1. Wrist, Hand and Finger Evaluation
ATTR 322
Krzyzanowicz- Spring ‘14

2. Objectives
Understand bony and soft tissue anatomy of the wrist, hand and fingers
Understand movement relationships of the wrist, hand and fingers
Describe common injuries including deforimities to the wrist, hand and fingers
Demonstrate the proper evaluation of the wrist, hand and fingers to include
Special tests
Palpation
MMT’s
Utilize EBP principles' in evaluation techniques

3. Clinical Anatomy

4. Clinical Anatomy Forearm Wrist Hand Fingers Distal Ulna Distal Radius
8 carpal bones
Hand
5 metacarpals
Fingers
14 phalanges

5. Clinical Anatomy Forearm Carpal bones
Distal radius broadens to form the ulnar notch on the medial surface to accept the ulnar head
Radial styloid process- anterolateral border
Carpal bones
Unusual shapes and irregular surfaces
Aligned in two rows
Proximal: scaphoid, lunate, triquetrum, pisiform
Distal: trapezium, trapezoid, capitate, hamate

7. Clinical Anatomy Metacarpals I (thumb)- V (little finger) Phalanx
Proximal
Middle
Distal

8. Articulations and Ligamentous Support
Distal radioulnar joint
Supination and pronation
Radiocarpal joint
Flexion and extension
Radial and ulnar deviation
Radial collateral ligament
Triangular fibrocarilaginous complex (TFCC)
On the ulnar side
Composed of an articular disk, ligaments and bone
Dissipates stresses on forearm during loading
Damaged by forced extension and pronation

10. Articulations Intercarpal joints Midcarpal joints
Joints between each carpal bone held in place by interosseous ligaments
Midcarpal joints
Separation of the proximal and distal carpal rows
Carpometacarpal Joints
First 3 metacarpals articulate with the carpal bone
Thumb is 1st CMC joint
Saddle joint, flex/ext and abd/add

14. Articulations
Metacarpophalangeal (MCP) and interphalangeal (IP) joints
MCP flex/ext and abd/add
IP flex/ext

16. Musculature Extensor muscles (p. 756-759) Flexor muscles
Posterolateral forearm; innervated by radial nerve
Flexor muscles
Anteriomedial forearm; innervated by median nerve- except flexor carpi ulnaris (ulnar)
Palmar muscles
Intrinsic muscles
Thenar eminence (thumb side)
Hypothenar eminence (5th digit side)

18. Nerves Ulnar nerve Radial nerve
Superficial just medial to carpal tunnel
Passes through the Tunnel of Guyon formed by the hamate and pisiform
Superficial branches provide sensory input on palmar side of little finger and medial side of ring finger
Deep branch innervates the hypothenar eminence
Radial nerve
Motor (posterior interosseous nerve) and sensory (superficial radial nerve)
Innervates wrist and finger extensors and dorsal hand
Easy way to check for nerve issue is wrist extension

19. Nerves
Median nerve
Follows the flexor digitorum superficialis through the forearm
Travels through the carpal tunnel laterally and divides into motor and palmar branches
Motor- supply thenar emience
Palmar- sensation to palmar surface of the thumb, index and middle finger

21. Carpal Tunnel Tunnel’s floor Roof
Formed by the proximal carpal bones
Roof
Formed by the transverse carpal ligament
Ten structures pass through the tunnel
Listed in text
Inflammation
Median nerve is effected
Grip strength is decreased

22. Carpal Tunnel

23. Clinical Examination Kinetic Chain History
Evaluation of elbow, shoulder, cervical spine may be needed in wrist, hand and finger evaluations
History
Previous injury, fractures (common)
General medical health
Peripheral vascular disease (raynaud’s)
Diabetic- chronic wrist pain
Pregnancy- increased risk of carpal tunnel syndrome

24. Clinical Examination History of present condition Duration
Location of pain
Which nerve?
MOI
FOOSH? Compression?
Sounds
Clicking usually means TFCC
Duration
Scaphoid?
Description of Sx
Aching/throbbing=bony or soft tissue
Burning/tingling=neurolo gic or vascular
Change in activity
ADL’s
Job (ergonomics)
Computer work

25. Inspection Functional Observation General Inspection
Replicate activities that cause pain and ADL’s
Compensating in shoulder?
Decreased grip strength
General Inspection
Posturing of wrist and hand
Gross deformity
Palmar creases
Lacerations or scars
Nails

