Wrist and Hand Conditions Chapter 16 Copyright 2013

Wrist and Hand Conditions Chapter 16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrist Articulations • Radiocarpal joint – Radius with scaphoid, lunate, and triquetrum – Condyloid joint – Sagittal plane motions (i. e. , flexion, extension, and hyperextension) – Frontal plane motions (i. e. , radial deviation and ulnar deviation) – Circumduction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrist Articulations (cont. ) • Intercarpal joints – Gliding joints – Minimal contribution to wrist movement • Distal radioulnar joint – Immediately adjacent to radiocarpal joint – TFCC – stabilizer Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hand Articulations • Carpometacarpal joints (CM) – Thumb • Saddle joint – Fingers • Gliding joints • Intermetacarpal joints (IM) • Metacarpophalangeal joints (MP) – Condyloid joints • Interphalangeal joints (IP) – PIP and DIP hinge joints Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Muscles Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Muscles (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Muscles (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Muscles (cont. ) • Tendon sheaths – Level of the metacarpal heads – point where flexor tendons enter a flexor tendon sheath – Annular pulleys • Keep flexor tendons and sheath closely applied to phalanges – Cruciate pulleys • Collapse to allow full digital flexion Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerves • Median nerve • Radial nerve • Ulnar nerve Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Blood Vessels • Radial artery • Ulnar artery • Numerous divisions Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinematics • Wrist movements – Flexion – Extension/ hyperextension – Radial deviation – Ulnar deviation – Circumduction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinematics (cont. ) • CM – Thumb – flexion, extension, abduction, adduction • MP – fingers – Fingers – minimal motion – Flexion – Extension – Abduction – Adduction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinematics (cont. ) • MP – thumb – Flexion – Extension • IP – Flexion – Extension Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinematics (Cont’d) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinetics • Wrist flexors of hand are 2× stronger than extensor muscles • Grips – Power – Precision – Lateral pinch; fencing – Maximum grip strength – exerted with wrist in ulnar deviation and slight hyperextension Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prevention of Injuries • Protective equipment – Pads and gloves • Physical conditioning – Strength and flexibility – Exercises for wrist and elbow • Proper skill technique – Instruction on falling Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Contusions and Skin Wounds • Always important to consider an underlying fracture • Contusion S&S: pain & discoloration • Skin wounds – typically abrasions and lacerations • Management – Standard acute for closed wound & open wound Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Sprains • Wrist – Mechanism: axial loading on proximal palm during fall on outstretched hand – S&S • Standard – sprain • Specific § Point tenderness on dorsum of radiocarpal joint § ↑ Pain with active or passive extension – Need to rule out fracture, especially scaphoid fx – Management: standard acute; NSAIDs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Sprains (cont. ) • Gamekeeper’s thumb – Tear of the UCL of the MP joint – Mechanism: MP in extension and forceful abduction – S&S • Palmar aspect of joint – pain; swelling • + abduction stress – Management: standard acute; instability: spica cast for 3 -6 weeks; severe: surgical repair Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Sprains (cont. ) • IP sprains – Excessive valgus and varus: collateral ligaments – Hyperextension stress: volar plate – S&S • Rapid swelling; masks condition – X-ray: rule out fracture and dislocation – Management: standard acute; “buddy” taping Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations • Distal radioulnar joint (DRUJ) – Isolated or with radial fracture – Mechanism: hyperextension • With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations (cont. ) – S&S • Pain; deformity; extensive swelling • Dorsal dislocation – ulnar head prominent dorsally; volar dislocation – wrist appears narrow (result of overlap of the distal radius and ulna) • elbow flexion and extension – normal unless fracture present; pronation and supination of forearm – limited – Management: immobilization of limb in vacuum splint; immediate transportation to physician Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations (cont. ) • Lunate – Axial loading displaces in volar direction – S&S • Point tenderness – dorsum of hand just distal to radius • Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal) • Passive and active motion may not be painful – Caution: bone into carpal tunnel – compression of median nerve – Management: immobilization of limb in vacuum splint; immediate transportation to physician Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations (cont. ) • Fingers – Can involve collateral ligaments and volar plate – MCP • Rare, but easily recognizable • Hyperextension or shear – PIP • Hyperextension and axial loading (e. g. , ball striking extended finger) – DIP • Usually occur dorsally • Individual often reduces injury on their own Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations (cont. ) – S&S: swollen, painful finger – Management: immobilization; ice; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dislocations (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains • Jersey finger – Rupture of flexor digitorum profundus from distal phalanx – Mechanism: rapid extension (from active flexion) – S&S • Unable to flex the DIP • Palpate tendon in proximal aspect of finger • Hematoma formation along the entire flexor tendon sheath – Management: standard acute; physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Mallet finger – Rupture of extensor tendon from distal phalanx – Mechanism: forceful flexion of PIP – S&S • Pain, swelling • Lack of extension at DIP – Management: standard acute; physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Boutonnière deformity – Rupture of central slip of extensor tendon at the middle phalanx – Mechanism: rapid forceful flexion of PIP – Result: hyperextension at MCP, flexion of PIP, hyperextension of DIP – S&S • No active extension • Deformity usually not present immediately, but develops over 2 -3 weeks – Management: standard acute; injury that limits PIP extension to <30º: immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Tendinopathies Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Tendinopathies – Trigger finger • Finger flexors contract but are unable to re-extend • Due to a nodule within tendon sheath or sheath too constricted to allow free motion • S&S § Locking usually occurs when wakening from sleep § Painful popping sensation when PIP joint is passively returned to extension • Management: NSAIDs, resting finger; splinting when necessary; possible cortisone injections into the sheath Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) – de Quervain's tenosynovitis • Stenosing tenosynovitis of APL and EPB • A forceful grasp, combined with repetitive use of thumb and ulnar deviation • S&S § Pain over radial styloid process ↑ with thumb and wrist motion § Point tenderness over the tendons § Pain with RROM thumb abduction § + Finkelstein’s test • Management: standard acute; NSAIDS Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) – de Quervain's tenosynovitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Intersection syndrome – Tendinitis or friction tendinitis in 1 st and 2 nd dorsal compartments of wrist – Overuse of radial extensors by excessive curling – S&S • Point tenderness on the dorsum of the forearm, 2 -3 finger breadths proximal to the wrist joint • Crepitus with AROM or PROM – Management: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activities Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Dupuytren’s contracture – Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformity – S&S • Fixed flexion deformity is visible • Finger cannot be extended – Management: surgical repair Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Gymnast’s wrist – Stress fracture to distal radial epiphyseal plate – Mechanism: compression (maximum dorsiflexion) – S&S: • Diffuse tenderness – dorsum of midcarpal area • ↑ pain with extreme motion – Management: splinting; NSAIDs; activity modification Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Strains (cont. ) • Ganglion cysts – Benign tumor mass on dorsal aspect of wrist – Associated with tissue sheath degeneration – Treatment: symptomatic Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Finger Tip Injuries • Subungual hematoma – Blood under fingernail – Due to direct trauma – Need to rule out fracture – Management • Soak in ice water for 10 -15 minutes • If pain does not diminish, may need to be drained under supervision of a physician • Refer to Application Strategy 16. 