wrist and hand anatomy
TRANSCRIPT
Wrist AnatomyBonesQuiz - What
bones comprise the wrist?
JointsQuiz - What joints
comprise the wrist?
Carpal Bones and Articulations
Proximal Row Where can you
palpate these? Scaphoid Lunate Triquetrum Pisiform
Radiocarpal joint Ulnocarpal joint
Intercarpal joints
Distal Row Where can you
palpate these? Trapezium Trapezoid Capitate Hamate
Intercarpal joints Carpometacarpal
joints (related to hand)
Articulations and ROMDistal Radioulnar joint Supination and Pronation – 80-90o
Ulna moves posteriorly and laterally with pronation
Radiocarpal joint (and Ulnocarpal joint) Flexion (80-90o) and Extension (75-85o) Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints Gliding
Soft tissue of WristLigaments Covered by a fibrous
capsule Radial and ulnar
collateral limit ulnar and radial
deviation; collectively limits flexion and extension
Intercarpal and Carpometacarpal
Soft tissue of WristLigaments Dorsal – limits flexion
Dorsal Radiocarpal Palmar - limit
extension Transverse carpal
ligament Palmar radiocarpal
Multiple divisions Palmar ulnocarpal
ligament Multiple divisions
Soft tissue of WristCartilage Triangular Fibrocartilage
Complex – TFCC “Meniscus” between
ulna and triquetrum Ulnar collateral ligament
and palmar ulnocarpal ligaments have attachments
Compressed with Pronation and Extension
Compressed with Ulnar deviation
Muscle Tissue of WristExtensor muscles Extensor
Retinaculum What’s its function?
Muscles innervated by radial nerve
There are 8 Name them…
Flexor Muscles Flexor retinaculum
(aka transverse carpal ligament)
Two compartments Superficial – 4 Deep – 3 Name them…
Innervated by median and ulnar nerve
FLEXORSEXTENSORS
Wrist and Hand AnatomyNerves/Vessels Radial & ulnar artery and veins Radial, ulnar, & median nerves
Carpal Tunnel - Flexor Tendons - 9 Median NerveMedian Nerve
Wrist InjuriesStrains Onset usually acute – FOOSH or Overexertion S/S: Active ROM limited
Wrist Ganglion Herniation of the joint capsule or synovial sheath
of a tendon.
Tx: Bible Therapy
Wrist InjuriesdeQuervain’s Disease - thumb/wriststenosing tenosynovitis of the extensor
pollicis brevis and abductor pollicis longus.
S/S: crepitation, tenderness, strength loss. Special Test: = Finkelstein’s testTx: RICE, NSAIDs
Wrist InjuriesSprains Onset is usually acute – FOOSH or overexertion Often diagnosed when other injuries are ruled out
Both active and passive ROM are effected S/S: Laxity, pain, swelling, limited ROM
Pain is usually with overstretching Special Tests: Varus/Valgus, Carpal Glide PRICE, Rehabilitation, Taping for prevention
Wrist InjuriesTriangular Fibrocartilage Injuries - TFCC Onset is usually acute MOI: Forced hyperextension of wrist with loading S/S: Pain with pronation/extension and/or ulnar
deviation; Pain with loading; Point tenderness; Swelling; Altered joint mechanics
Special Test: Valgus test elicits pain but no laxity and Varus test compresses and causes pain
Immobilization and Surgery are often necessary
Neural InjuriesCarpal Tunnel Syndrome Compression of median nerve
Fibrosis of the synovium of flexor tendons secondary to tenosynovitis
MOI: Insidious onset with repetitive wrist movement (and finger movement); Acute onset with trauma; Progressive degeneration
S/S: numbness palmar thumb, index, middle fingers, dull ache, weak finger flexion (grip). May worsen with sleep. Poor posture may predispose. Special Tests: Tinel’s sign
and Phalen’s Tx: Conservative (PRICE, NSAIDs) and Surgical
Neural InjuriesBiker’s Palsy Ulnar nerve compression Ulnar nerve passes through tunnel of Guyon between
pisiform and hamate. MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar
deviation Tx: Padding (Gloves), Ice, NSAIDs
Drop Wrist Syndrome Radial nerve compression at elbow Inability to extend wrist and fingers
Wrist InjuriesWrist Fractures Distal Radius/Ulna and Forearm Fractures Onset is acute MOI: Hyperextension or hyperflexion combined
with rotatory motion – FOOSH S/S: Deformity felt and observed; Crepitus Evaluated Neurovascular status Tx: Splint, Ice, Referral
Wrist InjuriesWrist Fractures Distal Radius/Ulna
Colles’ Fracture MOI: hyperextension-fall on outstretched S/S: “silver fork deformity” - radius & ulna posteriorly
