The Wrist Hand Fingers JOHN H ANDERSON MS

The Wrist, Hand, & Fingers JOHN H. ANDERSON, MS, ATC, LAT ASSOCIATE PROFESSOR EMERITUS ATHLETIC TRAINING PROGRAM TROY UNIVERSITY NATA MEMBER FOR OVER 50 YEARS 32 ND STUDENT SEATA MEETING FEBRUARY 25, 2017 STUDENT SEATA MEETING ATLANTA, GEORGIA

Evaluation of Wrist, Fingers, & Hand

History Location of Pain Mechanism of Injury Relevant Sounds Relevant Sensations Duration of Symptoms Description of Symptoms

Inspection General Area Posture of Hand Gross Deformity Palmar Creases Areas of Cuts or Scars

Inspection Wrist & Hand Continuity of the Distal Radius & Ulna Continuity of the Carpals & Metacarpals Posture Ganglion Cyst Thumb & Fingers Skin Fingernails Alignment of Fingernails Finger Deformities

Palpation of the Hand Metacarpals MCP Collateral Ligaments Phalanges IP Collateral Ligaments Thenar Compartment Thenar Webspace Central Compartment Hypothenar Compartment

Palpation of the Hand Ulnar Styloid Process Ulnar Collateral Ligament Radius Radial Styloid Process Radial Collateral Ligament Lister’s Tubercle

Palpation of the Carpals Scaphoid Trapezium Lunate Pisiform Hamate Capitate Trapezoid

Range of Motion Tests Wrist AROM PROM RROM Flexion Extension Radial Ulnar Deviation

Range of Motion Tests Thumb CMC AROM PROM RROM Flexion Extension Abduction Adduction Opposition

Range of Motion Tests Fingers AROM PROM RROM Flexion & Extension – MCP Abduction Flexion & Adduction – MCP & Extension – IP Joints

Ligamentous Tests Valgus & Varus Stress Testing Radiocarpal Joint Glide Testing of Wrist Valgus Ulnar & Varus Testing – IP Joints Collateral Ligament - Thumb

Neurological Testing Radial Nerve Median Nerve Ulnar Nerve

Special Tests Carpal Tunnel Syndrome Phalen’s Test De. Quervain’s Finkelstein Syndrome Test

Other Special Tests Others Tap or Percussion Test Compression Test Long Finger Flexor Test Tinel Test Wrinkle Digital or Shrivel Test Allen Test Bunnel Watson Littler Test

Signs Murphy’s Sign Froment’s Sign

General First Aid of Wrist & Hand Injuries

First Aid Care Ice Splint Soft, Inflated, or Rigid Position of Function Wrist Fingers Sling

Injuries to Wrist & Hand

Wrist Strain Mechanisms Symptoms AROM, RROM, & passive stretch Referral and Diagnostic Procedures Muscle spasm; swelling; ecchymosis; point tenderness; loss of function & strength; hematome formation; defect in musculotendinous unit with thirddegree injury; inflammation; possible Ca formation with third-degree injury Special Tests Pain increased with AROM & passive stretch; loss of function; possible snapping sound upon injury; muscle fatigue prior to injury; pain on RROM; tenderness Signs Trauma to musculotendinous unit, due to forcible contraction or stretching, and muscle fatigue Orthopedist is persistent S/S Classification of Injury First-, second-, third-degree strain

Wrist Luxation Common Term – Dislocated Wrist Mechanisms Direct trauma causing hyperextension of wrist Symptoms Pain & loss of function Signs Marked deformity; loss of function; swelling; point tenderness Referral and Diagnostic Procedures Orthopedist; X-Ray for possible fracture

Wrist Ganglion Common Term – Bible Cyst Mechanisms Symptoms Pain; loss of function; discomfort on use of hand & wrist Signs Herniation resulting from minor dorsal or volar capsule sprains of joint capsule through process of mucoid degeneration or herniation of synovial sheath of the flexor carpi radialis tendon sheath, digital extensors, and roof of the first dorsal compartment Appears slowly after injury as a bump on back of wrist. It may appear, then disappear, then reappear. Referral and Diagnostic Procedures Orthopedist; MRI

