The Forearm, Wrist, Hand, and Fingers Chapter 24

Forearm Anatomy Radius and Ulna: Elbow Joints: radioulnar joint Ulna: direct extension to the humerus Radius: extension of the hand

Forearm Anatomy Bone: proximal radial head, olecranon process, radial shaft, ulnar shaft, distal radius, radial styloid process, ulnar head, ulnar styloid

Forearm Anatomy Musculature: Consist of Flexors of the wrist and fingers are

Forearm Anatomy Nerve/Blood Supply: median and radial nerve and brachial, radial, and ulnar artery

Forearm Assessment History: What? Where? How? When? (some asked questions to figure out what happened to the forearm) Observation: forearm is first visually inspected for obvious deformities, swelling, and skin defects

Forearm Assessment Palpation: can reveal tenderness, edema, fracture deformity, change in skin temperature, a false joint, bone fragments, or a lack of continuity between bones •

Recognition and Management of Forearm Injuries Contusion Etiology: Signs and Symptoms: pain, swelling, and hematoma; Management:

Recognition and Management of Forearm Injuries Forearm Splints Etiology: Signs and Symptoms: Management: if problem occurs early in season, athlete should concentrate on increasing the strength of the forearm through resistance exercises, but if arises late in season, emphasis should be placed on rest and cryo therapy or heat and use of a supportive wrap during activity

Recognition and Management of Forearm Injuries Colles’ fracture Etiology: involve lower end of the radius or ulna; fall on outstretched hand, Signs and Symptoms: forward displacement of radius, makes visible deformity to the wrist; Management:

Recognition and Management of Forearm Injuries Forearm Splints Etiology: severe static contraction; Signs and Symptoms: dull ache between the extensor muscles, which cross the back of forearm; Management: rest, cryotherapy, heat and it also depends on when it occurs in the season, other actions should be taken depending on that

Wrist, Hand, and Finger Anatomy Bones: Joints:

Wrist, Hand, and Finger Anatomy Ligaments: “many at each joint in the hand” Musculature: “many intrinsic and extrinsic muscles”

Wrist, Hand, and Finger Anatomy Blood and Nerve Supply: ulnar, median, radial nerve and radial and ulnar superficial and deep palmar arch arteries.

Assessment of Wrist, Hand, and Finger Injuries History: asks about location & type of pain What increases or decreases the pain? Observation: hand usage as of writing or unbuttoning a shirt is observed. General attitude of the hand is observed. Opening and closing the hand Is the wrist or hand swollen? Are there any postural deviations?

Assessment of Wrist, Hand, and Finger Injuries Palpation Bony palpation includes carpals, meta-, and phalanges Soft tissue palpation includes ligament, fibro-cartilage -

Assessment of Wrist, Hand, and Finger Injuries Special Tests: -Finklestein’s test, Tinel’s Sign, Phalen’s test, valgus and varus stress test, Glide test, Lunotri- quetral Ballotment test, Allen’s test

Assessment of Wrist, Hand, and Finger Injuries Circulatory and Neurological Evaluation Allen test Range of motion is noted in all move- ments, active and resistance movements Functional Evaluation

Recognition and Management of Wrist, Hand, and Finger Injuries Wrist Sprain Etiology: can arise from any abnormal movement of the wrist; Signs and Symptoms: complains of pain, swelling, & difficulty moving the wrist; Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Triangular Fibrocartilage Complex Injury Etiology: caused by forced hyper-extension of the wrist; TFCC is also associated with sprain of the ulnar collateral ligament Signs and Symptoms: its common for no immediate report on injury from athlete; pain along the ulnar side of the wrist; Management: physician for treatment;

Recognition and Management of Wrist, Hand, and Finger Injuries Carpal tunnel syndrome Etiology: anterior aspect of the wrist; Signs and Symptoms: compression in the medial nerve will usually result in both sensory and motor deficits; Management: rest, immobilization, and nonsteroidal anti-inflammatory medication;

