Wrist, Hand and Finger Evaluation ATTR 322 Krzyzanowicz- Spring ‘14

Objectives Understand bony and soft tissue anatomy of the wrist, hand and fingers Understand movement relationships of the wrist, hand and fingers Describe common injuries including deforimities to the wrist, hand and fingers Demonstrate the proper evaluation of the wrist, hand and fingers to include Special tests Palpation MMT’s Utilize EBP principles' in evaluation techniques

Clinical Anatomy

Clinical Anatomy Forearm Wrist Hand Fingers Distal Ulna Distal Radius 8 carpal bones Hand 5 metacarpals Fingers 14 phalanges

Clinical Anatomy Forearm Carpal bones Distal radius broadens to form the ulnar notch on the medial surface to accept the ulnar head Radial styloid process- anterolateral border Carpal bones Unusual shapes and irregular surfaces Aligned in two rows Proximal: scaphoid, lunate, triquetrum, pisiform Distal: trapezium, trapezoid, capitate, hamate

Clinical Anatomy Metacarpals I (thumb)- V (little finger) Phalanx Proximal Middle Distal

Articulations and Ligamentous Support Distal radioulnar joint Supination and pronation Radiocarpal joint Flexion and extension Radial and ulnar deviation Radial collateral ligament Triangular fibrocarilaginous complex (TFCC) On the ulnar side Composed of an articular disk, ligaments and bone Dissipates stresses on forearm during loading Damaged by forced extension and pronation

Articulations Intercarpal joints Midcarpal joints Joints between each carpal bone held in place by interosseous ligaments Midcarpal joints Separation of the proximal and distal carpal rows Carpometacarpal Joints First 3 metacarpals articulate with the carpal bone Thumb is 1st CMC joint Saddle joint, flex/ext and abd/add

Articulations Metacarpophalangeal (MCP) and interphalangeal (IP) joints MCP flex/ext and abd/add IP flex/ext

Musculature Extensor muscles (p. 756-759) Flexor muscles Posterolateral forearm; innervated by radial nerve Flexor muscles Anteriomedial forearm; innervated by median nerve- except flexor carpi ulnaris (ulnar) Palmar muscles Intrinsic muscles Thenar eminence (thumb side) Hypothenar eminence (5th digit side)

Nerves Ulnar nerve Radial nerve Superficial just medial to carpal tunnel Passes through the Tunnel of Guyon formed by the hamate and pisiform Superficial branches provide sensory input on palmar side of little finger and medial side of ring finger Deep branch innervates the hypothenar eminence Radial nerve Motor (posterior interosseous nerve) and sensory (superficial radial nerve) Innervates wrist and finger extensors and dorsal hand Easy way to check for nerve issue is wrist extension

Nerves Median nerve Follows the flexor digitorum superficialis through the forearm Travels through the carpal tunnel laterally and divides into motor and palmar branches Motor- supply thenar emience Palmar- sensation to palmar surface of the thumb, index and middle finger

Carpal Tunnel Tunnel’s floor Roof Formed by the proximal carpal bones Roof Formed by the transverse carpal ligament Ten structures pass through the tunnel Listed in text Inflammation Median nerve is effected Grip strength is decreased

Carpal Tunnel

Clinical Examination Kinetic Chain History Evaluation of elbow, shoulder, cervical spine may be needed in wrist, hand and finger evaluations History Previous injury, fractures (common) General medical health Peripheral vascular disease (raynaud’s) Diabetic- chronic wrist pain Pregnancy- increased risk of carpal tunnel syndrome

Clinical Examination History of present condition Duration Location of pain Which nerve? MOI FOOSH? Compression? Sounds Clicking usually means TFCC Duration Scaphoid? Description of Sx Aching/throbbing=bony or soft tissue Burning/tingling=neurolo gic or vascular Change in activity ADL’s Job (ergonomics) Computer work

Inspection Functional Observation General Inspection Replicate activities that cause pain and ADL’s Compensating in shoulder? Decreased grip strength General Inspection Posturing of wrist and hand Gross deformity Palmar creases Lacerations or scars Nails

