1. The wrist & hand

2. The wrist/hand: Terms
Remember to use the anatomical position when referring to directional terminology of the wrist/hand.
Dorsum – Back of the hand
Palmar – Top of the hand or palm side
Thenar eminence
Hypothenar eminence
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3. The wrist/hand The Wrist - made up of 8 carpal bones.
The Wrist is a “Condyloid Joint” – The carpal bones are tightly bound together, allowing for little movement.
The Hand - made up of 5 metacarpals and the digits (fingers)
The metacarpals are identified by #1-5; the first metacarpal is the most lateral.
Each digit has 3 phalanges, they are a “Gliding Joint.”
The thumb only has 2 phalanges, it is a “Saddle Joint.”
Wrist ROM: Flexion, Extension, Ulnar Deviation, Radial Deviation
Finger ROM: Flexion, Extension, Adduction, Abduction
Thumb ROM: Flexion, Extension, Adduction, Abduction, Circumduction, Opposition

4. Wrist/hand Joints
Radiocarpal Joint: Radius articulation with the scaphoid, lunate, and triquetrium.
Carpometacarpal Joints (CM): Carpal bones & proximal metacarpals.
Metacarpalphalangeal (MP): Distal metacarpal & phalanges.
Interphalangeal (IP): Between the phalanges.
Proximal Interphalangeal (PIP): Proximal Phalange & Middle Phalange
Distal Interphalangeal (DIP): Middle Phalange & Distal Phalange

5. Bony anatomy: Carpal bones
“Some Leaders Try Positions That They Can’t Handle”
S = Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform
T = Trapezium
T = Trapezoid
C = Capitate
H = Hamate

6. Bony anatomy Distal Radius Radial Styloid Distal Ulna Ulnar Styloid
Anatomical Snuffbox
1st – 5th Metacarpals
Phalanges

7. Bony anatomy Distal Radius Radial Styloid Distal Ulna Ulnar Styloid
Anatomical Snuffbox
1st – 5th Metacarpals
Phalanges

8. Anterior Side - “The Flexors”
soft anatomy
Anterior Side - “The Flexors”
Flexor Carpi Ulnaris
Palmaris Longus
Flexor Carpi Radialis
Pronator Teres

9. Posterior Side - “The Extensors”
soft anatomy
Posterior Side - “The Extensors”
Extensor Carpi Ulnaris
Extensor Digitorum
Extensor Carpi Radialis Brevis
Extensor Carpi Radialis Longus

10. nerves Muscles of the wrist are controlled by the following nerves:
Radial
Ulnar
Median (Goes through the carpal tunnel)

11. Arteries/veins
Blood is supplied to the wrist and hand by the following arteries:
Radial artery
Ulnar artery
The ulnar, radial, cephalic, and basilic veins transport blood from the hand, back up the forearm, to the heart and lungs for re- oxygenation.
Like the nerves the radial and ulnar blood vessels run parallel to the radius and ulna.

12. Warm up What is the top of the hand called?
What is the back of the hand called?
*Remember to use the anatomical position*
What are the two divisions of the palmer surface of the hand? Where is each located?
What are the anatomical movements of the wrist? Finger? Thumb?
What are the three nerves that control the muscles of the wrist?
Is the flexor muscle group of the forearm located posterior or anterior? The extensor muscle group?
The scaphoid is located in the _________________.

13. Injury Presentation Project
Injury presentations
Injury Presentation Project

14. Wrist/hand evaluation & special tests

15. history MOI (Mechanism of Injury) C/C (Chief Complaint) Pain Type
Location of Pain
Severity of Pain
Pain with ADL (activities of daily living)
Previous Hx (history)
Onset: Acute vs. Chronic?