27. Ape

28. Bishop’s

29. Claw Hand

30. Dupuytern’s

31. Swan-neck

32. Volkmann’s

33. Inspection Wrist and Hand Thumb and Fingers
Continuity of distal radius/ulna; carpals/metacarpals
Alignment of MCP joints
Ganglion cyst
Thumb and Fingers
Skin and fingernails

34. Finger Deformities

35. Jersey finger

36. Mallet

37. Boutonniere deformity

38. Palpation Palpation of the wrist and finger flexor muscle group
Wrist flexor group
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor digitorum radialis
Flexor carpi radialis
Palmaris longus
Carpal tunnel

40. Palpation Palpation of the wrist and finger extensor muscle group
Wrist and finger extensor group
Extensor digitorum communis
Extensor pollicis longus
Abductor pollicis longus
Extensor pollicis brevis

41. Anatomical Snuffbox

42. Palpation Palpation of the hand Metacarpals
Collateral ligaments of the MCP joints
Phalanges
Collateral ligaments of the IP joints
Thenar compartment
Thenar webspace
Central compartment
Hypothenar compartments
Ulna
Ulnar styloid process
Ulnar collateral ligament
Distal radius and styloid process
Lister’s tubercle
Radial collateral ligament

43. Palpation Palpation of the carpals Acronym? Scaphoid Trapezium Lunate
Triquetrum
Pisiform
Hamate
Capitate
Trapezoid
Acronym?

44. Joint and Muscle Function Assessment
Range of Motion (wrist)
Flexion (80-90) and extension (75-85)
Ulnar deviation (35 degrees) and radial deviation (20 degrees)
Range of Motion (fingers and thumb)
Flexion and extension
Abduction and adduction
Opposition (thumb only)

45. Wrist ROM

46. First CMC Joint ROM

47. Finger ROM

48. Grip Dynamometry

49. Joint Stability Testing
Stress testing
Tests for collateral support of wrist ligaments
UCL (TFCC involvement)
RCL
Tests for collateral support of IP joints
UCL
Laxity in either could be an avulsion fracture

50. WRIST PATHOLOGIES

51. Scaphoid Fractures About 70% of all carpal fx’s involve the scaphoid
Bony block limiting wrist extension
Most prevalent in y/o
Poor blood supply
If fractured- compromises nutrition to proximal part
Causes nonunion fractures and avascular necrosis
Can result in instability of proximal carpal row

52. Scaphoid Fractures MOI S&S Usually FOOSH or forceful hyperextension
Ache in area of anatomical snuffbox, increases with palpation
Crepitus
Severe P! with overpressure (radial deviation, flex/ext)

53. Scaphoid Fractures Management X-ray MRI/CT scan Treat as a fracture
Usually doesn’t show though
MRI/CT scan
Better, but still not as sensitive
Treat as a fracture
Immobilize thumb and wrist (6+ weeks)
Surgical intervention
Bone from hip inserted at fx site
We miss scaphoid fx’s all the time! When in doubt refer it out

54. Scaphoid Fractures

55. Hamate Fractures MOI S&S
FOOSH; trauma to the palm swinging a golf club or baseball bat
Fractured through axial load applied to 4th or 5th metacarpal
S&S
Minimal swelling in the hypothenar eminence
Possible protrusion over hamate
Point tender over hamate
P! with 5th finger abd/add and with passive extension of 5th finger

56. Lunate Dislocation MOI S&S Forced hyperextension
Can displace dorsally or palmarly
S&S
P! along radial side of palmar or dorsal aspect of wrist that limits ROM
Bulge may be visible
Can cause parethesia in middle finger
Third knuckle is level with other knuckles
Possibility of scaphoid fx as well

57. http://www.imageinterpretation.co.uk/wrist.h tml

58. Wrist Sprains Very general term Scapholunate ligaments MOI S&S
Rule out carpal fx (scaphoid), and TFCC
Scapholunate ligaments
Most common sprain to the wrist
MOI
Typically forced hyperextension
S&S
Wrist and hand giving way; numbness; decreased ROM

59. Wrist Sprains Special Tests Treatment Watson’s test (show in lab)
X-ray to r/o fx (if you think it’s needed)
Rest
Soft splint, cast, etc

60. Watson’s Test

61. Triangular Fibrocartilage Complex
TFCC
Trauma or repeated injury to TFCC and UCL can result in permanent disability
Increased risk in sports in the closed kinetic chain
MOI
Forced hyperextension (blocking, weightlifting)
Repeated weight bearing causing degeneration
S&S
P! along ulnar side of wrist; decreased ROM due to P!

