1. Wrist and Hand Conditions

2. Anatomy

3. Wrist Articulations Radiocarpal joint Intercarpal joints
Distal radioulnar joint
Carpometacarpal joints (CM)
Intermetacarpal joints (IM)
Metacarpophalangeal joints (MP)
Interphalangeal joints (IP)

4. Nerves
Median nerve
Radial nerve
Ulnar nerve

5. Blood Vessels
Radial artery
Ulnar artery
Numerous divisions

6. Kinematics Wrist movements Flexion Extension/ hyperextension
Radial deviation
Ulnar deviation
Circumduction

7. Kinematics Thumb – flexion, extension, abduction, adduction
MP – fingers
Fingers – minimal motion
Flexion
Extension
Abduction
Adduction

8. Kinematics Cont’d…

9. Prevention of Injuries
Protective equipment
Pads and gloves
Physical conditioning
Strength and flexibility
Exercises for wrist and elbow
Proper skill technique
Instruction on falling

10. Sprains
Wrist
Mechanism: axial loading on proximal palm during fall on outstretched hand
S&S
Standard – sprain
Specific
Point tenderness on dorsum of radiocarpal joint
↑ Pain with active or passive extension
Need to rule out fracture, especially scaphoid fx
Management: standard acute; NSAIDs

11. Sprains Cont’d… Gamekeeper’s thumb Tear of the UCL of the MP joint
Mechanism: MP in extension and forceful abduction
S&S
Palmar aspect of joint – pain; swelling
+ abduction stress
Management: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repair

12. Sprains (cont.) IP sprains
Excessive valgus and varus: collateral ligaments
Hyperextension stress: volar plate
S&S
Rapid swelling; masks condition
X-ray: rule out fracture and dislocation
Management: standard acute; “buddy” taping
IP Collateral Ligament Sprains
-- ligament failure usually occurs at its attachment to the proximal phalanx or, less frequently, in the mid-portion
S&S
-- obvious deformity may not be present, unless there is a fracture or total rupture of the supporting tissues that causes a dorsal dislocation 12

13. Dislocations Lunate Axial loading displaces in volar direction S&S
Point tenderness – dorsum of hand just distal to radius
Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal)
Passive and active motion may not be painful
Caution: bone into carpal tunnel – compression of median nerve
Management: immobilization of limb in vacuum splint; immediate transportation to physician

15. Dislocations Cont’d… Fingers S&S: swollen, painful finger
Can involve collateral ligaments and volar plate
MCP
Rare, but easily recognizable
Hyperextension or shear
PIP
Hyperextension and axial loading (e.g., ball striking extended finger)
DIP
Usually occur dorsally
Individual often reduces injury on their own
S&S: swollen, painful finger
Management: immobilization; ice; immediate physician referral

17. Strains
Jersey finger
Rupture of flexor digitorum profundus from distal phalanx
Mechanism: rapid extension (from active flexion)
S&S
Unable to flex the DIP
Palpate tendon in proximal aspect of finger
Hematoma formation along the entire flexor tendon sheath
Management: standard acute; physician referral

18. Strains Cont’d… Mallet finger
Rupture of extensor tendon from distal phalanx
Mechanism: forceful flexion of PIP
S&S
Pain, swelling
Lack of extension at DIP
Management: standard acute; physician referral

20. Strains Cont’d… Boutonnière deformity
Rupture of central slip of extensor tendon at the middle phalanx
Mechanism: rapid forceful flexion of PIP
Result: hyperextension at MCP, flexion of PIP, hyperextension of DIP
S&S
No active extension
Deformity usually not present immediately, but develops over 2-3 weeks
Management: standard acute; injury that limits PIP extension to <30º: immediate physician referral

22. Strains Cont’d… Ganglion cysts
Benign tumor mass on dorsal aspect of wrist
Associated with tissue sheath degeneration
Treatment: symptomatic

23. Finger Injuries Subungual hematoma Blood under fingernail
Due to direct trauma
Need to rule out fracture
Management
Soak in ice water for minutes
If pain does not diminish, may need to be drained under supervision of a physician
Refer to Field Strategy 15.1