16. History cont Other symptoms: numbness, tingling, tightness?
What increases or decreased pain?
Hear anything? Snap, Crack, or Pop?
Sport Specific: changes in technique

17. observation
Deformity? (Mallet finger, Volkmann’s contracture, Trigger finger, Boutonniere, etc.)
Guarding
Swelling
Ecchymosis
Hematoma
Abrasions
Scars
Malalignment
Nails – Subungal Hematoma
Ganglion
Knuckle inspection
Thenar & Hypothenar eminence

18. Bony Palpation
While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity.
Lunate
Triquetrum
Pisiform
Distal Radius
Trapezium
Radial Styloid
Trapezoid
Distal Ulna
Capitate
Ulnar Styloid
Hamate
Anatomical Snuff Box
Scaphoid

19. soft Palpation Flexor Muscle Group: Palmaris Longus
While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity.
Flexor Muscle Group:
Palmaris Longus
Flexor Carpi Ulnaris
Flexor Carpi Radialis
Pronator Teres
While palpating check for crepitus, spasm, tightness/tension, point tenderness, warmth, deformity.
Extensor Muscle Group:
Extensor Digitorum
Extensor Carpi Ulnaris
Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis

20. rom
Instruct the athlete to perform the following movements bilaterally:
Ulnar Deviation
Radial Deviation
Compare the ROM between the uninvolved and involved extremity.
Phalanges:
Finger Flexion
Movements should be smooth and painless.
Finger Extension
Limited ROM on one side indicates potential injury.
Abduction
Adduction
Wrist:
Thumb: Flex, Ext, Abd, Add &
Flexion
Circumduction
Extension
Opposition

21. Weakness on one side indicates potential injury or deformity.
Manual muscle tests
MMT = manually testing an athlete’s strength to note any abnormalities due to injury.
Compare the strength between the involved and uninvolved extremity to note any differences.
Weakness on one side indicates potential injury or deformity.

22. Manual muscle tests
Wrist Extension: Place your hand on the dorsal aspect of the athlete’s hand and instruct the athlete to push up against your hand as you provide isometric resistance.
Weakness indicates potential injury or deformity to the extensor carpi radialis longus, extensor carpi radialis brevis, and/or extensor carpi ulnaris.

23. Manual muscle tests
Wrist Flexion: Place your hand on the palmar aspect of the athlete’s hand and instruct the athlete to push down against your hand as you provide isometric resistance.
Weakness indicates potential injury or deformity to the flexor carpi radialis and/or flexor carpi ulnaris.

24. Manual muscle tests
Ulnar Deviation: Place your hand on the ulnar aspect of the athlete’s closed hand and instruct the athlete to press against your hand as you provide isometric resistance.
Weakness indicates potential injury or deformity to the flexor carpi ulnaris and/or extensor carpi ulnaris.

25. Manual muscle tests
Radial Deviation: Place your hand on the radial aspect of the athlete’s closed hand and instruct the athlete to press against your hand as you provide isometric resistance.
Weakness indicates potential injury or deformity to the flexor carpi radialis and/or extensor carpi radialis.

26. Manual muscle tests
Finger Extension: Place one finger on the dorsal aspect of the athlete’s finger that is being tested and have the athlete push the finger up into extension as you provide isometric resistance.

27. Manual muscle tests
Finger Flexion: Place one finger on the palmar aspect of the athlete’s finger that is being tested and have the athlete flex the finger as you provide isometric resistance.

28. Manual muscle tests
Finger Abduction: Place one finger on the lateral aspect of the athlete’s finger that is being tested. Place another finger on the lateral aspect of one of the adjacent fingers. Instruct the athlete to abduct the fingers as you provide isometric resistance.

29. Manual muscle tests
Finger Adduction: Place one finger between the athlete’s finger to be tested and the one next to it. Instruct the athlete to adduct the fingers as you provide isometric resistance.