62. Triangular Fibrocartilage Complex
S&S
P! when pushing up from a chair
Palpation
Ulnar styloid process- avulsed UCL?
Treatment
Cortizone injection
Surgical management
Casting usually 6-8 weeks

64. Carpal Tunnel Syndrome
Refers to the S&S caused by compression of median nerve as it passes through the carpal tunnel
Most frequented causes is fibrosis of the synovium of the flexor tendons secondary to tenosynovitis
May occur due to repetitive microtrauma, acute trauma to the carpal tunnel or progressive degeneration of the carpal tunnels structures

66. Carpal Tunnel Syndrome
S&S
Paresthesia and P! along median nerve distribution
Thumb, index, middle & lat. Half of ring finger)
Often occurring at night
Relieved when shaking
Inspection may reveal
Atrophy of thenar muscles
Decreased grip strength
Other symptoms
Decreased strength in abductor pollicis brevis and opponens pollicis

67. Carpal Tunnel Syndrome
Other symptoms
Poor posture (forward head, rounded shoulders)
Mimic s&s for C7 impingement
May need to evaluate c-spine and elbow
Special Tests
Tinel’s sign= not a great test
Phalen’s and reverse phalen’s Tx
Rest, postural training, NSAID’s, splinting
Surgical intervention

68. Phalan’s Test

69. Wrist Ganglion “Bible Cyst”
A synovial cyst characterized by herniation of synovial fluid through the joint capsule or synovial sheath of the tendon
May form on dorsal or volar aspect
Signs and symptoms
Observable and palpable localized mass
Tenderness and discomfort with wrist extension (dorsal ganglion)
May or may not impede ROM or function

70. Ganglion Cyst

71. HAND AND FINGER PATHOLOGIES

72. Metacarpal Fractures
Typically fractured due to a compressive force along the bone’s shaft
Such as punching with a fist
Common to hear the bone snap
Gross deformity is common
Immediate swelling
Tenderness along fracture site (pinpoint usually)
crepitus?
Fingers or metacarpal may rotate when hand is attempting to flex
Could happen to any of the metacarpals

73. Boxer’s Fracture Fracture to the 5th metacarpal Treatment
Common incidence after an improperly thrown punch
Depressed 5th MCP joint
Treatment
Casting or ORIF
Usually casted 6-8 weeks
Special Tests
Compression test (rotate)

76. Collateral Ligament Injuries
Trauma to the collateral ligaments of the fingers usually results from a dislocation
Can result from direct trauma too though
Stub, jam your finger
Pain and swelling usually set it
Hurts like hell!
Varus/Valgus testing
Treatment though?

77. Phalanx Fractures Fractures of distal phalanx are the most common
MOI is usually direct trauma, shear force or crushing force
S&S include
Gross deformity, swelling, inability to move finger, heard and felt a snap, crepitus Tx
Splint, surgical intervention

79. Finger Dislocations Very common in contact sports and basketball
ALWAYS CHECK FOR AN OPEN DISLOCATION
DO NOT relocate as a student
DO NOT relocate a thumb!
MOI:
Direct truama, shear force
S&S
Gross deformity, pain and inability to move joint Tx
Reduce (if possible), splint and refer for x-ray (good chance it’s fractured)

82. Volar Plate Rupture Results from hyperextension of the PIP joint
Pain and tenderness on the palmer aspect
Loss of function
Swelling
Disruption can cause subluxation and permanent hyperextension
Complications are a swan-neck or pseudo- boutonniere deformity

83. Volar Plate Injury

84. Volar Plate Injury

85. Tendon Avulsions
Very common and can occur from direct blows or abrupt forces (throwing)
Flexor Digitorum Profundus (Jersey Finger) rupture-
Occurs when distal phalanx is forcefully extended while the finger is flexing (grabbing)
Signs and symptoms
Immediate pain and LOF
Swelling
Point tenderness at tendinous attachment
Complete rupture results in inability to flex distal phalanx
Incomplete rupture results in pain and weakness
Unable to flex DIP joint against resistance

