Hand and Wrist Evaluation

History How did this injury occur (mechanism) When did you hurt your wrist/thumb? Where does it hurt? Did you hear any sounds or feel a pop? Any previous history? Pain Levels & Types of Pain Training Methods What activities recreates the pain? Did you continue activity after injury?

Observation Obvious Deformities Discoloration / ecchymosis Swelling Attitude of hand Slightly flex at all joints when at rest Bilateral Comparison of wrist/hand Palmar surface, dorsal surface, knuckles, finger nails

Palpation Boney Radius Ulna Anatomical Snuffbox Metacarpals Phalanges Carpal Bones

Palpation Continued Soft Tissue Tunnels 1 - 6 Carpal Tunnel Tunnel of Guyon Thenar eminence Hypothenar eminence Palmar aponeurosis

Tunnels of the Wrist

Carpal Tunnel

Tunnel of Guyon Structures in the Tunnel of Guyon Ulnar nerve and Ulnar artery The nerve and artery runs right between the Hook of the Hamate and the pisiform

Thenar Eminence Thenar Eminence Supplied by Median Nerve Observations Located under the thumb Made up of 3 muscles More developed on dominant hand Supplied by Median Nerve Observations Size Shape Consistancy Atrophy or Hypertrophy

Hypothenar Eminence Hypohenar Eminence Supplied by the Ulnar nerve Runs from Pinkie to Pisiform Made up of 3 muscles More developed on dominant hand Supplied by the Ulnar nerve Observations Size Shape Consistency Atrophy or hypertrophy

Palmar Aponeurosis Center of the hand Shape of a Triangle Finger Flexors run through this Unable to palpate muscles due to thick fibrous tissue

Conditions found in the Wrist/Hand Ganglion Cyst DeQuervain’s Disease Fractured Bone (Scaphoid) Carpal Tunnel Syndrome Joint Capsular Contractures (DIP, PIP, MP joint, CMC) Colles’ Fracture Dupuytren Contracture Trigger Finger Subungual Hematoma Swan neck Deformity Boutonniere deformity Mallet finger deformity Bowler’s Thumb Jersey Finger Handlebar Palsy

Ganglion Cyst Herniation of joint capsule or tendon sheath Usually found on the back of the wrist but can found anywhere a tendon is in the hand May feel soft, rubbery, or very hard Pain with the appearance of a lump TX includes intense pressure or aspiration followed by a compression pad

DeQuervain’s Disease Tenosynovitis or inflammation of the tendon sheath in the wrist. Occurs in Tunnel 1 Tunnel narrows and pain is felt when the abductor pollicis longus and extensor pollicis brevis moves in the tunnel Seen in athletes whose sport requires great deal of wrist ROM Pain is an achy pain which radiates into forearm or hand Special Test: Finklestein’s test TX Immobilization, rest, cryotherapy, and antiinflammatory medication

DeQuervain’s Disease

Fractured Scaphoid Falling on an outstretched hand At risk for avascular necrosis Loss of blood supply Often misdiagnosised as a wrist sprain Requires immediate immobilization

Carpal Tunnel Syndrome Structures found in CT 8 long finger flexor tendons Their synovial sheath The median nerve Inflammation of tendons and sheath Leads to compression of median nerve Occurs in athletes who perform repeated wrist flexion or direct trauma to tunnel SX Tingling, numbness in the thumb, index finger, middle finger and palm of the hand Atrophy of the thenar eminence Weakness in thumb movement Possitive Tinnel sign and Phalens test TX Rest, immobilization, and NSAIDS Can lead to injections of Corticosteriod and possible surgical intervention

Colles Fracture Fracture of the Head of the Radius with or without the a fracture in the ulna Displacement is usually dorsal TX Closed reduction and immobilization

Dupuytren’s Contracture Nodules form in palmer aponeurosis Limits extension Causes Flexion Flexion deformity usually found in ring and little finger Surgery is required

Trigger Finger / Thumb Nodule forms on the Tendon due to overuse Tenosynovitis Pain and funny clicking sound with extension Snapping is both palpable and audible Lump can be felt at the end of the sheath TX Immobilization, rest, cryotherapy, and antiinflammatory medication Steroid injections Last option splinting finger in extension