Recognition and Management of Wrist, Hand, and Finger Injuries Tenosynovitis Etiology: Signs and Symptoms: pain with use or pain in passive stretching; Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Tendinitis Etiology: sports that require repetitive pulling movements and sports that place prolonged pressure on the palms Signs and Symptoms: Management: ice massage for 10 minutes 4x’s a day for the 1st 48-72 hours, NSAIDs, and rest;

Recognition and Management of Wrist, Hand, and Finger Injuries Nerve Compression, Entrapment, Palsy Etiology: Signs and Symptoms: *(see pictures on next slide)*  THANK YOU  Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Nerve Compression, Entrapment, Palsy Claw hand Drop wrist Ape hand Bishop’s, or benediction, hand

Recognition and Management of Wrist, Hand, and Finger Injuries De Quervain’s Disease (aka) Hoffman’s Disease Etiology: stenosing tenosynovitis in the thumb; Signs and Symptoms: point tenderness, aching pain, weakness during thumb extension and abduction, and there may be a painful snapping and catching of the tendons during movement Management: involves immobilization, rest, cyrotherapy, and anti-inflammatory medication.

Recognition and Management of Wrist, Hand, and Finger Injuries Dislocation of the Lunate Bone Etiology: hyperextension of the wrist; dislocation of the lunate; Signs and Symptoms: pain, swelling, difficulty in executing wrist and finger flexion, numbness or even paralysis of the flexor muscles Management: (if not bone deterioration may occur)

Recognition and Management of Wrist, Hand, and Finger Injuries Hamate Fracture Etiology: may occur from fall but most likely from contact while the athlete is holding a sports implement such as a tennis racket, a baseball bat, etc. Signs and Symptoms: wrist pain and weakness and point tenderness are experienced; Management: casting of the wrist;

Recognition and Management of Wrist, Hand, and Finger Injuries Scaphoid Fracture Etiology: force on the outstretched hand, which compresses the scaphoid bone between the radius and the 2nd row of carpal bones Signs and Symptoms: Management: cold should be applied, the area splinted, and the athlete referred to a physician for x-ray study and casting

Recognition and Management of Wrist, Hand, and Finger Injuries Wrist Ganglion Etiology: synovial cyst; Signs and Symptoms: pain with a lump at the site; pain increases with use; Management: break down the swelling through digital pressure and then apply a felt pressure pad for a period of time

Recognition and Management of Wrist, Hand, and Finger Injuries Contusion to hand and fingers Etiology: irregular bony structure combined with little protective fat and muscle padding, are prone to bruising in sports Signs and Symptoms: this condition is easily identified from the history of trauma and the pain and swelling of soft tissues Management: cold and compression followed by gradual warming of the warming bath;

Recognition and Management of Wrist, Hand, and Finger Injuries Bowler’s Thumb Etiology: a perineural fibrosis of the subcutaneous ulnar digital nerve of the thumb can occur from the pressure of a bowling ball thumbhole & cause the development of fibrotic tissue around the ulnar nerve Signs and Symptoms: Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Jersey finger Etiology: Signs and Symptoms: pain & point tenderness; b/c the tendon is no longer attached to the distal phalanx, the DIP joint can’t be flexed and the finger is in an extended position Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Trigger finger or thumb Etiology: repeated movement can cause the tendons of the wrist and hand to sustain irritation that results in tenosynovitis Signs and Symptoms: when finger of thumb is flexed, there is resistance to re-extension, producing a snapping that is both palpable & audible; Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Mallet finger Etiology: Signs and Symptoms: Management: RICE is given for pain & swelling, if there’s no fracture it should be immediately splinted

Recognition and Management of Wrist, Hand, and Finger Injuries Mallet finger

Recognition and Management of Wrist, Hand, and Finger Injuries Boutonniere deformity (aka) button-hole Etiology: a rupture of the extensor tendon dorsal to the middle phalanx, trauma occurs to the tip of the finger Signs and Symptoms: severe pain and inability to extend the DIP joint; Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Boutonniere deformity (aka) button-hole

