The wrist & hand

The wrist/hand: Terms Remember to use the anatomical position when referring to directional terminology of the wrist/hand. Dorsum – Back of the hand Palmar – Top of the hand or palm side Thenar eminence Hypothenar eminence https://www.youtube.com/watch?v =zyl6eoU-3Rg

The wrist/hand The Wrist - made up of 8 carpal bones. The Wrist is a “Condyloid Joint” – The carpal bones are tightly bound together, allowing for little movement. The Hand - made up of 5 metacarpals and the digits (fingers) The metacarpals are identified by #1-5; the first metacarpal is the most lateral. Each digit has 3 phalanges, they are a “Gliding Joint.” The thumb only has 2 phalanges, it is a “Saddle Joint.” Wrist ROM: Flexion, Extension, Ulnar Deviation, Radial Deviation Finger ROM: Flexion, Extension, Adduction, Abduction Thumb ROM: Flexion, Extension, Adduction, Abduction, Circumduction, Opposition

Wrist/hand Joints Radiocarpal Joint: Radius articulation with the scaphoid, lunate, and triquetrium. Carpometacarpal Joints (CM): Carpal bones & proximal metacarpals. Metacarpalphalangeal (MP): Distal metacarpal & phalanges. Interphalangeal (IP): Between the phalanges. Proximal Interphalangeal (PIP): Proximal Phalange & Middle Phalange Distal Interphalangeal (DIP): Middle Phalange & Distal Phalange

Bony anatomy: Carpal bones “Some Leaders Try Positions That They Can’t Handle” S = Scaphoid L = Lunate T = Triquetrum P = Pisiform T = Trapezium T = Trapezoid C = Capitate H = Hamate

Bony anatomy Distal Radius Radial Styloid Distal Ulna Ulnar Styloid Anatomical Snuffbox 1st – 5th Metacarpals Phalanges

Bony anatomy Distal Radius Radial Styloid Distal Ulna Ulnar Styloid Anatomical Snuffbox 1st – 5th Metacarpals Phalanges

Anterior Side - “The Flexors” soft anatomy Anterior Side - “The Flexors” Flexor Carpi Ulnaris Palmaris Longus Flexor Carpi Radialis Pronator Teres

Posterior Side - “The Extensors” soft anatomy Posterior Side - “The Extensors” Extensor Carpi Ulnaris Extensor Digitorum Extensor Carpi Radialis Brevis Extensor Carpi Radialis Longus

nerves Muscles of the wrist are controlled by the following nerves: Radial Ulnar Median (Goes through the carpal tunnel)

Arteries/veins Blood is supplied to the wrist and hand by the following arteries: Radial artery Ulnar artery The ulnar, radial, cephalic, and basilic veins transport blood from the hand, back up the forearm, to the heart and lungs for re- oxygenation. Like the nerves the radial and ulnar blood vessels run parallel to the radius and ulna.

Warm up What is the top of the hand called? What is the back of the hand called? *Remember to use the anatomical position* What are the two divisions of the palmer surface of the hand? Where is each located? What are the anatomical movements of the wrist? Finger? Thumb? What are the three nerves that control the muscles of the wrist? Is the flexor muscle group of the forearm located posterior or anterior? The extensor muscle group? The scaphoid is located in the _________________.

Injury Presentation Project Injury presentations Injury Presentation Project

Wrist/hand evaluation & special tests

history MOI (Mechanism of Injury) C/C (Chief Complaint) Pain Type Location of Pain Severity of Pain Pain with ADL (activities of daily living) Previous Hx (history) Onset: Acute vs. Chronic?