Subungual Hematoma Pooling of blood under the nail due to a direct blow TX Relieve pressure Drill through nail

Swan Neck Deformity Tearing of volar plate in PIP joint due to severe hyperextension force Pain and swelling at PIP joint Passively hyperextended TX RICE Splinted at 20 -30 degrees of flexion for 3 weeks Buddy tape

Boutonniere Deformity Rupture of the extensor tendon dorsal to the middle phalanx Trauma occurs to tip of the finger DIP extension PIP Flexion SX Severe pain and inability to extend DIP joint Obvious deformity and swelling TX PIP is splinted into extension for 5 – 8 weeks While extended athlete is encouraged to flex DIP

Mallet Finger Deformity AKA baseball or basketball finger Tearing of extensor tendon at the DIP joint Ice and splint

Bowler’s Thumb Irritation to the ulnar digital nerve due to pressure from the thumb hole Causes thickening and decrease sensation in the ulnar digital nerve SX Pain, tingling during pressure to the irritated area and numbness TX Padding thumbhole Decrease amount of bowling

Jersey Finger Often occurs in the Distal phalanx of the ring finger Tearing of the flexor digitorum profundus tendon Athlete is unable to flex DIP joint Unable to ever flex DIP without surgery

Handlebar Palsy Compression of the Ulnar nerve From absorption of vibration and shock through the handle bars Causing numbness, tingling or pain

Special Tests Flexor Digitorum Superficialis Test Flexor Digitorum Profundus Test Bunnel-Littler Test Retinacular Test Allen Test Finklestein Test Tinnel Sign for Carpal Tunnel Syndrome Phalens Test Referred Pain from shoulder and Elbow

Flexor Digitorum Superficialis Test Tests the Flexor Digitorum Superficialis of the 3rd digit How to? Extend all fingers except the one being tested Then flex the finger in question at the PIP joint Positive Finding Unable to flex finger Means the FDS isn’t intact or is torn

Flexor Digitorum Profundus Test Tests the Flexor Digitorum Profundus of the 3rd digit How to? Flex the finger in question at the DIP joint Positive Finding Unable to flex finger Means the FDP isn’t intact or is torn

Bunnel-Littler Test Evaluates the tightness of intrinsic muscles or joint capsular tightness How? Hold MP joint in slight extension Try to flex PIP joint Positive finding Unable to bend = tightness in intrinsic muscles

Bunnel-Littler Test Slight Extension of MP Joint + Flex PIP joint Able to flex Unable to flex Intrinsic muscles aren’t tight Slight Flexion of MP Joint + Flex PIP Joint Able to flex Unable to flex Tight Intrinsic muscles Joint Capsular tightness

Retinacular Test Tests Tightness in the Retinacular Ligaments How Hold PIP in neutral position and try and move the DIP joint To differentiate between Retinacular lig. Tightness and joint capsular tightness Flex the PIP joint and repeat test If DIP then flexes the Retinacular lig. Is tight If the DIP still doesn’t flex then there is DIP joint capsular tightness

Allen Test Determines whether or not the radial or ulnar arteries are at full capacity How? Instruct athlete to open and close his fist quickly several times and then squeeze his fist tightly so that venous blood is forced out of palm Place thumb over radial artery and index finger over ulnar and press down Have athlete open hand (palm should be pale) Release one artery while keeping pressure on the other artery. The hand should flush immediately If not part or all of that artery is blocked Repeat with both arteries.

Finklestein Test Test for Tenosynovitis or Dequervain’s disease in tunnel 1 How? Tuck thumb in fist Then ulnar deviate the wrist Positive finding Sharp pain in the area of the tunnel

Tinnel Sign for Carpal Tunnel Syndrome Tap on the Transverse (volar) Carpal Ligament Positive finding Reoccurrence of symptoms

Phalens Test Testing for carpal tunnel syndrome How? Positive Test Flex patient’s wrists to its maximal degree and hold that position for at least a minute Positive Test Tingling of fingers Pain or numbness