Wrist and Hand Conditions

Anatomy

Wrist Articulations Radiocarpal joint Intercarpal joints Distal radioulnar joint Carpometacarpal joints (CM) Intermetacarpal joints (IM) Metacarpophalangeal joints (MP) Interphalangeal joints (IP)

Nerves Median nerve Radial nerve Ulnar nerve

Blood Vessels Radial artery Ulnar artery Numerous divisions

Kinematics Wrist movements Flexion Extension/ hyperextension Radial deviation Ulnar deviation Circumduction

Kinematics Thumb – flexion, extension, abduction, adduction MP – fingers Fingers – minimal motion Flexion Extension Abduction Adduction

Kinematics Cont’d…

Prevention of Injuries Protective equipment Pads and gloves Physical conditioning Strength and flexibility Exercises for wrist and elbow Proper skill technique Instruction on falling

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

Sprains Cont’d… 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

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 IP Collateral Ligament Sprains -- ligament failure usually occurs at its attachment to the proximal phalanx or, less frequently, in the mid-portion S&S -- obvious deformity may not be present, unless there is a fracture or total rupture of the supporting tissues that causes a dorsal dislocation 12

Dislocations 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

Dislocations Cont’d… Fingers S&S: swollen, painful finger 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 S&S: swollen, painful finger Management: immobilization; ice; immediate physician referral

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

Strains Cont’d… 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

Strains Cont’d… 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

Strains Cont’d… Ganglion cysts Benign tumor mass on dorsal aspect of wrist Associated with tissue sheath degeneration Treatment: symptomatic

Finger 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 Field Strategy 15.1

Nerve Entrapment Syndromes 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 Grip strength and pinch strength may be limited Weak thumb abduction Management: physician referral carpal tunnel syndrome (CTS) -- most common compression syndrome of wrist and hand, but not commonly seen in the physically active population -- typically seen in dominant extremity -- sporting activities with predisposition: activities that involve repetitive or continuous flexion and extension of the wrist, such as cycling, throwing sports, racquet sports, archery, and gymnastics -- etiologies other than traumatic causes include: infectious origin (e.g., diphtheria, mumps, influenza, pneumonia, meningitis, malaria, syphilis, typhoid, dysentery, tuberculosis, gonococcus); metabolic causes (e.g., hypothyroidism, diabetes, rheumatoid arthritis, gout, vitamin deficiency, heavy metals poisoning, and carbon monoxide poisoning) S&S -- relieved by “shaking out their hands”; + “flick” -- generally, only one extremity is affected -- grip strength and pinch strength may be limited -- common complaint is difficulty manipulating coins -- diminished sensitivity to pain and weak thumb abduction are more predictive of abnormal nerve conduction Management -- immobilization in slight wrist extension with a dorsal splint is used to rest the wrist for up to 3-5 weeks, particularly at night when symptoms occur -- ice cup or ice bag, NSAIDs, or in some situations, diuretics, can initially reduce swelling and pain in the area caused by tenosynovitis -- compression wrap should be avoided -- in cases that do not respond well to conservative treatment, surgical decompression or carpal tunnel release can be performed

Nerve Entrapment Syndromes Cont’d… 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

Fractures Distal radius/ulna fracture Mechanism: axial loading; fall on outstretched hand

Fractures Cont’d… Scaphoid fracture S&S History of falling on an outstretched hand Point tenderness in anatomic snuff box Pain with inward pressure along long axis ↑ pain with wrist extension and radial deviation Management: standard acute; splint; physician referral Concern: aseptic necrosis

Fractures Cont’d… 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; ultimately casted in fisted position

Assessment History Observation/inspection Palpation 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

Range of Motion (ROM) Active range of motion (AROM) Forearm pronation/supination Wrist Flexion/extension Radial deviation/ulnar deviation Fingers and thumb Abduction/adduction Opposition of thumb and little finger Passive range of motion (PROM) Normal end feel – tissue stretch 34

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 35

ROM (cont.) 36

ROM (cont.)

Stress Tests Wrist ligamentous instability tests Varus and valgus Finger ligamentous instability tests Anterior/posterior glide Wrist Valgus stress (tests UCL) Patient (pt) is seated with forearm supported; elbow flexed 90; forearm pronated; fingers relaxed (neutral/flexed) Examiner sits/stands lateral to pt; one hand grasps distal forearm; other hand across the metacarpals Examiner applies valgus stress, radially deviating the wrist Test is + if: pain and/or increased laxity when compared bilaterally = sprain of UCL Varus stress (tests RCL) Same as valgus, except varus stress is applied, ulnarly deviating the wrist Test is + if: pain and/or increased laxity when compared bilaterally = sprain of RCL IP joints Valgus stress (tests collateral ligaments) Pt is sitting or standing; joint being tested placed in extension Examiner stabilizes phalanx proximal to joint being tested Examiner grasps the distal phalanx to the joint being tested and applies a valgus stress to the joint Test is + if: increased pain, gapping compared bilaterally = collateral ligament sprain Varus stress (tests integrity of joint capsule) Same as valgus, except varus stress is applied Anterior-posterior glide Same as valgus/varus, except anterior posterior stress is applied Test is + if: increased pain, gapping compared bilaterally = joint capsule sprain Thumb Valgus stress (tests integrity of UCL at thumbs) Pt is sitting or standing; examiner in front or to side of pt Examiner stabilizes 1st metacarpal with one hand and proximal phalanx with other hand While stabilizing 1st metacarpal with the thumb, examiner gently abducts and extends, then applies a valgus stress to the UCL Test is + if: increased laxity on ulnar aspect of 1st MCP joint compared to uninjured side = UCL sprain 38

Special Tests (cont.) Carpal tunnel compression test Pt is sitting or standing Using thumbs, examiner applies even pressure over carpal tunnel (30 seconds) + test = numbing or tingling into palmar aspect of thumb Indication: median nerve compression 39