Colles’ Fracture Common Term – Broken Wrist Mechanisms Symptoms Sudden pain; los of function; direct & indirect tenderness Signs Indirect or direct trauma to the distal forearm by falling on an outstretched hand or hyperextended wrist fracturing the distal end of the radius & ulna Loss of function; possible deformity; rapid swelling; direct &/or indirect tenderness; possible bony deviation, crepitus, or false motion; delayed ecchymosis; possible median nerve damage Referral and Diagnostic Procedures Orthopedist; X-Ray

Carpal Fracture Mechanism – Direct trauma Symptoms Sudden pain; loss of function; direct or indirect tenderness Signs Loss of function; possible deformity; rapid swelling; direct or indirect tenderness; possible tenderness, crepitus, & false motion; delayed ecchymosis Referral and Diagnostic Procedures Orthopedist; X-Ray

Tenosynovitis Mechanisms Overuse; direct trauma; repetitive trauma Symptoms Pain on AROM and RROM; pain on passive stretch; loss of function Signs Swelling; thickened tendon in chronic cases; snowball crepitus; inflammation Special Tests AROM; RROM; passive stretch Referral and Diagnostic Orthopedist if s/s persist Procedures

Carpal Tunnel Syndrome Mechanisms Symptoms Point tenderness at wrist; pain over carpal tunnel; poor finger flexion Special Tests Numbness & tingling in fingers; pain; loss of function Signs Compression of median nerve as it passes beneath the flexor retinaculum on the volar aspect of the wrist Tinel’s sign; Phalen’s test; Electromyography; nerve conduction study Referral and Diagnostic Procedures Orthopedist; X-Ray

Lunate Luxation Common Term – Dislocated Carpal Bone Mechanisms Indirect trauma; fall on outstretched hand or hyperextended wrist Symptoms Pain; loss of function; numbness of flexor muscles due to pressure on median nerve; tenderness Signs Marked deformity; loss of function; swelling; point tenderness; Murphy’s sign Referral and Diagnostic Procedures Orthopedist; X-Ray for possible fracture

Navicular (scaphoid) Fracture Mechanisms Symptoms Loss of function; rapid swelling; direct tenderness to anatomic snuffbox; indirect tenderness; possible bony deviation, crepitus, & false motion; delayed ecchymosis Special Tests Sudden pain; loss of function; direct & indirect tenderness Signs Indirect trauma to an outstretched hand (thumb) or hyperextended wrist Compress of thumb; pressure into anatomic snuffbox Referral and Diagnostic Procedures Orthopedist; X-Ray

Ulnar Collateral Ligament Sprain Thumb Common Terms Mechanisms Abduction stress test of thumb Referral and Diagnostic Procedures Point tenderness over ulnar collateral ligament; swelling; hemorrhage; possible deformity with third-degree injury; ecchymosis; possible instability with second- and third-degree injuries; inflammation Special Tests Pain on AROM, RROM, & passive stress; loss of function; tenderness Signs Forced abduction & hyperextension of thumb causing sprain of the ulnar collateral ligament Symptoms Gamekeeper’s Thumb or Skier’s Thumb Orthopedist; X-Ray for possible avulsion fracture of ligament Classification of Injury First-, second-, third-degree

Bowler’s Hand Common Term – Bowler’s Thumb Mechanisms Overuse of the thumb, such as in the hole of a bowling ball, causing pressure on the ulnar nerve Symptoms Numbness; pain; tingling Signs Loss of sensation of thumb; loss of strength Referral and Diagnostic Procedures Neurologist is s/s persist

De. Quervain’s Disease Common Term Mechanisms Extensive wrist motion, as in gripping sports, to the abductor pollicis longus & extensor pollicis brevis tendons & their sheaths at the radial styloid; excessive radial or ulnar deviation; combination of these movements Symptoms Tenosynovitis of Wrist Aching; radiating pains into hand & forearm; loss of strength; pain; inability to grip; point tenderness Signs Painful crepitus of the tendon at the base of the thumb; weakness of thumb extension & abduction; parathesia over the dorsum of the thumb; weakness in ulnar deviation; inflammation; possible stenosis of the fibro-osseous canal; possible localized swelling Special Test – Finkelstein’s Test Referral and Diagnostic Procedures Orthopedist if s/s persist