History cont Other symptoms: numbness, tingling, tightness? What increases or decreased pain? Hear anything? Snap, Crack, or Pop? Sport Specific: changes in technique

observation Deformity? (Mallet finger, Volkmann’s contracture, Trigger finger, Boutonniere, etc.) Guarding Swelling Ecchymosis Hematoma Abrasions Scars Malalignment Nails – Subungal Hematoma Ganglion Knuckle inspection Thenar & Hypothenar eminence

Bony Palpation While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity. Lunate Triquetrum Pisiform Distal Radius Trapezium Radial Styloid Trapezoid Distal Ulna Capitate Ulnar Styloid Hamate Anatomical Snuff Box Scaphoid

soft Palpation Flexor Muscle Group: Palmaris Longus While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity. Flexor Muscle Group: Palmaris Longus Flexor Carpi Ulnaris Flexor Carpi Radialis Pronator Teres While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity. Extensor Muscle Group: Extensor Digitorum Extensor Carpi Ulnaris Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis

rom Instruct the athlete to perform the following movements bilaterally: Ulnar Deviation Radial Deviation Compare the ROM between the uninvolved and involved extremity. Phalanges: Finger Flexion Movements should be smooth and painless. Finger Extension Limited ROM on one side indicates potential injury. Abduction Adduction Wrist: Thumb: Flex, Ext, Abd, Add & Flexion Circumduction Extension Opposition

Weakness on one side indicates potential injury or deformity. Manual muscle tests MMT = manually testing an athlete’s strength to note any abnormalities due to injury. Compare the strength between the involved and uninvolved extremity to note any differences. Weakness on one side indicates potential injury or deformity.

Manual muscle tests Wrist Extension: Place your hand on the dorsal aspect of the athlete’s hand and instruct the athlete to push up against your hand as you provide isometric resistance. Weakness indicates potential injury or deformity to the extensor carpi radialis longus, extensor carpi radialis brevis, and/or extensor carpi ulnaris.

Manual muscle tests Wrist Flexion: Place your hand on the palmar aspect of the athlete’s hand and instruct the athlete to push down against your hand as you provide isometric resistance. Weakness indicates potential injury or deformity to the flexor carpi radialis and/or flexor carpi ulnaris.

Manual muscle tests Ulnar Deviation: Place your hand on the ulnar aspect of the athlete’s closed hand and instruct the athlete to press against your hand as you provide isometric resistance. Weakness indicates potential injury or deformity to the flexor carpi ulnaris and/or extensor carpi ulnaris.

Manual muscle tests Radial Deviation: Place your hand on the radial aspect of the athlete’s closed hand and instruct the athlete to press against your hand as you provide isometric resistance. Weakness indicates potential injury or deformity to the flexor carpi radialis and/or extensor carpi radialis.

Manual muscle tests Finger Extension: Place one finger on the dorsal aspect of the athlete’s finger that is being tested and have the athlete push the finger up into extension as you provide isometric resistance.

Manual muscle tests Finger Flexion: Place one finger on the palmar aspect of the athlete’s finger that is being tested and have the athlete flex the finger as you provide isometric resistance.

Manual muscle tests Finger Abduction: Place one finger on the lateral aspect of the athlete’s finger that is being tested. Place another finger on the lateral aspect of one of the adjacent fingers. Instruct the athlete to abduct the fingers as you provide isometric resistance.

Manual muscle tests Finger Adduction: Place one finger between the athlete’s finger to be tested and the one next to it. Instruct the athlete to adduct the fingers as you provide isometric resistance.

Compression Test Injury: Fracture – Carpal, Metacarpal, or Phalanx Patient Position: Standing or sitting Examiner Position: Standing in front of the patient Examiner Hand Position: Distal or proximal to fx site Exam Procedure: Apply compression to the affected structures. Place one finger on either side of the injured extremity above or below the possible fx site and compress the area between your fingers. Do NOT place either hand directly over the suspected fx site!! + Sign: Pain at fracture site

percussion Test Injury: Fracture – Carpal, Metacarpal, or Phalanx Patient Position: Standing or sitting, elbow flexed, making a fist or phalanx extended Examiner Position: Standing in front of the patient Examiner Hand Position: Stabilizing elbow Exam Procedure: Apply a firm strike to fist with an open hand, or flick knuckle or phalanx. + Sign: Pain at fracture site

