Wrist Evaluation and Injuries

Wrist Injuries  Wrist and hand injuries are very common in athletes  Most often occur when an athlete FOOSHs  Foosh = Falling on an outstretched hand

Evaluation Process  The evaluation process for a hand and wrist injury follows the same protocol as any other joint injury.

H-O-P-S  History  Observation  Palpation  Special Tests

History  Take a comprehensive history from the athlete  This is when you are asking about what happened to them  You want to find out EVERYTHING you can before you even though the athlete!  It is important to ask open-ended, non leading questions  This means limit questions that involve a yes or no answer  Sometimes this is difficult to avoid

History  Determine the mechanism of injury or MOI ; knowing how this happened could help guide you along your evaluation  REMEMBER: Unless you saw the injury, take everything with a grain of salt, athletes can exaggerate  “My arm twisted four times and it snapped”  Determine if the injury is acute or chronic  Acute- resent, sudden onset  Chronic- occurs over time

History  What happened? Or Can you explain what happened?  How long as this been going on?  How many times has this happened before?  Have you been evaluated before? What did the doctor say?  If you describe the pain how would you explain it? (you can provide suggestions like: stabbing, shooting, sore, aching, dull etc).  On a scale of 1-10 how would you rate your pain?  What makes it better? What makes it worse?  Did you hear / feel a snap, crack or pop?  Is there any numbness or tingling  Any important medical issues that I should know about?  Point with one finger where it hurts the most.  What have you been doing for the pain?

Observation  The observation begins when athlete walks in to the room  Look at the athlete as a whole; the way they walk and carry themselves  Athletes with a legitimate hand / wrist injury will self- splint

Observation  Look for open wounds or obvious deformity  Look for bleeding  Look for redness / discoloration  Look for swelling  Look for scars / skin condition  The more you observe in the beginning the more efficient your evaluation will be

Observation  Always compare bilaterally!!!!!!  Why???  So you can tell if something is abnormal or not

What do you see here?

Palpation  This is the physical component of the evaluation  ALWAYS ASK PERMISSION  Even if it’s a given  Always leave the door open  Always have someone of the same sex in the room if you feel uncomfortable

Palpation  Always start away from the injured area, slowly moving toward it  Start with bones and ligaments first  Then move on to muscle and soft tissue  Pay attention to the athlete’s facial expressions  KNOW YOUR ANATOMY!!!!!!!!

Palpation; 6 things to palpate for!  Use your finger tips while palpating; you don’t need to use a lot of force  Feel for muscle and bone symmetry  Feel for crepitus; a crunching, cracking or clicking sound of a bone  Feel for temperature differences; could indicate swelling  Identify areas of point tenderness; places of pain  Identify range of motion deficiencies  Identify strength deficiencies

Get with a Partner  Work on palpating the hand/wrist using just your finger tips!  Find the following bones:  Radius  Ulna  Carpals  Metacarpals  Phalanges (all 14)

Special Tests  Special Tests are test specifically designed to rule in or out specific injuries.  When done properly they can increase the chances of an accurate diagnosis!

Wrist Special Tests  Axial Compression  Carpal Glides  Compression  Finkelstein’s  Mallet Finger  Jersey Finger  Pinch Test  Murphy’s Sign  Flick Test  Thumb Varus/Valgus  MP, DIP, PIP Varus/Valgus

Axial Compression  Purpose:  Check for fracture of phalange or metacarpal  Could also indicate a bruise  How to do it:  Hold hand with nondominate hand, hold injured finger in hand and apply a gentle but deliberate pressure straight towards the wrist  Positive test  Pain  Crepitus

Carpal Glides  Purpose:  To detect sprains of carpal joints  How to:  Have patient sit in pronation, stabilize with one hand and provide a back and forth pressure to the carpal bone(s)  Positive test:  Pain and laxity when compared bilaterally

Compression Test  Purpose:  To detect fracture or contusion  How to  Gently squeeze the metacarpals, with pressure increasing but be mindful of general sensitivity in the area w/o injury  Positive test  Pain  Crepitus

Finkelstein’ Test  Purpose  To detect deQuerveins tendonitis  How to  Patient holds thumb in fist and ulnarly deviates wrist  Positive test  pain

Froment’s Test (aka Pinch test)  Purpose  Test ulnar nerve issues in the thumb  How to  Have an athlete pinch paper between thumb and index finger  Gently pull on the paper  Positive Test  Weakness compared bilaterally  Inability to hold paper

Murphy’s Sign  Purpose  Detect fracture of metacarpal or dislocation of carpal bone  How to  Have athlete make a fist and look at their knuckles  Positive test  Obvious deviation from normal knuckle pattern  May appear depressed or sunken in  May not look even

Flick Test  Purpose  Detect fracture in phalax  How to  Flick the distal phalange  Positive sign  Pain especially if it radiates

Thumb Varus/Valgus (same for all IP joints)  Purpose  Detect sprains in main thumb ligaments  How to  Stabilize with opposite hand  Varus: Provide gentle pressure from the inside pushing out  Valgus: Provide gentle pressure from the outside pushing in  Positive Test:  Pain and laxity compared bilaterally

Fractures  Colles’ Fracture (distal radius)  Scaphoid Fracture  Boxer’s Fracture (5 th metacarpal)  Metacarpal Fracture  Phalange Fracture

Colles’ Fracture  Mechanism – FOOH, hyperextended wrist  S/S – sudden pain, LOF, possible deformity ( dorsal displacement of radius ), possible crepitus, possible median nerve damage

Colles

Scaphoid Fracture  Mechanism – FOOH or hyperextended wrist  S/S – sudden pain (or insidious onset), LOF (may be delayed), tender in snuffbox  Commonly results in avascular necrosis if not treated properly

Boxer’s Fracture  Mechanism – striking with a fist  S/S – sudden pain, LOF, unable to grip, rapid swelling  Check knuckle contour

Boxer’s Fracture

Metacarpal Fracture  Mechanism – direct trauma  S/S – LOF, rapid swelling, possible bony deviation, positive compression test  Check knuckle contour

Phalanges Fracture  Mechanism – torsion to the end of finger, longitudinal force applied to tip of finger, secondary to dislocation  S/S – LOF, rapid swelling, possible bony deviation, positive flick test, crooked fingernails, subungual hematoma

Phalange Fracture

Metacarpalphalangeal luxation  Most common in thumb, tear of volar plate  Mechanism – extension and abduction  S/S – obvious deformity, LOF

Mallet (Hammer) Finger  Mechanism – force to fingertip, forced flexion of distal phalanx  S/S – pain, LOF, unable to extend DIP, deformity

Jersey Finger  Mechanism – forced extension of distal phalanx  S/S – pain at DIP, LOF, swelling, palpable mass on palm of hand, unable to flex IP joints Flexor Digitorum Profundus Tendon

Gamekeeper’s Thumb  Mechanism – forced abduction & hyperextension  S/S – pain on ROM, LOF, tenderness, possible deformity, positive stress test