1. Copyright © 2015. F.A. Davis Company Chapter 17 Wrist, Hand, and Finger Pathologies

2. Copyright © 2015. F.A. Davis Company Clinical Anatomy  Bony anatomy  Distal radius  Ulnar notch  Radial styloid process  Ulnar head

3. Copyright © 2015. F.A. Davis Company Clinical Anatomy  Bony anatomy  Carpal bones  Metacarpals  Phalanx  Proximal  Middle (not in thumb)  Distal  Sesamoid bones

4. Copyright © 2015. F.A. Davis Company Clinical Anatomy  Articulations and ligamentous support  Distal radioulnar joint  Radiocarpal joint  Intercarpal joints  Midcarpal joints  Carpometacarpal joints  Metacarpophalangeal and interphalangeal joints

5. Copyright © 2015. F.A. Davis Company Clinical Anatomy Palmar (volar) ligaments of the wrist and hand Dorsal ligaments of the wrist and hand

6. Copyright © 2015. F.A. Davis Company The Triangular Fibrocartilage Complex (TFCC) Several ligaments and other fibrous structures attach to the fibrocartilage. As a unit, the TFCC provides support to the distal radioulnar joint. L = lunate; TQ = triquetrum.

7. Copyright © 2015. F.A. Davis Company Clinical Anatomy

8. Copyright © 2015. F.A. Davis Company Clinical Anatomy  Nerves  Ulnar nerve  Median nerve  Radial nerve  The carpal tunnel

9. Copyright © 2015. F.A. Davis Company Clinical Anatomy Extensor compartment

10. Copyright © 2015. F.A. Davis Company Clinical Anatomy Hand intrinsic muscles

11. Copyright © 2015. F.A. Davis Company Clinical Anatomy Hand intrinsic muscles

12. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers Past history  Previous history  Loss of function from previous injury  General medical health  Rheumatoid arthritis  PVD (peripheral vascular disease)  Raynaud phenomenon History of the present condition  Location of pain  MOI  Relevant sounds or sensations  Duration of symptoms  Description of symptoms  Changes in activity

13. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Inspection  Functional observation  General inspection  Posturing of the wrist and hand  Gross deformity  Palmar creases  Lacerations or scars

14. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Inspection  Wrist and hand  Continuity of the distal radius and ulna  Continuity of the carpals and metacarpals  Alignment of the MCP joints  Posture of the wrist and hand  Ganglion cyst

15. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Inspection  Thumb and fingers  Inspection of the skin and fingernails  Subungual hematoma  Felon  Paronychia  Alignment of fingernails  Muscle contour  Individual finger deformities

16. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Palpation of the palmar (anterior) wrist 1.Radius 2.Flexor carpi radialis 3.Palmaris longus 4.Carpal tunnel 5.Ulna 6.Flexor carpi ulnaris 7.TFCC 8.Pisiform 9.Hamate

17. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Palpation of the dorsal (posterior) wrist 1. Ulna 2. Ulnar head 3. Ulnar styloid process 4. Ulnar collateral ligament 5. Extensor carpi ulnaris 6. Lister tubercle 7. Distal radius or styloid process 8. Radial collateral ligament 9. Scaphoid 10. Lunate 11. Triquetrum 12. Trapezium 13. Capitate 14. Trapezoid 15. Extensor carpi radialis brevis 16. Extensor carpi radialis longus

18. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Palpation of the hand 1. Thenar eminence 2. Central compartment 3. Hypothenar compartment 4. Metacarpals 5. Collateral ligaments of the metacarpophalangeal joints 6. Phalanges 7. Collateral ligaments of the IP joints 8. Thenar webspace 9. Extensor digitorum 10-12. Extensor digitorum 13. Extensor pollicis longus 14. Abductor pollicis longus and extensor pollicis brevis

19. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Joint and muscle function assessment  Wrist  Thumb  Finger  Active range of motion (AROM)  Manual muscle test (MMT)  Passive range of motion (PROM)