1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Finger Tip Injuries (cont. ) • Paronychia – Infection along nail fold – Fold is red, swollen, and painful; can produce purulent drainage – Management • Warm water soaks and germicide. • More severe cases, physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes • Median nerve – Anterior interosseous nerve syndrome • Following set of strenuous or repetitive elbow motion exercises • Affects motor but not sensation • S&S • Acute – sudden loss of use of flexor pollicis longus index finger profundus tendons • Gradual – weakness becomes apparent during heavy activity • + pinch grip test • Management: splint extremity; avoid heavy activity Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) – Carpal tunnel syndrome • Median nerve, finger flexors, and flexor pollicis longus • Due to direct trauma, repetitive overuse, or anatomic anomalies • S&S § Awakening pain in middle of night; often relieved by “shaking out their hands” § Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger § + Phalen’s maneuver; + Tinel’s sign § Weak thumb abduction • Management: physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) • Carpal tunnel Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) • Ulnar nerve entrapment – Ulnar tunnel syndrome • Due to repetitive compressive trauma to the palmar aspect of the hand • S&S § Numbness in the ulnar nerve distribution (especially little finger) § + Froment’s sign § Slight weakness in grip strength § + Tinel’s sign • Management: splinting, NSAIDs; activity modification Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) • Ulnar nerve entrapment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) – Cyclist's palsy • Due to leaning on handlebar for extended period; leads to swelling in hypothenar area • Symptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of ride • Key: proper padding; varying hand position – Bowler’s thumb • Compression of ulnar digital sensory nerve • S&S § Numbness, tingling, or pain – medial aspect of thumb • Management: standard acute; NSAIDs; immobilization Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) • Radial nerve entrapment – Distal posterior interosseous nerve syndrome • Due to compression associated with repetitive and forceful wrist dorsiflexion • S&S • Deep, dull ache in wrist, reproduced with: § Forceful wrist extension § Deep palpation of forearm with wrist in flexion • Management: standard acute; activity modification Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Entrapment Syndromes (cont. ) – Superficial radial nerve entrapment • Compressed at the wrist § Aggravated by repeated pronation and supination § Tight wrist straps • S&S § Burning pain and sensory changes in dorsoradial aspect of wrist, hand, dorsal thumb, and index finger § + Tinel’s sign • Management: standard acute; activity modification Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures • Distal radius/ulna fracture – Mechanism: axial loading; fall on outstretched hand – Monteggia’s • Distal ulna with associated dislocation of radial head – Galeazzi's • Distal radius with associated dislocation or subluxation of distal radioulnar joint – Colles’ • Distal metaphysis of radius, with displacement of distal fragment dorsally Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Distal radius/ulna fracture (cont. ) – Smith’s • Distal radius, with displacement of distal fragment toward palmar aspect – S&S: normal fracture – Concerns: • Circulatory impairment • Nerve damage – Management: immobilization in a vacuum splint; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Forearm fractures Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Scaphoid fracture – S&S • History of falling on an outstretched hand • Point tenderness in anatomic snuff box • Pain with inward pressure along axis • ↑ pain with wrist extension and radial deviation – Management: standard acute; splint; physician referral – Concern: aseptic necrosis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Lunate fracture – Rare in sports – S&S: dorsal wrist pain, swelling, and weakness of wrist associated with use – Concern: Kienböck’s disease – Management: standard acute; splint; physician referral • Hamate fracture – Direct impact; when striking a stationary object with a racquet or club in full swing Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) – S&S • Tenderness – hypothenar mass • Painful RROM abduction of the small finger • ↓ grip strength – Management: standard acute; splint; physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Triquetrum fracture – Caused by impingement of ulnar styloid into dorsum of triquetrum – S&S • History of acute wrist dorsiflexion injury or direct trauma • Pain – dorsal wrist over triquetrum – Management: standard acute; splint; physician referral • Metacarpal fracture (typical) – Mechanism: axial compression Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) – S&S: • ↑ pain and palpable – palm, directly over involved metacarpal • ↑ pain with percussion and compression – Management: immobilize in position of function; ice without compression; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Bennett’s fracture – Articular fracture – proximal end of first metacarpal – Mechanism: axial compression – Pull of APL tendon displaces shaft proximally; deep volar ligament holds small medial fragment in place → fracture -dislocation – S&S • Localized pain and swelling; ↑ pain with inward pressure long axis – Management: standard acute; splint; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Rolando fracture – Similar to Bennett’s fracture – Intra-articular fracture – proximal end of first metacarpal; tends to be more comminuted – S&S: same as Bennett’s, but ↑ deformity – Management: standard acute; splint; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Boxer’s fracture – Distal metaphysis or neck of fourth or fifth metacarpals – Inherently unstable – S&S • Sudden pain, inability to grip, rapid swelling, and deformity • Point tenderness; crepitus • ↑ pain with axial compression and percussion – Management: standard acute; splint; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fractures (cont. ) • Phalangeal fracture – Mechanism: compression; hyperextension – S&S: • ↑ pain with circulative compression of phalanx • ↑ pain with percussion and compression (long axis) – Management: standard acute; splint; immediate physician referral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment • History • Observation/inspection – Expose entire arm • Palpation – Pain, unable or unwilling to move wrist or hand; determine the possibility of a fracture or dislocation before moving the wrist or hand – Proximal to distal • Physical examination tests Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Range of Motion (ROM) • Active range of motion (AROM) – Forearm pronation/supination – Wrist • Flexion/extension • Radial deviation/ulnar deviation – Fingers and thumb • Flexion/extension • Abduction/adduction • Opposition of thumb and little finger • Passive range of motion (PROM) – Normal end feel – tissue stretch Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