Recognition and Management of Wrist, Hand, and Finger Injuries Dupuytren’s Contracture Etiology: (nodules develop in the palmer aponeurosis that limit finger extension and eventually cause a flexion deformity) Signs and Symptoms: the little fingers moves into the palm of the hand and cannot be extended Management: (immediately removed)

Recognition and Management of Wrist, Hand, and Finger Injuries Sprains, Dislocations, and Fractures of Phalanges Etiology: phalanges are prone to sprains cause by a blow delivered to the tip or by violent twisting, the sprain affects the capsular, ligamentous , and tendinous tissues Signs and Symptoms: recognition is accomplished primarily through the history and the sprain symptoms:

Recognition and Management of Wrist, Hand, and Finger Injuries Gamekeepers Thumb Etiology: a sprain of the ulnar collateral ligament of the MCP joint of the thumb; Signs and Symptoms: Management: proper, immediate, & follow-up care must be performed, & a thumb splint should be taken care of for 3-4 weeks

Recognition and Management of Wrist, Hand, and Finger Injuries PIP Dorsal dislocation Etiology: seen in collisions or contact sports; Signs and Symptoms: pain & swelling over the PIP; Management: RICE, splinting, & analgesics, & a physician; finger is splinted at 20-30 degrees for 3 weeks;

Recognition and Management of Wrist, Hand, and Finger Injuries PIP Dorsal Dislocation

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries

Recognition and Management of Wrist, Hand, and Finger Injuries MCP dislocation Etiology: Signs and Symptoms: pain, swelling, and stiffness at the MCP joint; the proximal phalanx is dorsally angulated at 60-90 degrees Management: RICE, splinting, and analgesics; reduced, buddy tape, and given early ROM

Recognition and Management of Wrist, Hand, and Finger Injuries Metacarpal fracture Etiology: Signs and Symptoms: pain & swelling; Management: RICE & analgesics followed by X-ray ‘s;

Recognition and Management of Wrist, Hand, and Finger Injuries Bennett’s Fracture Etiology: Signs and Symptoms: pain & swelling over the base of the thumb; the thumb’s CMC appears deformed; Management: structure is unstable and must be referred to an orthopedic surgeon

Recognition and Management of Wrist, Hand, and Finger Injuries Distal phalangeal fracture Etiology: Signs and Symptoms: pain and swelling of the distal phalanx; there may be deformity; Management: RICE and analgesics, a protective splint, and subungual hematoma is drained

Recognition and Management of Wrist, Hand, and Finger Injuries Middle phalangeal fracture Etiology: Signs and Symptoms: pain and swelling with tenderness over the middle phalanx, there may be deformity, and X-ray show bone displacement Management: RICE and analgesics are given;

Recognition and Management of Wrist, Hand, and Finger Injuries Proximal phalangeal fracture Etiology: Signs and Symptoms: Management:

Recognition and Management of Wrist, Hand, and Finger Injuries Fingernail deformity Scaling or ridging- Ridging and poor development- Clubbing and cyanosis- Spooning or depression-

Rehabilitation Principles for the Forearm, Wrist, Hand, and Fingers General Body Conditioning- cardio-respiratory fitness, strength, flexibility, and neuromuscular control. Many exercises such as walking, running, stair climbing, aerobics, cycling, and a variety of resistance and flexibility activities Joint Mobilization-

Rehabilitation Principles for the Forearm, Wrist, Hand, and Fingers Flexibility- a pain-free ROM is a major goal of rehab of the lower arm. It should include active assisted and active pain-free stretching exercises Strength- restoring grip strength is essential; it can be regained by gripping a number of different devices

Rehabilitation Principles for the Forearm, Wrist, Hand, and Fingers Neuromuscular Control: hand and finger rehab requires a restoration of dexterity, which includes pinching and other fine motor activities such as buttoning buttons, tying shoes, and picking up small objects Return to Activity: criteria for the return to a sport after wrist or hand injury are grip strength equal to the unaffected limb, full range of motion, and full dexterity; instituted by adduction, abduction, flexion, extension, opposition, and circumduction