Smith’s Fracture (Reverse Colles) MOI: hyperflexed S/S: “garden spade deformity” - radius
& ulna anteriorly
Wrist InjuriesWrist Fractures Scaphoid - most common carpal
MOI: fall on outstretched hand S/S: wrist aches, pain in anatomical
snuff box, painful handshake or with overpressure
Tx: Splint, Referral, Ice Plain X-rays may not be enough Immobilization (long and/or short) –
12 weeks Risk: aseptic necrosis and non-
union fractures Preiser’s Disease Surgery may be necessary
Wrist InjuriesWrist Dislocations Radius or Ulna Lunate is very common
MOI: force hyperextension Dorsal displacement = perilunate dislocation Palmar displacement (total rupture) = lunate
dislocation S/S: Deformity, 3rd Knuckle is lower (Murphy’s sign),
Paresthesia of middle finger, weak finger flexion Risk: Untreated or repeated trauma
Kienbock’s Disease Decreased grip, pain with ulnar deviation, weak
extension, pain with passive 3rd finger extension Immobilization – 6-8 weeks; Surgery may be
necessary
Wrist Injury PreventionGood technique!But…these help
Lumbricals
1234Palmar Interossei
Dorsal Interossei
Flexor tendon arrangement
Extensor Hood, Long extensor tendon, and lateral bands
Finger flexor tendons
Unique fingerLook at pulleysystem
ObservationRelaxed position of hand Fingers slightly flexed
Relative shortness of finger flexorsSkin and Nail health Discoloration, texture, hair patterns
Finger alignment Tips of fingers should align with finger flexion
Hand abnormalities Finger and metacarpal positioning Muscle atrophy
Range of motion
Range of MotionCarpometacarpal Flexion (70-80o)/Extension Abduction (70-80o)/Adduction Opposition
Metacarpophalangeal Flexion (85-105o)/Extension (20-35o) Abduction/Adduction (20-25o)
Interphangeal joints Thumb flexion (80-90o) PIP flexion (110-120o) DIP flexion (80-90o)
PalpationMetacarpals and joints Collateral ligaments of MCPs
Phalanges and joints Collateral ligaments of PIPs and DIPs
Thenar compartment muscles
Thenar webspace muscles
Central compartment Palmar fascia and muscles
Hypothenar compartment muscles
PathologyTendon pathology Trigger Finger/Thumb Mallet Finger Boutonniere Deformity Jersey Finger Dupuytren’s Contracture Swan Neck Deformity
Joint pathology Sprains
Bony pathology Fractures Dislocations
Dupuytren’s Contracture
Swan Neck Deformity
Tendon pathologyTrigger Finger or Thumb Etiology
Repeated motion of fingers may cause irritation, producing tenosynovitis
Inflammation of tendon sheath (flexor tendons of wrist, fingers and thumb, abductor pollicis)
Thickening forming a nodule that does not slide easily Signs and Symptoms
Resistance to re-extension, produces snapping that is palpable, audible and painful
Palpation produces pain and lump can be felt w/in tendon sheath Management
Immobilization, rest, cryotherapy and NSAID’s Ultrasound and ice are also beneficial Injection
Tendon pathologyMallet Finger (baseball or basketball finger) Etiology
Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion
Avulses extensor digitorum at distal phalanx Signs and Symptoms
Unable to extend distal end of finger (carrying at 30 degree angle)
Point tenderness at sight of injury X-ray shows avulsed bone on dorsal proximal distal
phalanx Management
RICE and splinting in hyperextension for 6-8 weeks
Tendon pathologyBoutonniere Deformity Etiology
Rupture of extensor tendon dorsal to the middle phalanx – bone passes through central slip
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
Cold application, followed by splinting in PIP extension and DIP flexion
Splinting must be continued for 5-8 weeks
Tendon pathologyJersey Finger Etiology
Rupture of flexor digitorum profundus tendon from insertion on distal phalanx
Often occurs w/ ring finger when athlete tries to grab a jersey
Signs and Symptoms DIP can not be flexed, finger remains extended Pain and point tenderness over distal phalanx
Management Must be surgically repaired Rehab requires 12 weeks and there is often poor gliding
of tendon, w/ possibility of re-rupture
Tendon pathologyDupuytren’s ContractureEtiology
Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity
Signs and SymptomsOften develops in 4th or 5th finger (flexion deformity)
ManagementTissue nodules must be removed as they can
ultimately interfere w/ normal hand function
Dupuytren’s Contracture