Wrist valgus stress test Injury: UCL injury (wrist) Patient Position: Seated with 90 degrees of elbow flexion and forearm pronated Examiner Position: Lateral to the patient Examiner Hand Position: Distal forearm and dorsal hand over the metacarpals Exam Procedure: Apply valgus stress by radially deviating the wrist. + Sign: Pain and/or joint laxity

Wrist Valgus stress

Wrist varus stress test Injury: RCL injury (wrist) Patient Position: Seated with 90 degrees of elbow flexion and forearm pronated Examiner Position: Lateral to the patient Examiner Hand Position: Distal forearm and dorsal hand over the metacarpals Exam Procedure: Apply varus stress by ulnarly deviating the wrist. + Sign: Pain and/or joint laxity

Valgus/varus stress test (ip joints) Injury: UCL or RCL injury (Interphalangeal Joints) Patient Position: Seated, forearm pronated, testing joint is in extension Examiner Position: Lateral to the patient Examiner Hand Position: Stabilizing proximal phalanx and distal phalanx to testing joint Exam Procedure: Apply valgus stress for UCL and varus stress for RCL + Sign: Pain and/or joint laxity

Valgus/varus stress tests https://www.youtube.com/watch?v=ewyk6mC912g

Gamekeeper’s thumb Test Definition: Application of a valgus stress to the medial joint line at the base of the thumb to assess the possibility of injury to the UCL ligament. Injury: UCL pathology at the 1st MCP Joint Patient Position: Standing or sitting with thumb slightly abducted Examiner Position: Standing in front of the patient Examiner Hand Position: Stabilizing 1st metacarpal and proximal phalanx Exam Procedure: With 30 degrees of MCP Joint flexion, apply a valgus stress. + Sign: Pain and/or joint laxity https://www.youtube.com/watch?v=M04FDmRMAIQ

Gamekeeper’s thumb test

Gamekeeper’s thumb test

Finkelstein’s test Definition: Stretching or lengthening of the thumb tendon to assess the possibility of DeQuervain’s syndrome, or tenosynovitis of the thumb tendon. https://www.youtube.com/watch?v=KbakSxU7OmI Injury: DeQuervain’s Syndrome Patient Position: Seated with 90 degrees of elbow flexion and forearm in neutral Examiner Position: Standing in front of the patient Examiner Hand Position: None Exam Procedure: Patient makes first with thumb inside, then actively performs ulnar deviation of the wrist. + Sign: Radial styloid process pain https://www.youtube.com/watch?v=lfe4TfpbAfk

Finkelstein’s test https://www.youtube.com/watch?v=eL2Uzfd26SA

This test can be performed two ways! Phalen’s test Definition: Compression of the median and ulnar nerves to assess the possibility of impingement. This test can be performed two ways! Injury: Carpal Tunnel Syndrome Patient Position: 1)Seated or standing with 90 degrees of elbow flexion and forearm pronation. 2)Elbow and wrist in 90 degrees of flexion with backs of hand together Examiner Position: Standing in front of the patient Examiner Hand Position: 1)Stabilizing posterior elbow and hand 2)Gently grasping the athlete’s palms Exam Procedure: 1)Passively flex the wrist and hold at the end range of flexion for 1 minute. 2) Gently squeeze hands together. + Sign: Tingling through the wrist and hand

Phalen’s test #1

Phalen’s test #2 https://www.youtube.com/watch?v=DZ9UGuA8oAE

scenario A football player falls to the ground and lands on his closed fist causing an axial load of the metacarpals. He is c/o pain over the 5th metacarpal. What injury do you suspect? What is your treatment plan?

scenario A volleyball player, going up to block a spike, receives an axial force. What injury do you suspect occurs as a result? What soft tissue structure is affected?

scenario A baseball catcher receives a pitch that jams and avulses the extensor tendon of the distal interphalangeal joint of the second finger. What is this injury called? How is it treated immediately at the time of the injury? How is is managed post traumatically?