86. Jersey finger

88. Extensor Tendon Avulsion
Mallet finger
Results from an extended distal phalanx that is suddenly and forcefully flexed (catching)
May be an avulsion fracture or tendon rupture
Signs and symptoms
Severe pain and immediate LOF
Point tenderness over distal attachment
Flexion deformity of the distal phalanx
Inability to actively extend the distal phalanx
Avulsion fracture has better chance to heal without surgery

89. Mallet Finger

91. Boutonniere Deformity
Extensor Tendon Rupture
Characterized by flexion of the PIP joint and hyperextension of the DIP joint
Injury to the central slip of the extensor digitorum tendon at the PIP joint from forceful flexion (“Buttonhole rupture”)
Signs and symptoms
Localized pain and swelling over middle phalanx
Point tenderness near the tendon insertion
Weakness with extension of the PIP joint
PIP joint will be flexed; DIP joint is hyperextended

92. Boutonniere Deformity

94. Splinting of Common Finger Injuries
Deformity
Splinting Position
Jersey Finger
DIP Joint in flexion
Mallet Finger
DIP Joint in extension
Boutonniere Deformity
PIP and DIP joints in extension
Phalanx fracture
Position found
Metacarpal fracture
Palmar surface of wrist and hand
Unreduced dislocations

95. Dupuyten’s Contracture
Flexion deformity typically seen in the older adult population
Flexion contracture of the MCP and PIP joints as a result of contracture of the palmar fascia
Typically affects the fourth and fifth digits

97. Tendonitis/Tendosynovitis
Inflammation of the tendon or its synovial sheath
Results from overuse or repetitive motion, direct trauma, and continued use following a tendon injury
Signs and symptoms
Point tenderness over involved tendon
Swelling
Palpable crepitus
Pain with active and resisted motion
Pain with passive stretching of the tendon

98. DeQuervain’s Disease
Tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons on the radial side of the thumb; Causes inflammation of tendons
Results from repetitive motion that combines gripping and wrist ulnar deviation
Signs and Symptoms
Pain along thumb side of wrist which may either appear gradually or suddenly; may travel into wrist and forearm
Pain is usually worse with use of the hand & thumb, especially when forcefully grasping things or twisting the wrist
There may be occasional catching or snapping of the thumb

99. DeQuervain’s Tenosynovitis

100. Finkelstein’s Test

101. Gamekeeper’s Thumb
Involves the ulnar collateral ligament (UCL) of the thumb (MCP Joint)
A.k.a. –skiers thumb
Results from forced abduction and hyperextension of the thumb or axial load to the thumb
Avulsion fracture is very common
Signs and symptoms
Pain, swelling, and visible bruising
Point tenderness over UCL
Instability consistent with degree of injury
Laxity >35° & absent end feel = rupture of UCL

102. Figure 14.6

103. Classification & Treatment of Gamekeeper’s Thumb
Type 1: incomplete rupture
Type 2: complete rupture; distal end may displace superficial & proximal to the adductor aponeurosis
Short arm thumb spica cast (6-10 wks) for incomplete rupture
Cast should incase both the IP and MP joints, with thumb in slight adduction
Protective splint until pain free & complete ROM

104. Bennett’s Fracture Involves the base of first metacarpal bone
MOI: striking an object with a closed fist
Metacarpal displaced due to pull from abductor pollicis longus
Signs and symptoms
Immediate localized pain, rapid swelling, and LOF
Deformity may or may not be present
Crepitus at the MCP
↑ pain on axial compression of 1st metacarpal

105. Bennett’s Fracture

106. On-Field Evaluation
Usually athletes with hand, finger or wrist injuries leave the field on their own
Cradling and protecting injured area
Deformity is usually obvious and may involve open or closed fractures or dislocations of the fingers
Always remove the glove(s)
Cut off if needed

107. Fractures and Dislocations
Fractures of radius and ulna as well as dislocations of the radiocarpal joint must be immobilized in the position found
Vacuum splint or SAM Splint
Always check pulse and neuro status before and after
Open fracture/dislocations should be covered with sterile gauze
IP dislocations
Reduce (if you can), splint and x-ray to r/o fx
Hand and finger
Immobilize, splint and x-ray (24h rule)
Lacerations
Superficial structures of tendons, etc- refer to E.D.

109. Review Wrist, hand and finger injuries are very common! Many injuries
Wrist can be difficult to diagnose properly due to many small involved structures
Many injuries
Remember MOI and distinguishing sign or symptom for each injury
Practice
Makes perfect, don’t get scared of the wrist, hand and finger- attack it