20. Copyright © 2015. F.A. Davis Company Selective Tissue Test: Grip Dynamometry

21. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Joint stability tests  Stress testing  Collateral support of the wrist ligaments  Collateral support of the IP joints  Support for the UCL  Joint play tests

22. Copyright © 2015. F.A. Davis Company Ligaments Stressed During Wrist Passive Range of Motion Ligaments Stressed Passive MovementPrimarySecondary ExtensionPalmar ulnocarpal Radial collateral Palmar radiocarpal Ulnar collateral FlexionDorsal radiocarpalRadial collateral Ulnar collateral Radial DeviationUlnar collateralPalmar ulnocarpal Ulnar DeviationRadial collateralPalmar radiocarpal

23. Copyright © 2015. F.A. Davis Company Radial Collateral and Ulnar Collateral Ligament Stress Tests of the Wrist

24. Copyright © 2015. F.A. Davis Company Valgus and Varus Testing of the Interphalangeal Joints

25. Copyright © 2015. F.A. Davis Company Test for Laxity of the Thumb MCP Collateral Ligaments

26. Copyright © 2015. F.A. Davis Company Clinical Examination of Injuries to the Wrist, Hand, and Fingers  Neurological testing  Upper quarter screen  Pathologies  Carpal tunnel syndrome  Drop wrist syndrome

27. Copyright © 2015. F.A. Davis Company Pathologies of the Wrist, Hand, and Fingers and Related Special Tests  Wrist pathology  Distal forearm fractures  Scaphoid fractures  Hamate fractures  Perilunate and lunate dislocation  Wrist sprains  TFCC injury  Carpal tunnel syndrome

28. Copyright © 2015. F.A. Davis Company

36. On-Field Evaluation and Management of Wrist, Hand, and Finger Injuries  Lacerations  Management  Use universal precautions  Take precautions against infection  Lacerations involving the fascia should be referred to determine if suturing is needed.

37. Copyright © 2015. F.A. Davis Company Selective Tissue Test: Watson Test for Scapholunate Instability

38. Copyright © 2015. F.A. Davis Company

42. Selective Tissue Test: Phalen Test

43. Copyright © 2015. F.A. Davis Company Pathologies of the Wrist, Hand, and Fingers and Related Special Tests  Hand pathology  Metacarpal fractures

44. Copyright © 2015. F.A. Davis Company

46. Pathologies of the Wrist, Hand, and Fingers and Related Special Tests  Finger pathology  Collateral ligament injuries  Boutonnière deformity  Finger fractures  Tendon ruptures and avulsion fractures  Mallet finger

47. Copyright © 2015. F.A. Davis Company Pathologies of the Wrist, Hand, and Fingers and Related Special Tests  Thumb pathology  De Quervain’s syndrome  Thumb sprain  MCP joint dislocation  Thumb fractures

48. Copyright © 2015. F.A. Davis Company

50. Selective Tissue Test: Finkelstein’s Test for de Quervain’s Syndrome

51. Copyright © 2015. F.A. Davis Company

53. On-Field Evaluation and Management of Wrist, Hand, and Finger Injuries  Interphalangeal joint dislocations  Management  Reduction can be performed by trained personnel by applying traction  If unreduced, splint on the palmar aspect and apply ice pack  Splint  Refer for imaging

54. Copyright © 2015. F.A. Davis Company On-Field Evaluation and Management of Wrist, Hand, and Finger Injuries  Hand and finger fractures  Management  Splint  If wrist and hand both injured, leave nailbeds exposed to check capillary refill

55. Copyright © 2015. F.A. Davis Company Splinting of Common Finger Injuries DeformitySplinting Position Jersey fingerDIP joint in flexion Mallet fingerDIP joint in extension Boutonnière deformityPIP and DIP joints in extension Phalanx fracturePosition found Metacarpal fracturePalmar surface of wrist and hand Unreduced dislocationsPosition found DIP = distal interphalangeal; PIP = proximal interphalangeal