Ape

Bishop’s

Claw Hand

Dupuytern’s

Swan-neck

Volkmann’s

Inspection Wrist and Hand Thumb and Fingers Continuity of distal radius/ulna; carpals/metacarpals Alignment of MCP joints Ganglion cyst Thumb and Fingers Skin and fingernails

Finger Deformities

Jersey finger

Mallet

Boutonniere deformity

Palpation Palpation of the wrist and finger flexor muscle group Wrist flexor group Flexor carpi ulnaris Flexor digitorum profundus Flexor digitorum radialis Flexor carpi radialis Palmaris longus Carpal tunnel

Palpation Palpation of the wrist and finger extensor muscle group Wrist and finger extensor group Extensor digitorum communis Extensor pollicis longus Abductor pollicis longus Extensor pollicis brevis

Anatomical Snuffbox

Palpation Palpation of the hand Metacarpals Collateral ligaments of the MCP joints Phalanges Collateral ligaments of the IP joints Thenar compartment Thenar webspace Central compartment Hypothenar compartments Ulna Ulnar styloid process Ulnar collateral ligament Distal radius and styloid process Lister’s tubercle Radial collateral ligament

Palpation Palpation of the carpals Acronym? Scaphoid Trapezium Lunate Triquetrum Pisiform Hamate Capitate Trapezoid Acronym?

Joint and Muscle Function Assessment Range of Motion (wrist) Flexion (80-90) and extension (75-85) Ulnar deviation (35 degrees) and radial deviation (20 degrees) Range of Motion (fingers and thumb) Flexion and extension Abduction and adduction Opposition (thumb only)

Wrist ROM

First CMC Joint ROM

Finger ROM

Grip Dynamometry

Joint Stability Testing Stress testing Tests for collateral support of wrist ligaments UCL (TFCC involvement) RCL Tests for collateral support of IP joints UCL Laxity in either could be an avulsion fracture

WRIST PATHOLOGIES

Scaphoid Fractures About 70% of all carpal fx’s involve the scaphoid Bony block limiting wrist extension Most prevalent in 15-30 y/o Poor blood supply If fractured- compromises nutrition to proximal part Causes nonunion fractures and avascular necrosis Can result in instability of proximal carpal row

Scaphoid Fractures MOI S&S Usually FOOSH or forceful hyperextension Ache in area of anatomical snuffbox, increases with palpation Crepitus Severe P! with overpressure (radial deviation, flex/ext)

Scaphoid Fractures Management X-ray MRI/CT scan Treat as a fracture Usually doesn’t show though MRI/CT scan Better, but still not as sensitive Treat as a fracture Immobilize thumb and wrist (6+ weeks) Surgical intervention Bone from hip inserted at fx site We miss scaphoid fx’s all the time! When in doubt refer it out

Scaphoid Fractures

Hamate Fractures MOI S&S FOOSH; trauma to the palm swinging a golf club or baseball bat Fractured through axial load applied to 4th or 5th metacarpal S&S Minimal swelling in the hypothenar eminence Possible protrusion over hamate Point tender over hamate P! with 5th finger abd/add and with passive extension of 5th finger

Lunate Dislocation MOI S&S Forced hyperextension Can displace dorsally or palmarly S&S P! along radial side of palmar or dorsal aspect of wrist that limits ROM Bulge may be visible Can cause parethesia in middle finger Third knuckle is level with other knuckles Possibility of scaphoid fx as well

http://www.imageinterpretation.co.uk/wrist.h tml

Wrist Sprains Very general term Scapholunate ligaments MOI S&S Rule out carpal fx (scaphoid), and TFCC Scapholunate ligaments Most common sprain to the wrist MOI Typically forced hyperextension S&S Wrist and hand giving way; numbness; decreased ROM

Wrist Sprains Special Tests Treatment Watson’s test (show in lab) X-ray to r/o fx (if you think it’s needed) Rest Soft splint, cast, etc

Watson’s Test

Triangular Fibrocartilage Complex TFCC Trauma or repeated injury to TFCC and UCL can result in permanent disability Increased risk in sports in the closed kinetic chain MOI Forced hyperextension (blocking, weightlifting) Repeated weight bearing causing degeneration S&S P! along ulnar side of wrist; decreased ROM due to P!

