artery
Radial artery - The radial artery lies superficially in front of the distal end of the radius, between the tendons of the brachioradialis and flexor carpi radialis; it is here that clinician takes the radial pulse (where it is commonly used to assess the heart rate and cardiac rhythm). The radial artery supplies the muscles on the radial side of the forearm and wrist. Ulnar Artery – The ulnar artery supplies the muscles on the ulnar side of the forearm. These two arteries form superficial and deep palmar arches, which in turn supply the digital arteries. 5/3/2016 Sports Medicine - Mr. Cronin

Special Tests Finkelstein’s Test Tinel’s Sign Phalen’s Test
Valgus/Varus and Glide Tests for the Wrist, MCP and IP Joints Luntriquetral Ballotment Test Allen’s Test Circulatory and Neurological Evaluation Dermatomes and Myotomes Nailbed Pinch Functional Evaluation Finkelstein's test is used to diagnose De Quervain's tenosynovitis in people who have wrist pain. To perform the test, the examining physician or therapist grasps the thumb and ulnar deviates the hand sharply, as shown in the image. If sharp pain occurs along the distal radius (top of forearm, close to wrist; see image), de Quervain's tenosynovitis is likely. Tinel's sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. It takes its name from French neurologist Jules Tinel (1879–1952). Phalen's maneuver is a diagnostic test for carpal tunnel syndrome discovered by an American orthopedist named George S. Phalen. Valgus/Varus and Glide Stress Tests are 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 is used to assess the condition of the lunate bone. A positive test indicates instability that often results in dislocation of the lunate The Allen’s test is a worldwide used test to determine whether the patency of the radial or ulnar artery is normal. It is performed prior to radial cannulation (is a technique in which a cannula {a thin tube inserted into a vein or body cavity to administer medicine, drain off fluid, or insert a surgical instrument} is placed inside a vein to provide venous access. Venous access allows sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.) or catheterization (catheterization, a long thin tube called a catheter is inserted in an artery or vein in your groin, neck or arm and threaded through your blood vessels, usually to the heart), because placement of such a catheter often results in thrombosis. Therefore the test is used to reduce the risk of ischemia to the hand. Dermatome - an area of the skin supplied by nerves from a single spinal root. Myotome - a group of muscles innervated from a single spinal nerve. 5/3/2016 Sports Medicine - Mr. Cronin

Common Injuries to the Wrist, Hand, and Fingers
Wrist Sprains Tenosynovitis Tendinitis Nerve Compression, Entrapment, Palsy Carpal Tunnel Syndrome deQuervain’s Syndrome Dislocation of the Lunate Scaphoid Fracture Hamate Fracture Wrist Ganglion Trigger Finger or Thumb Extensor Tendon Avulsion (Mallet Finger) Boutonniere Deformity Flexor Digitorum Profundus Rupture (Jersey Finger) Gamekeeper’s Thumb MCP Dislocation Bennett’s Fracture Metacarpal Fracture (Boxer’s Fracture) 5/3/2016 Sports Medicine - Mr. Cronin

Wrist Sprains Etiology Signs/Symptoms Management Etiology
-most common wrist injury and is often poorly managed; can arise from any abnormal, forced movement of the wrist; falling on the hyperextended wrist most common, but violent flexion or torsion will alos tear supporting tissue Signs/Symptoms -pain, swelling, difficulty moving the wrist; tenderness, swelling and limited ROM Management -if pain is severe enough—send for x-ray; mild-moderate sprains treat with RICE, splinting, and analgesics; hand strengthening exercises as soon as possible. Tape for support 5/3/2016 Sports Medicine - Mr. Cronin

Wrist Tenosynovitis vs. Tendonitis
Etiology Tenosynovitis = repetitive wrist accelerations and decelerations; repetitive use and overuse of the wrist tendons and their sheaths Tendonitis = repetitive wrist flexion; overuse of the wrist Signs/Symptoms Management Etiology Signs/Symptoms -pain in passive stretching or with use, tenderness and swelling; pain, weakness Management -RICE, NSAIDs, rest; wait for swelling to subside and ROM to be restored; begin PRE program 5/3/2016 Sports Medicine - Mr. Cronin