30. Compression Test Injury: Fracture – Carpal, Metacarpal, or Phalanx
Patient Position: Standing or sitting
Examiner Position: Standing in front of the patient
Examiner Hand Position: Distal or proximal to fx site
Exam Procedure: Apply compression to the affected structures. Place one finger on either side of the injured extremity above or below the possible fx site and compress the area between your fingers. Do NOT place either hand directly over the suspected fx site!!
+ Sign: Pain at fracture site

31. percussion Test Injury: Fracture – Carpal, Metacarpal, or Phalanx
Patient Position: Standing or sitting, elbow flexed, making a fist or phalanx extended
Examiner Position: Standing in front of the patient
Examiner Hand Position: Stabilizing elbow
Exam Procedure: Apply a firm strike to fist with an open hand, or flick knuckle or phalanx.
+ Sign: Pain at fracture site

32. Wrist valgus stress test
Injury: UCL injury (wrist)
Patient Position: Seated with 90 degrees of elbow flexion and forearm pronated
Examiner Position: Lateral to the patient
Examiner Hand Position: Distal forearm and dorsal hand over the metacarpals
Exam Procedure: Apply valgus stress by radially deviating the wrist.
+ Sign: Pain and/or joint laxity

33. Wrist Valgus stress

34. Wrist varus stress test
Injury: RCL injury (wrist)
Patient Position: Seated with 90 degrees of elbow flexion and forearm pronated
Examiner Position: Lateral to the patient
Examiner Hand Position: Distal forearm and dorsal hand over the metacarpals
Exam Procedure: Apply varus stress by ulnarly deviating the wrist.
+ Sign: Pain and/or joint laxity

35. Valgus/varus stress test (ip joints)
Injury: UCL or RCL injury (Interphalangeal Joints)
Patient Position: Seated, forearm pronated, testing joint is in extension
Examiner Position: Lateral to the patient
Examiner Hand Position: Stabilizing proximal phalanx and distal phalanx to testing joint
Exam Procedure: Apply valgus stress for UCL and varus stress for RCL
+ Sign: Pain and/or joint laxity

36. Valgus/varus stress tests

37. Gamekeeper’s thumb Test
Definition: Application of a valgus stress to the medial joint line at the base of the thumb to assess the possibility of injury to the UCL ligament.
Injury: UCL pathology at the 1st MCP Joint
Patient Position: Standing or sitting with thumb slightly abducted
Examiner Position: Standing in front of the patient
Examiner Hand Position: Stabilizing 1st metacarpal and proximal phalanx
Exam Procedure: With 30 degrees of MCP Joint flexion, apply a valgus stress.
+ Sign: Pain and/or joint laxity

38. Gamekeeper’s thumb test

39. Gamekeeper’s thumb test

40. Finkelstein’s test
Definition: Stretching or lengthening of the thumb tendon to assess the possibility of DeQuervain’s syndrome, or tenosynovitis of the thumb tendon.
Injury: DeQuervain’s Syndrome
Patient Position: Seated with 90 degrees of elbow flexion and forearm in neutral
Examiner Position: Standing in front of the patient
Examiner Hand Position: None
Exam Procedure: Patient makes first with thumb inside, then actively performs ulnar deviation of the wrist.
+ Sign: Radial styloid process pain

41. Finkelstein’s test

42. This test can be performed two ways!
Phalen’s test
Definition: Compression of the median and ulnar nerves to assess the possibility of impingement.
This test can be performed two ways!
Injury: Carpal Tunnel Syndrome
Patient Position: 1)Seated or standing with 90 degrees of elbow flexion and forearm pronation. 2)Elbow and wrist in 90 degrees of flexion with backs of hand together
Examiner Position: Standing in front of the patient
Examiner Hand Position: 1)Stabilizing posterior elbow and hand 2)Gently grasping the athlete’s palms
Exam Procedure: 1)Passively flex the wrist and hold at the end range of flexion for 1 minute. 2) Gently squeeze hands together.
+ Sign: Tingling through the wrist and hand

43. Phalen’s test #1

44. Phalen’s test #2

45. scenario
A football player falls to the ground and lands on his closed fist causing an axial load of the metacarpals. He is c/o pain over the 5th metacarpal. What injury do you suspect? What is your treatment plan?

46. scenario
A volleyball player, going up to block a spike, receives an axial force. What injury do you suspect occurs as a result? What soft tissue structure is affected?

47. scenario
A baseball catcher receives a pitch that jams and avulses the extensor tendon of the distal interphalangeal joint of the second finger. What is this injury called? How is it treated immediately at the time of the injury? How is is managed post traumatically?