Triangular Fibrocartilage Complex S&S P! when pushing up from a chair Palpation Ulnar styloid process- avulsed UCL? Treatment Cortizone injection Surgical management Casting usually 6-8 weeks

Carpal Tunnel Syndrome Refers to the S&S caused by compression of median nerve as it passes through the carpal tunnel Most frequented causes is fibrosis of the synovium of the flexor tendons secondary to tenosynovitis May occur due to repetitive microtrauma, acute trauma to the carpal tunnel or progressive degeneration of the carpal tunnels structures

Carpal Tunnel Syndrome S&S Paresthesia and P! along median nerve distribution Thumb, index, middle & lat. Half of ring finger) Often occurring at night Relieved when shaking Inspection may reveal Atrophy of thenar muscles Decreased grip strength Other symptoms Decreased strength in abductor pollicis brevis and opponens pollicis

Carpal Tunnel Syndrome Other symptoms Poor posture (forward head, rounded shoulders) Mimic s&s for C7 impingement May need to evaluate c-spine and elbow Special Tests Tinel’s sign= not a great test Phalen’s and reverse phalen’s Tx Rest, postural training, NSAID’s, splinting Surgical intervention

Phalan’s Test

Wrist Ganglion “Bible Cyst” A synovial cyst characterized by herniation of synovial fluid through the joint capsule or synovial sheath of the tendon May form on dorsal or volar aspect Signs and symptoms Observable and palpable localized mass Tenderness and discomfort with wrist extension (dorsal ganglion) May or may not impede ROM or function

Ganglion Cyst

HAND AND FINGER PATHOLOGIES

Metacarpal Fractures Typically fractured due to a compressive force along the bone’s shaft Such as punching with a fist Common to hear the bone snap Gross deformity is common Immediate swelling Tenderness along fracture site (pinpoint usually) crepitus? Fingers or metacarpal may rotate when hand is attempting to flex Could happen to any of the metacarpals

Boxer’s Fracture Fracture to the 5th metacarpal Treatment Common incidence after an improperly thrown punch Depressed 5th MCP joint Treatment Casting or ORIF Usually casted 6-8 weeks Special Tests Compression test (rotate)

Collateral Ligament Injuries Trauma to the collateral ligaments of the fingers usually results from a dislocation Can result from direct trauma too though Stub, jam your finger Pain and swelling usually set it Hurts like hell! Varus/Valgus testing Treatment though?

Phalanx Fractures Fractures of distal phalanx are the most common MOI is usually direct trauma, shear force or crushing force S&S include Gross deformity, swelling, inability to move finger, heard and felt a snap, crepitus Tx Splint, surgical intervention

Finger Dislocations Very common in contact sports and basketball ALWAYS CHECK FOR AN OPEN DISLOCATION DO NOT relocate as a student DO NOT relocate a thumb! MOI: Direct truama, shear force S&S Gross deformity, pain and inability to move joint Tx Reduce (if possible), splint and refer for x-ray (good chance it’s fractured)

Volar Plate Rupture Results from hyperextension of the PIP joint Pain and tenderness on the palmer aspect Loss of function Swelling Disruption can cause subluxation and permanent hyperextension Complications are a swan-neck or pseudo- boutonniere deformity

Volar Plate Injury

Volar Plate Injury

Tendon Avulsions Very common and can occur from direct blows or abrupt forces (throwing) Flexor Digitorum Profundus (Jersey Finger) rupture- Occurs when distal phalanx is forcefully extended while the finger is flexing (grabbing) Signs and symptoms Immediate pain and LOF Swelling Point tenderness at tendinous attachment Complete rupture results in inability to flex distal phalanx Incomplete rupture results in pain and weakness Unable to flex DIP joint against resistance