Carpal Tunnel Syndrome
Etiology Signs/Symptoms Management The carpal tunnel is located on the anterior aspect of the wrist. The floor of the carpal tunnel is formed by the carpal bones and the roof by the transverse carpal ligament. A number of anatomical structures course through this limited space, including eight long finger flexor tendons, their synovial sheaths and the median nerve. Etiology -an inflammation of the tendons and synovial sheaths within the space, which ultimately leads to compression of the median nerve; activities that require repeated wrist flexion, direct trauma to the anterior aspect of the wrist Signs/Symptoms -sensory: tingling, numbness and paresthesia in the arc of the median nerve innervation over the thumb, index and middle fingers and the palm of the hand -motor: weakness in thumb movement (lumbrical muscles of the index and middle fingers and three of thenar muscles) Management -conservative; rest, immobilization, NSAIDs; if the syndrome persists, injection with a corticosteroid and possible surgical decompression of the transverse carpal ligament may be necessary 5/3/2016 Sports Medicine - Mr. Cronin

deQuervian’s Syndrome
Aka Hoffman’s disease Etiology Signs/Symptoms Management Stenosing tenosynovitis in the thumb Etiology -the first tunnel of the wrist becomes contracted and narrowed as a result of the inflammation of the synovial lining. The tendons that go through the first tunnel are the extensor pollicis brevis and abductor pollicis longus, which move through the same synovial sheath. Because the tendons move through a groove of the radiostyloid process, constant wrist movement can be a source of irritation. Signs/Symptoms -aching pain which may radiate into the hand or forearm; movements of the wrist tend to increase pain; + Finkelstein’s test; point tenderness & weakness during thumb extension and abduction, and there may be painful snapping and catching of the tendons during movement. Management -immobilization (brace), rest, cryotherapy, NSAIDs; ultrasound & ice massage are beneficial as well. Joint mobs not indicated. 5/3/2016 Sports Medicine - Mr. Cronin

Lunate Dislocation Etiology Signs/Symptoms Management Etiology
-forceful hyperextension of the wrist; most commonly dislocated carpal bone; when the stretching force is released, the lunate bone is dislocated anteriorly (palmar side) Signs/Symptoms -pain, swelling, difficulty in executing wrist and finger flexion; may also be numbness or even paralysis of the flexor muscles because of lunate pressure on the median nerve Management -send for reduction; if it is not recognized early enough, bone deterioration may occur, requiring surgical removal (resulting in 1-2 month recovery) 5/3/2016 Sports Medicine - Mr. Cronin

Scaphoid Fracture Etiology Signs/Symptoms Management Etiology
-most frequently fracture carpal bone; force on an outstretched hand, which compresses the scaphoid bone between the radius and second row of carpal bones; can be mistaken for a severe wrist/thumb sprain; without proper splinting, the scaphoid fracture often fails to heal because of an inadequate supply of blood; thus, degeneration and necrosis occur (Presier’s disease = avascular necrosis of the scaphoid bone) Signs/Symptoms -swelling in the area of the carpal bones; severe point tenderness of the scaphoid bone in the anatomical snuffbox; scaphoid pain that is elicited by upward pressure exerted on the long axis of the thumb and by radial flexion and ulnar deviation; absence of the ability to provoke pain by applying pressure in the anatomical snuffbox is perhaps the best way to distinguish a scaphoid fracture from a wrist sprain Management -ice; splint; refer; cast for about 6 weeks followed by strengthening exercises coupled with protective taping (no immobilization for rehab); wrist needs protection against impact loading for an additional 3 months; if fx is through whole bone and unstable, surgery to put in a screw is indicated or it may not heal properly 5/3/2016 Sports Medicine - Mr. Cronin

Hamate Fracture Etiology Signs/Symptoms Management Etiology
-can occur from a fall; commonly occurs from contact while the athlete is holding a sports implement, such as a tennis racket, baseball bat, lacrosse stick, hockey stick, or golf club Signs/Symptoms -wrist pain and weakness and point tenderness; pull of the muscular attachments can cause nonunion (non-healing fx) Management -casting of the wrist is usually the treatment of choice; can be protected by a doughnut-type pad that takes pressure off the area 5/3/2016 Sports Medicine - Mr. Cronin

Wrist Ganglion Etiology Signs/Symptoms Management Etiology
-aka synovial cyst -herniation of the joint capsule or of the synovial sheath of a tendon; usually appears slowly after a wrist sprain/strain; contains a clear, mucinous fluid; usually appears on the back of the wrist but can appear at any tendinous point in the wrist/hand Signs/Symptoms -occasional pain with a lump at the site; pain increases w/ use; cystic structure that may feel soft, rubbery or very hard Management -apply pressure (old method) -new method = combo of aspiration and chemical cauterization, w/ subsequent application of a pressure pad -neither method can prevent it from returning; ultrasound can reduce the size; surgical removal is the most effective of the various methods of treatment 5/3/2016 Sports Medicine - Mr. Cronin