Tendon pathologySwan Neck Deformity Etiology
Distal tear of volar plate or finger trauma may cause Swan Neck deformity
Flexed MCP, extended PIP, and flexed DIP Signs and Symptoms
Pain, swelling w/ varying degrees of hyperextension Tenderness over volar plate of PIP Indication of volar plate tear = passive hyperextension
Management RICE and analgesics Splint in PIP 20-30 degrees of flexion/DIP extension for 3
weeks; followed by buddy taping
Joint pathologySprains PhalangesEtiology
Phalanges are prone to sprains caused by direct blows or twisting
Signs and SymptomsRecognition primarily occurs through historySprain symptoms - pain, severe swelling and
hemorrhaging
Joint pathologyGamekeeper’s Thumb Etiology
Sprain of UCL of MCP joint of the thumb Mechanism is forceful abduction of proximal phalanx occasionally
combined w/ hyperextension Signs and Symptoms
Pain over UCL in addition to weak and painful pinch Management
Immediate follow-up must occur If instability exists, athlete should be referred to orthopedist If stable, X-ray should be performed to rule out fracture
Thumb splint should be applied for protection for 3 weeks or until pain free
Splint should extend from wrist to end of thumb in neutral position Thumb spica should be used following splinting for support
Joint pathologySprains of Interphalangeal Joints of Fingers Etiology
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 possible
Management RICE, X-ray examination and possible splinting Splint at 30-40 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
Joint pathologyPIP Dorsal Dislocation
Etiology Hyperextension that
disrupts volar plate at middle phalanx
Signs and Symptoms Pain and swelling over PIP Obvious deformity,
disability and possible avulsion
Management Treated w/ RICE, splinting
and analgesics followed by reduction
After reduction, finger is splinted at 20-30 degrees of flexion for 3 weeks -- followed by buddy taping
PIP Palmar Dislocation Etiology
Caused by twist while it is semiflexed
Signs and Symptoms Pain and swelling over PIP;
point tenderness over dorsal side
Finger displays angular or rotational deformity
Management Treat w/ RICE, splinting
and analgesics followed by reduction
Splint in full extension for 4-5 weeks after which it is protected for 6-8 weeks during activity
Open Dislocation
Joint pathologyMCP DislocationEtiology
Caused by twisting or shearing forceSigns and Symptoms
Pain, swelling and stiffness at MCP jointProximal phalanx is angulated at 60-90 degrees
ManagementRICE, following reduction splinting in slight flexion (3
weeks)Buddy taping following splintingTherapy
Bony PathologyMetacarpal Fracture Etiology
Direct axial force or compressive force Fractures of the 5th metacarpal = Boxer’s Fracture
Signs and Symptoms Pain and swelling; possible angular or rotational deformity
Management RICE, analgesics are given followed by X-ray examinations Deformity is reduced, followed by splinting - 4 weeks of
splinting after which therapy starts Unstable fracture may need to be surgically pinned
Bony pathologyBennett’s Fracture Etiology
Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb
Signs and Symptoms CMC may appeared to be deformed - X-ray will indicate
fracture Athlete will complain of pain and swelling over the base
of the thumb Management
Structurally unstable and must be referred to an orthopedic surgeon
Surgery and immobilization – season ending
Bony pathologyDistal Phalangeal FractureEtiology
Crushing forceSigns and Symptoms
Complaint of pain and swelling of distal phalanxSubungual hematoma is often seen in this condition
ManagementRICE and analgesics are givenProtective splint is applied as a means for pain reliefSubungual hematoma is drained
Bony pathologyMiddle Phalangeal Fracture Etiology
Occurs from direct trauma or twist Signs and Symptoms
Pain and swelling w/ tenderness over middle phalanx Possible deformity; X-ray will show bone displacement
Management RICE and analgesics No deformity - buddy tape w/ splint for activity Deformity - immobilization for 3-4 weeks and a protective
splint for an additional 9-10 weeks during activity
Bony pathologyProximal Phalangeal FractureEtiology
May be spiral or angularSigns and Symptoms
Complaint of pain, swelling, deformity Inspection reveals varying degrees of deformity