25. Nerve Entrapment Syndromes
Carpal tunnel syndrome
Median nerve, finger flexors, and flexor pollicis longus
Due to direct trauma, repetitive overuse, or anatomic anomalies
S&S
Awakening pain in middle of night; often relieved by “shaking out their hands”
Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger
Grip strength and pinch strength may be limited
Weak thumb abduction
Management: physician referral
carpal tunnel syndrome (CTS)
-- most common compression syndrome of wrist and hand, but not commonly seen in the physically active population
-- typically seen in dominant extremity
-- sporting activities with predisposition: activities that involve repetitive or continuous flexion and extension of the wrist, such as cycling, throwing sports, racquet sports, archery, and gymnastics
-- etiologies other than traumatic causes include: infectious origin (e.g., diphtheria, mumps, influenza, pneumonia, meningitis, malaria, syphilis, typhoid, dysentery, tuberculosis, gonococcus); metabolic causes (e.g., hypothyroidism, diabetes, rheumatoid arthritis, gout, vitamin deficiency, heavy metals poisoning, and carbon monoxide poisoning)
S&S
-- relieved by “shaking out their hands”; + “flick”
-- generally, only one extremity is affected
-- grip strength and pinch strength may be limited
-- common complaint is difficulty manipulating coins
-- diminished sensitivity to pain and weak thumb abduction are more predictive of abnormal nerve conduction
Management
-- immobilization in slight wrist extension with a dorsal splint is used to rest the wrist for up to 3-5 weeks, particularly at night when symptoms occur
-- ice cup or ice bag, NSAIDs, or in some situations, diuretics, can initially reduce swelling and pain in the area caused by tenosynovitis
-- compression wrap should be avoided
-- in cases that do not respond well to conservative treatment, surgical decompression or carpal tunnel release can be performed

27. Nerve Entrapment Syndromes Cont’d…
Cyclist's palsy
Due to leaning on handlebar for extended period; leads to swelling in hypothenar area
Symptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of ride
Key: proper padding; varying hand position

28. Fractures Distal radius/ulna fracture
Mechanism: axial loading; fall on outstretched hand

29. Fractures Cont’d… Scaphoid fracture S&S
History of falling on an outstretched hand
Point tenderness in anatomic snuff box
Pain with inward pressure along long axis
↑ pain with wrist extension and radial deviation
Management: standard acute; splint; physician referral
Concern: aseptic necrosis

31. Fractures Cont’d… Boxer’s fracture
Distal metaphysis or neck of fourth or fifth metacarpals
Inherently unstable
S&S
Sudden pain, inability to grip, rapid swelling, and deformity
Point tenderness; crepitus
↑ pain with axial compression and percussion
Management: standard acute; splint; immediate physician referral; ultimately casted in fisted position

33. Assessment History Observation/inspection Palpation
Expose entire arm
Palpation
Pain, unable or unwilling to move wrist or hand; determine the possibility of a fracture or dislocation before moving the wrist or hand
Proximal to distal
Physical examination tests

34. Range of Motion (ROM) Active range of motion (AROM)
Forearm pronation/supination
Wrist
Flexion/extension
Radial deviation/ulnar deviation
Fingers and thumb
Abduction/adduction
Opposition of thumb and little finger
Passive range of motion (PROM)
Normal end feel – tissue stretch 34

35. ROM (cont.) Resisted range of motion (RROM) Supination Pronation
Wrist flexion
Wrist extension
Ulnar deviation
Radial deviation
Finger flexion/extension
Finger abduction/adduction
Thumb flexion/extension
Thumb abduction/adduction
Opposition 35

36. ROM (cont.) 36

37. ROM (cont.)

38. Stress Tests Wrist ligamentous instability tests
Varus and valgus
Finger ligamentous instability tests
Anterior/posterior glide
Wrist
Valgus stress (tests UCL)
Patient (pt) is seated with forearm supported; elbow flexed 90; forearm pronated; fingers relaxed (neutral/flexed)
Examiner sits/stands lateral to pt; one hand grasps distal forearm; other hand across the metacarpals
Examiner applies valgus stress, radially deviating the wrist
Test is + if: pain and/or increased laxity when compared bilaterally = sprain of UCL
Varus stress (tests RCL)
Same as valgus, except varus stress is applied, ulnarly deviating the wrist
Test is + if: pain and/or increased laxity when compared bilaterally = sprain of RCL
IP joints
Valgus stress (tests collateral ligaments)
Pt is sitting or standing; joint being tested placed in extension
Examiner stabilizes phalanx proximal to joint being tested
Examiner grasps the distal phalanx to the joint being tested and applies a valgus stress to the joint
Test is + if: increased pain, gapping compared bilaterally = collateral ligament sprain
Varus stress (tests integrity of joint capsule)
Same as valgus, except varus stress is applied
Anterior-posterior glide
Same as valgus/varus, except anterior posterior stress is applied
Test is + if: increased pain, gapping compared bilaterally = joint capsule sprain
Thumb
Valgus stress (tests integrity of UCL at thumbs)
Pt is sitting or standing; examiner in front or to side of pt
Examiner stabilizes 1st metacarpal with one hand and proximal phalanx with other hand
While stabilizing 1st metacarpal with the thumb, examiner gently abducts and extends, then applies a valgus stress to the UCL
Test is + if: increased laxity on ulnar aspect of 1st MCP joint compared to uninjured side = UCL sprain 38

39. Special Tests (cont.) Carpal tunnel compression test
Pt is sitting or standing
Using thumbs, examiner applies even pressure over carpal tunnel (30 seconds)
+ test = numbing or tingling into palmar aspect of thumb
Indication: median nerve compression 39