1. Chapter 24: The Forearm, Wrist, Hand and Finger

2. Anatomy of the Forearm

6. Blood and Nerve Supply
Most of the flexors are supplied by the median nerve
Most of the extensor are controlled by the radial nerve
Blood is supplied by the radial and ulnar arteries

7. Assessment of the Forearm
History
What was the cause?
What were the symptoms at the time of injury, did they occur later, were they localized or diffuse?
Was there swelling and discoloration?
What treatment was given and how does it feel now?

8. Observation Palpation
Visually inspect for deformities, swelling and skin defects
Range of motion
Pain w/ motion
Palpation
Palpated at distant sites and at point of injury
Can reveal tenderness, edema, fracture, deformity, changes in skin temperature, a false joint, bone fragments or lack of bone continuity

9. Palpation: Bony and Soft Tissue
Proximal head of radius
Olecranon process
Radial shaft
Ulnar shaft
Distal radius and ulna
Radial styloid
Ulnar head
Ulnar styloid
Distal radioulnar joint
Radiocarpal joint
Extensor retinaculum
Flexor retinaculum
Extensor carpi radialis longus and brevis
Extensor carpi ulnaris
Brachioradialis
Extensor pollicis longus and brevis

10. Palpation (continued)
Abductor pollicis longus
Extensor indicus supinator
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor digitorum profundus
Flexor pollicis longus
Pronator quadratus
Pronator teres

11. Anatomy of the Wrist, Hand and Fingers

18. Blood and Nerve Supply Three major nerves
Ulnar, median and radial
Ulnar and radial arteries supply the hand
Two arterial arches (superficial and deep palmar arches)

19. Assessment of the Wrist, Hand and Fingers
History
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of, pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?

20. Observation Postural deviations
Is the part held still, stiff or protected?
Wrist or hand swollen or discolored?
General attitude
What movements can be performed fully and rhythmically?
Thumb to finger touching
Color of nailbeds

21. Palpation: Bony Scaphoid Trapezoid Trapezium Lunate Capitate
Triquetral
Pisiform
Hamate (hook)
Metacarpals 1-5
Proximal, middle and distal phalanges of the fingers
Proximal and distal phalanges of the thumb

22. Palpation: Soft Tissue
Triangular fibrocartilage
Ligaments of the carpals
Carpometacarpal joints and ligaments
Metacarpophylangeal joints and ligaments
Proximal and distal interphylangeal joints and ligaments
Flexor carpi radialis
Flexor carpi ulnaris
Lumbricale muscles
Flexor digitorum superficialis and profundus
Palmer interossi
Flexor pollicis longus and brevis
Abductor pollicis brevis
Opponens pollicis
Opponens digiti minimi

23. Palpation: Soft Tissue
Extensor carpi radialis longus and brevis
Extensor carpi ulnaris
Extensor digitorum
Extensor indicis
Extensor digiti minimi
Dorsal interossi
Extensor pollicis brevis and longus Abductor pollicis longus

24. Special Tests Finklestein’s Test Tinel’s Sign
Test for de Quervain’s syndrome
Athlete makes a fist w/ thumb tucked inside
Wrist is ulnarly deviated
Positive sign is pain indicating stenosising tenosynovitis
Pain over carpal tunnel could indicate carpal tunnel syndrome
Tinel’s Sign
Produced by tapping over transverse carpal ligament
Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome

25. Phalen’s Test Test for carpal tunnel syndrome
Position is held for approximately one minute
If test is positive, pain will be produced in region of carpal tunnel

26. Valgus/Varus and Glide Stress Tests
Tests used to assess ligamentous integrity of joints in hands and fingers
Valgus and varus tests are used to test collateral ligaments
Anterior and posterior glides are used to assess the joint capsule

27. Lunotriquetral Ballotment Test
Stabilize lunate while sliding the triquetral anteriorly and posteriorly
Assessing laxity, pain and crepitus
Positive test indicates instability that often results in dislocation of the lunate

28. Circulatory and Neurological Evaluation
Hands should be felt for temperature
Cold hands indicate decreased circulation
Pinching fingernails can also help detect circulatory problems (capillary refill)
Allen’s test can also be used
Athlete instructed to clench fist 3-4 times, holding it on the final time
Pressure applied to ulnar and radial arteries
Athlete then opens hand (palm should be blanched)
One artery is released and should fill immediately (both should be checked)
Hand’s neurological functioning should also be tested (sensation and motor functioning)

29. Functional Evaluation
Range of motion in all movements of wrist and fingers should be assessed
Active, resistive and passive motions should be assessed and compared bilaterally
Wrist - flexion, extension, radial and ulnar deviation
MCP joint - flexion and extension
PIP and DIP joints - flexion and extension
Fingers - abduction and adduction
MCP, PIP and DIP of thumb - flexion and extension
Thumb - abduction, adduction and opposition
5th finger - opposition