ManagementRICE and analgesics are given as neededFracture stability is maintained by immobilization of
the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping
LacerationsSuperficial location of tendons and nerves predisposes athletes to damage form shallow lacerations.Any laceration to the fascia below the cutaneous layer should receive a referralR/O trauma to tendons and nervesPrevent infectionSuture to ensure minimal scarring
Finger Nail PathologySubungual Hematoma MOI: finger caught between two surfaces Presents with bleeding under nail bed Draining – Drill or Cauterize
Paronychia Infection around fingernail beds S/S: Redness, pain, drainage Warm soaks (Betadine), Antibiotic, Referral
Changes in normal appearance - indicative of a number of different diseases
Scaling or ridging = psoriasis Ridging and poor development = hyperthyroidism Clubbing and cyanosis = congenital heart disorders or chronic respiratory
disease Spooning or depression = chronic alcoholism or vitamin deficiency
Prevention of Hand Injuries
ProtectionGloves, Grips, Braces
Proper TechniqueSport and Ergonomics
Physical ConditioningReps and Sets for muscles of Hand
Theraputty, Wrist curls/extensions, Fist pumps
Problem Solving
Putting it together withCase studies
History What is the cause of pain? Mechanism of injury? Previous history? Location, duration and intensity of pain? Creptitus, numbness, distortion in temperature? Sounds or sensations? Technique changes? Weakness or fatigue? What provides relief?
ObservationFunctional Evaluation Range of motion in all movements of wrist should be
assessed Active, resistive and passive motions should be assessed
and compared bilaterally Wrist - flexion, extension, radial and ulnar deviation
Wrist “attitude” How do the carpals and metacarpals align with the distal
radius and ulna? Is there symmetry?
How are those tendons looking? Is there a palmaris longus? - 10% of population it is absent
Become a “palm reader”?
PalpationBony and Soft Tissue Palpation
Are they where they should be?Do they feel like they should feel?
Circulatory and Neurological EvaluationHands should be felt for temperature
Cold hands indicate decreased circulationTake pulse – radial arteryPinching fingernails can also help detect circulatory
problems (capillary refill)Hand’s neurological functioning should also be
tested (sensation and motor functioning)
Is it nerve?
What test is this?
What other test is common for nerve injury?
How else can you detect a neural injury?
Is it the ligaments or joints?
Which tests are these?
What are some distinguishing characteristics of a ligament or joint injury?
Is it muscle or tendon?
What test assesses these structures?
What are some distinguishing characteristics of a muscle injury?
How do you assess the function of a muscle?
Is it bone?What is are distinguishing signs of a potential fractures?
Case study #1A 28 year old woman complains of pain in the right hand over the last 3 months. She reports numerous FOOSH incidents and currently works as a cashier at a grocery store. The pain awakens her at night and is relieved only by vigorous rubbing of her hand and motion of the fingers and wrist. There is some tingling in the index and middle fingers. What is your assessment plan?
Case study #2A 18 year old boy reports with wrist pain and swelling on the dorsum of his wrist and hand. He notes the pain is more near the base of the thumb. He is an active weightlifter. He says he tripped and experienced a FOOSH while playing recreational football. He states that after the injury the wrist hurt, he rested 2 days and iced, the pain decreased, but then with weightlifting the swelling has developed the last 5 days. Now it is very swollen and painful. What is your assessment plan?
Case study #3A 22 year old golfer comes to you with pain along his right medial wrist. He reports that while on spring break he went skiing and had a FOOSH. The wrist was achy but didn’t bother after a few hours especially since he put snow on it for 20 minutes. Now that he has returned to school and golf practice he is having trouble controlling his drives and long iron shots because of pain in his wrist at the top of the swing. What is your assessment plan?