Jersey finger

Extensor Tendon Avulsion Mallet finger Results from an extended distal phalanx that is suddenly and forcefully flexed (catching) May be an avulsion fracture or tendon rupture Signs and symptoms Severe pain and immediate LOF Point tenderness over distal attachment Flexion deformity of the distal phalanx Inability to actively extend the distal phalanx Avulsion fracture has better chance to heal without surgery

Mallet Finger

Boutonniere Deformity Extensor Tendon Rupture Characterized by flexion of the PIP joint and hyperextension of the DIP joint Injury to the central slip of the extensor digitorum tendon at the PIP joint from forceful flexion (“Buttonhole rupture”) Signs and symptoms Localized pain and swelling over middle phalanx Point tenderness near the tendon insertion Weakness with extension of the PIP joint PIP joint will be flexed; DIP joint is hyperextended

Boutonniere Deformity

Splinting of Common Finger Injuries Deformity Splinting Position Jersey Finger DIP Joint in flexion Mallet Finger DIP Joint in extension Boutonniere Deformity PIP and DIP joints in extension Phalanx fracture Position found Metacarpal fracture Palmar surface of wrist and hand Unreduced dislocations

Dupuyten’s Contracture Flexion deformity typically seen in the older adult population Flexion contracture of the MCP and PIP joints as a result of contracture of the palmar fascia Typically affects the fourth and fifth digits

Tendonitis/Tendosynovitis Inflammation of the tendon or its synovial sheath Results from overuse or repetitive motion, direct trauma, and continued use following a tendon injury Signs and symptoms Point tenderness over involved tendon Swelling Palpable crepitus Pain with active and resisted motion Pain with passive stretching of the tendon

DeQuervain’s Disease Tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons on the radial side of the thumb; Causes inflammation of tendons Results from repetitive motion that combines gripping and wrist ulnar deviation Signs and Symptoms Pain along thumb side of wrist which may either appear gradually or suddenly; may travel into wrist and forearm Pain is usually worse with use of the hand & thumb, especially when forcefully grasping things or twisting the wrist There may be occasional catching or snapping of the thumb

DeQuervain’s Tenosynovitis

Finkelstein’s Test

Gamekeeper’s Thumb Involves the ulnar collateral ligament (UCL) of the thumb (MCP Joint) A.k.a. –skiers thumb Results from forced abduction and hyperextension of the thumb or axial load to the thumb Avulsion fracture is very common Signs and symptoms Pain, swelling, and visible bruising Point tenderness over UCL Instability consistent with degree of injury Laxity >35° & absent end feel = rupture of UCL

Figure 14.6

Classification & Treatment of Gamekeeper’s Thumb Type 1: incomplete rupture Type 2: complete rupture; distal end may displace superficial & proximal to the adductor aponeurosis Short arm thumb spica cast (6-10 wks) for incomplete rupture Cast should incase both the IP and MP joints, with thumb in slight adduction Protective splint until pain free & complete ROM

Bennett’s Fracture Involves the base of first metacarpal bone MOI: striking an object with a closed fist Metacarpal displaced due to pull from abductor pollicis longus Signs and symptoms Immediate localized pain, rapid swelling, and LOF Deformity may or may not be present Crepitus at the MCP ↑ pain on axial compression of 1st metacarpal

Bennett’s Fracture

On-Field Evaluation Usually athletes with hand, finger or wrist injuries leave the field on their own Cradling and protecting injured area Deformity is usually obvious and may involve open or closed fractures or dislocations of the fingers Always remove the glove(s) Cut off if needed

Fractures and Dislocations Fractures of radius and ulna as well as dislocations of the radiocarpal joint must be immobilized in the position found Vacuum splint or SAM Splint Always check pulse and neuro status before and after Open fracture/dislocations should be covered with sterile gauze IP dislocations Reduce (if you can), splint and x-ray to r/o fx Hand and finger Immobilize, splint and x-ray (24h rule) Lacerations Superficial structures of tendons, etc- refer to E.D.

Review Wrist, hand and finger injuries are very common! Many injuries Wrist can be difficult to diagnose properly due to many small involved structures Many injuries Remember MOI and distinguishing sign or symptom for each injury Practice Makes perfect, don’t get scared of the wrist, hand and finger- attack it