ROM (cont. ) • Normal ranges – Supination: 90° – Pronation: 90° – Wrist flexion: 80 -90° – Wrist extension: 70 -90° – Radial deviation: 15° – Ulnar deviation: 30 -45° Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

ROM (cont. ) • Resisted range of motion (RROM) – Supination – Pronation – Wrist flexion – Wrist extension – Ulnar deviation – Radial deviation – Finger flexion/extension – Finger abduction/adduction – Thumb flexion/extension – Thumb abduction/adduction – Opposition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

ROM (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

ROM (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stress Tests • Wrist ligamentous instability tests – Varus and valgus • Finger ligamentous instability tests – Varus and valgus – Anterior/posterior glide Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests • Finkelstein’s test for de Quervain’s tenosynovitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests (cont. ) • Flexor digitorum superficialis (test for rupture of FDS) • Flexor digitorum profundus • Extensor tendon rupture Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests (cont. ) • Carpal tunnel compression test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests (cont. ) • Phalen’s wrist flexion test • Tinel’s sign Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests (cont. ) • Pinch-grip test for anterior interosseous nerve entrapment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Special Tests (cont. ) • Froment’s sign for ulnar nerve paralysis • Allen test for circulation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fracture Assessment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests • Myotomes – Scapular elevation - C 4 – Shoulder abduction - C 5 – Elbow flexion and/or wrist extension - C 6 – Elbow extension and/or wrist flexion - C 7 – Thumb extension and/or ulnar deviation - C 8 – Abduction and/or adduction of fingers - T 1 • Reflexes – Biceps - C 5 -C 6 – Brachioradialis - C 6 – Triceps – C 7 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests (cont. ) • Dermatomes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rehabilitation • Restoration of motion – Concern: joint contractures and stiffness – begin AROM ASAP – Use of opposite hand to supply load • Restoration of proprioception and balance – Closed-chain exercises • Muscular strength, endurance, and power – Open-chain exercises – PNF-resisted exercises • Cardiovascular fitness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins