1. ATTR 322 Krzyzanowicz- Spring ‘13

2.  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

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

5.  Forearm ◦ 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.  Metacarpals ◦ I (thumb)- V (little finger)  Phalanx  Proximal  Middle  Distal

8.  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

10.  Intercarpal 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 1 st CMC joint  Saddle joint, flex/ext and abd/add

11.  Metacarpophalangeal (MCP) and interphalangeal (IP) joints ◦ MCP flex/ext and abd/add ◦ IP flex/ext

13.  Extensor muscles (p. 756-759) ◦ 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 (5 th digit side)

15.  Ulnar 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

16.  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

18.  Tunnel’s floor ◦ 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

20.  Kinetic Chain ◦ 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

21.  History of present condition ◦ 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

22.  Functional Observation ◦ 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

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

26.  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

28.  Palpation of the wrist and finger extensor muscle group 1.Wrist and finger extensor group 2.Extensor digitorum communis 3.Extensor pollicis longus 4.Abductor pollicis longus 5.Extensor pollicis brevis 6.Abductor pollicis longus

30.  Palpation of the hand 1.Metacarpals 2.Collateral ligaments of the MCP joints 3.Phalanges 4.Collateral ligaments of the IP joints 5.Thenar compartment 6.Thenar webspace 7.Central compartment 8.Hypothenar compartments 9.Ulna 10.Ulnar styloid process 11.Ulnar collateral ligament 12.Distal radius and styloid process 13.Lister’s tubercle 14.Radial collateral ligament

31.  Palpation of the carpals 1.Scaphoid 2.Trapezium 3.Lunate 4.Triquetrum 5.Pisiform 6.Hamate 7.Capitate 8.Trapezoid Acronym?

32.  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)

37.  Stress testing ◦ Tests for collateral support of wrist ligaments  UCL (TFCC involvement)  RCL ◦ Tests for collateral support of IP joints  UCL  RCL  Laxity in either could be an avulsion fracture

38.  MOI ◦ Typically FOOSH  Vulnerable in child and adolescent ◦ Colles’ fracture  Fracture of distal radius; displaced dorsally ◦ Reverse Colles’ fracture or Smith’s fracture  Fracture of distal radius; displaced palmarly  S&S ◦ Gross deformity, severe pain, rapid swelling, noises

40.  Treatment ◦ Stabilize fracture ◦ Check capillary bed refill ◦ Check distal pulse ◦ Check neurological function ◦ Splint using SAM Splint  Place arm in sling ◦ Usually requires surgical intervention

41. WRIST PATHOLOGIES

42.  About 70% of all carpal fx’s involve the scaphoid ◦ Bony block limiting wrist extension ◦ Most prevalent in 15-30 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

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

44.  Management ◦ X-ray  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

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

47.  MOI ◦ 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

48.  http://www.imageinterpretation.co.uk/wrist.h tml

49.  Very general term ◦ 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

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

52.  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!

53.  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

55.  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

57.  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

58.  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

60.  “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

62. HAND AND FINGER PATHOLOGIES

63.  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

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

67.  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?

68.  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

70.  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)

73.  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

76.  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

79.  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

82.  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

85. DeformitySplinting Position Jersey FingerDIP Joint in flexion Mallet FingerDIP Joint in extension Boutonniere DeformityPIP and DIP joints in extension Phalanx fracturePosition found Metacarpal fracturePalmar surface of wrist and hand Unreduced dislocationsPosition found

86.  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

88.  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

89.  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

92.  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

94.  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

95.  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 1 st metacarpal

97.  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

98.  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.

100.  Wrist, hand and finger injuries are very common! ◦ 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