Trigger Finger/Thumb Etiology Signs/Symptoms Management Etiology
Stenosing tenosynovitis; it is most commonly occurs in a flexor tendon that runs through a common sheath with other tendons; nonspecific overuse Signs/Symptoms Patient complains when the finger or thumb is flexed, there is resistance to re-extension, producing a snapping that is both palpable and audible; during palpation, tenderness is produced, and a lump can be felt at the base of the flexor tendon sheath Management Similar to deQuervain’s syndrome; if unsuccessful, steroid injections may produce relief; if that is unsuccessful, splinting the tendon sheath is the last option 5/3/2016 Sports Medicine - Mr. Cronin

Mallet Finger Etiology Signs/Symptoms Management
Baseball finger/basketball finger Signs/Symptoms Management Etiology A blow from an object that strikes the tip of the finger, jamming and avulsing the extensor tendon from its insertion, along with a piece of bone Signs/Symptoms Pain at DIP; x-ray may show a bony avulsion from dorsal proximal distal phalanx; unable to extend finger, carrying it at approximately a 30 degree angle; point tenderness at injury site; avulsed bone can often be palpated Management RICE; if no fx, immediately splint in a position of extension for 6-8 weeks 5/3/2016 Sports Medicine - Mr. Cronin

Boutonniere Deformity
Etiology Buttonhole deformity Signs/Symptoms Management Etiology Rupture of the extensor tendon dorsal to the middle phalanx. Trauma occurs to the tip of the finger, which forces the DIP joint into extension and PIP joint into flexion. The extensor expansion tears over the PIP joint, and the two sides slide down below the axis of volation of the PIP joint. The PIP articulation then pops through the extensor expansion tear, much as a button pops through a buttonhole Signs/Symptoms Severe pain and an inability to extend the DIP joint; swelling, point tenderness and obvious deformity Management Ice; splint PIP in extension; if not splinted properly the deformity will become permanent; splint for 5-8 weeks; while finger is splinted, patient is encouraged to flex the DIP 5/3/2016 Sports Medicine - Mr. Cronin

Jersey Finger Etiology Signs/Symptoms Management Etiology
Rupture of the flexor digitorum profundus tendon from its insertion on the distal phalanx. Most often in the ring finger when the athlete tries to grab the jersey of an opponent and either ruptures the tendon or avulses a small piece of the bone Signs/Symptoms The DIP joint cannot be flexed, and the finger is in an extended position; pain and point tenderness over the distal phalanx Management Surgically repair the tendon or flexion at the DIP joint will not be restored which will lead to weakness in grip strength; otherwise, function will be relatively normal. If surgery-rehab requires 12 weeks & there is often poor gliding of the tendon with the possibility of re-rupture; a lot of people opt to not do the surgery… 5/3/2016 Sports Medicine - Mr. Cronin

Gamekeeper’s Thumb Etiology Signs/Symptoms Management Skier's thumb
Sprain of the UCL of the MCP joint of the thumb Forced abduction of the proximal phalanx, which is occasionally combined with hyperextension Signs/Symptoms Pain over UCL ligament, weakness, painful pinch; inspection shows tenderness and swelling over the medial aspect of the thumb; discoloration Management If there is instability in the joints the patient should be immediately referred to an orthopedist; if the joint is stable, x-ray examination should be performed to r/o fx; splint for 3 weeks or until the thumb is pain free; splint should hold the thumb in a neutral position; thumb taping for return to sports; complete tear will require surgery to return to normal function 5/3/2016 Sports Medicine - Mr. Cronin

MCP Dislocation Etiology Signs/Symptoms Management Etiology
Twisting or shear force Signs/Symptoms Pain, swelling, and stiffness at the MCP joint. The proximal phalanx is dorsally angulated at degrees Management RICE, splinting, analgesics; send to get reduced, buddy taped and early ROM exercises 5/3/2016 Sports Medicine - Mr. Cronin

Bennett’s Fracture Etiology Signs/Symptoms Management Etiology
Occurs in the first metacarpal just distal to the CMC joint of the thumb as a result of an axial and abduction force to the thumb Signs/Symptoms Pain and swelling over the base of the thumb. The thumb’s CMC appears deformed. X-ray shows fx Management Refer to an orthopedic surgeon 5/3/2016 Sports Medicine - Mr. Cronin

Metacarpal Fracture (Boxer’s Fracture)
Etiology Signs/Symptoms Management Etiology Direct axial force or a compressive force such as being stepped on. Fractures of the 5th metacarpal are associated with boxing and martial arts and are usually called a boxer’s fracture (can also happen from punching hard objects with improper form) Signs/Symptoms Pain & swelling; could have a deformity Management RICE and analgesics; splint; x-ray; splint for 4 weeks and early ROM exercises after 5/3/2016 Sports Medicine - Mr. Cronin

The Forearm, Wrist, Hand, and Fingers

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The Forearm, Wrist, Hand, and Fingers

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