Bennett’s Fracture Mechanisms Indirect trauma, such as striking an object with a closed fist on the first metacarpal Symptoms Sudden pain; loss of function; direct or indirect tenderness Signs Loss of function; possible deformity; rapid swelling; direct tenderness at the base of first metacarpal; indirect tenderness; possible bony deviation, crepitus, & false motion; delayed ecchymosis; “click” felt as joint subluxes Referral and Diagnostic Procedures Orthopedist; X-Ray

Ulnar Neuropathy Common Terms Mechanisms Irritation of ulnar nerve caused by abnormal pressure on the hands due to excessive body weight forced forward while the wrists are in prolonged extension; pressure on hypothenar eminence & road vibration during cycling Symptoms Handlebar or Cycle Palsy Loss of strength; pain when riding; pain at rest; decrease in skin sensitivity; sharp burning pain Signs Weakness of motor function; minimal sensory findings; loss of coordination of ulnar nerve in fourth & fifth finger Special Test – Ulnar Nerve Motor Test Referral and Diagnostic Procedures Neurologist; EMG study

Hamate Fracture Mechanisms Indirect trauma to wrist; fall on outstretched or hyperextended wrist Symptoms Sudden pain; loss of function; direct & indirect tenderness Signs Loss of function; possible deformity; rapid swelling; direct & indirect tenderness; possible bony deviation, crepitus, & false motion; delayed ecchymosis Referral and Diagnostic Procedures Orthopedist; X-Ray; CT Scan

Fifth Metacarpal Fracture Common Term – Boxer’s Fracture Mechanisms Symptoms Indirect trauma, such as a striking blow with the fist Sudden pain; loss of function; direct or indirect tenderness; poor ability to grip Signs Loss of function; inability to grip; possible deformity; rapid swelling; direct & indirect tenderness; possible bony deviation, crepitus, & false motion; delayed ecchymosis Special Tests – Axial Load Test Referral and Diagnostic Procedures Orthopedist; X-Ray

Mallet Finger Common Term – Hammer Finger Mechanisms Symptoms Deformity; fingertip is dropped down; possible crepitus; inability to extend distal phalanx; finger carried at 30 degrees Special Tests Pain; loss of function; inability to extend distal phalanx Signs Longitudinal force to the fingertip; forced flexion of the distal phalanx Range of motion of distal phalanx (extension) Referral and Diagnostic Procedures Orthopedist; X-Ray for possible avulsion fracture

Boutonnière Deformity Common Term – Buttonhole Deformity Mechanisms Symptoms Trauma to middle phalanx; forced flexion of the proximal interphalangeal joint; rupture of extensor tendon of the middle phalanx Pain at point of injury; loss of function Signs Point tenderness over the dorsal middle phalanx; swelling; flexion deformity of proximal interphalangeal joint; instability to extend the finger; hyperextension of distal joint Special Tests – PIP Range of Motion Referral and Diagnostic Procedures Orthopedist; X-Ray for possible fracture

Phalange Luxation Common Term – Dislocated Finger Mechanisms Direct trauma to joint of a phalanx; indirect force applied to the distal tip of the finger Symptoms Pain; loss of function Signs Marked deformity; loss of function; swelling; point tenderness Referral and Diagnostic Procedures Orthopedist; X-Ray for possible fracture

Flexor Digitorum Profundus Tendon Rupture Common Term- Jersey Finger Mechanisms Symptoms Swelling; loss of function; pain distal to interphalangeal joints on volar surface; palpable mass on palm of injured hand; lacks full flexion of IP joints when joint is held in extension Special Test Pain; loss of function Signs Forced extension of flexed distal phalanx Flexor Digitorum Profundus Test Referral and Diagnostic Procedure Orthopedist

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