1. THE WRIST AND HAND
Chapter 22

2. ANATOMY
I. Bones
The hand and wrist contain 27 bones
1. 14 phalanges
2. 5 metacarpals
3. 8 carpals
Fingers are numbered just like the toes, with the thumb being the #1 Phalanx and the little finger being the #5 phalanx

3. A. Phalanges Make up the fingers and thumb
There are 14 parts altogether
1. Distal Phalanges (5)
2. Interphalanges or Middle Phalanges (4 the thumb doesn‘t have one)
3. Proximal Phalanges (5)
a. Finger tips b. Middle bone of fingers c. Most proximal bone of fingers

4. B. Metacarpals
There are 5
They make up the actual hand
C. Carpals
There are 8 irregularely shaped carpal bones
They make up the wrist
1. Trapezium
2. Trapezoid
3. Scaphoid
4. Lunate
5. Triquetral
6. Pisiform
7. Capitate
8. Hamate

6. II. Muscles
There are many, many muscles associated with wrist, hand, and finger movement
All flexor muscle groups are located on the anterior aspect of the forearm

7. All Extensor muscle groups are located on the posterior aspect of the forearm

8. WRIST AND HAND INJURIES

9. A. Ligamentous Injuries
1. Wrist Sprain a. fall or a sudden twist b. structure injured depends on stress placed on the wrist
Signs and Symptoms
Pain
Point Tenderness
Limited Range of Motion
Swelling
Decreased Grip Strength
Treatment: Usually PRICE
Tape or brace when athlete returns to competition

10. DO NOT TRY TO REDUCE THE DISLOCATION!!!!
2. Lunate Dislocation
a. falling on the hand b. hyper-flexed or hyper-extended for a dislocation of a carpal bone to occur c. The most commonly dislocated carpal is the Lunate
Signs and Symptoms:
Deformity
Pain
Point Tenderness
Swelling
Difficulty extending the wrist and flexing the fingers
Numbness and paralysis of flexor muscle
Treatment: Splint
Ice
Refer to Physician immediately
DO NOT TRY TO REDUCE THE DISLOCATION!!!!

11. b. Also called Gamekeeper‘s or Skier‘s thumb
3. Thumb Sprain
a. Usually involves the MCL of the metacarpal-phalangeal joint
b. Also called Gamekeeper‘s or Skier‘s thumb
c. Forceful abduction is the typical Mechanism of Injury (MOI), as in catching a basketball)
Gamekeeper‘s thumb = old term, injury occured frequently as hunters tried to break a bird‘s neck off before cooking them
Skier‘s thumb= a very frequent skiing injury...as skier crashes, the thumb gets caught behind the ski pole, which forces it into abduction

12. Treatment Signs and Symptoms
Pain
Point tenderness
Swelling
Decreased ROM
Positive Valgus Stress Test
PRICE
For 3rd degree send to physician for X-rays
Tape when returning to activity

13. 4. Interphalangeal Collateral Ligament Sprains
a. Typical MOI is being hit by a basketball straight on or getting a finger caught in opponent‘s facemask or jersey

14. Signs and Symptoms Treatment
Pain
Point Tenderness
Limited ROM
Swelling
Positive Stress Test
PRICE
Buddy Tape when returning to activity

15. 5. Finger Dislocation
a. Can occur dorsal or volar
b. Should NEVER be reduced by anyone other than a physician
(Tiny tendons, nerves, and blood vessels course their way through the joint spaces and can be permanently damaged if the relocation is done improperly)
Volar dislocations are very prone to complications...Dr Piatek hates to relocate them even after x-rays rule out a fracture. The volar plate (thick band of fibrous tissue, including the flexor tendon) is very likely to get caught in the joint All dislocations (volar and dorsal) can hide fractures of the phalnge. A force big enough to pop the finger out of place is also strong enough to break the bone. If somebody tries to pull the finger back in place that is fractured as well, the sharp bone edges can sever nerves, tendons, and blood vessels which might lead to permanent damage. Advice: If you ever dislocate any joint, DO NOT let anybody but a physician put it back in place. It‘s not a good time to play „hero“.

17. Signs and Symptoms
Pain
Deformity
Possible signs of shock
Treatment
Ice, splint, send to physician

18. Finger Amputation

19. B. Muscle and Tendon Injuries

20. 1. Tendinitis
a. Like in any other bodypart, repetitive stress, direct impact, or overuse can cause tendinitis in the hand or wrist

21. b. De Quervain‘s tendinitis
1) affects the abductor pollicis longus and extensor pollicis brevis tendons
2) Common among shot-putters

22. Signs and Symptoms Treatment Ice, rest,
Pain
Point Tenderness
Swelling
Crepitus (grinding sensation)
Difficulty abducting the thumb
Ice, rest,
Alter activity to reduce the repetitive movement

23. 2. Mallet Finger
a. Is an avulsion fracture of the extensor digitorum tendon
b. MOI is being hit with a ball on the tip of the finger (e.g. Baseball, basketball)
Avulsion fracture = a tendon is ripped out of its bony attachment rather than tearing itself...you would rather have an avulsion fracture than a rupture of ligament or tendon...heals a lot faster and usually better

24. Inability to extend the distal interphalangeal joint (DIP)
Signs and Symptoms
Pain
Point tenderness
Swelling
Inability to extend the distal interphalangeal joint (DIP)
Athlete will not be able to lift the tip of the finger

25. Splint, ice, and send to physician
Treatment
Splint, ice, and send to physician
Physician will most likely place athlete in a brace in slight hyperextension, so the bone can heal
Many times athletes figure that the injury isn‘t anything bad and don‘t report it. In that instance, the finger tip will permanently be unable to be extended. The injury only heals properly if splinted in extension for at least 3 weeks.

26. b. A common MOI is getting a finger stuck in an opponent‘s jersey
3. Jersey Finger
a. Is very similar to Mallet finger, except it involves the deep flexor tendon
b. A common MOI is getting a finger stuck in an opponent‘s jersey

27. Signs and Symptoms
Pain
Point tenderness
Swelling
Inability to flex the DIP joint

28. Ice, splint and send to physician
Treatment
Ice, splint and send to physician
Usually this injury requires surgical intervention within a week
Surgery within a week because after that time the torn off tendon starts to deteriorate and will be too short to be reconnected
Report all finger injuries...An orthopaedics nightmare is the attitude: It‘s just a finger!

29. 4. Boutonniere Deformity
a. Involves the Proximal Interphalangeal Joint (PIP)
b. A hard impact can cause a tear in the joint capsule, which can cause the extensor tendons to fall laterally

31. Signs and Symptoms Treatment
Pain
Point tenderness
Swelling
Inability to extend the PIP joint
Ice, splint, refer to physician

32. C. Bone Injuries

33. 1. Fractures
a. All bones in the wrist and hand are prone to fractures, because they often get into harms way
b. A complication associated with a scaphoid fracture is avascular necrosis, which is death of the bone due to a lack of blood supply

34. a. The scaphoid, one of the 8 carpal bones, has a blood supply on only one side of the bone, therefore if it fractures, the broken off side will die if not immobilized

35. b. The scaphoid is located in the Anatomical Snuff Box and a fracture of this bone is often mistaken as a sprained wrist
c. Typical MOI is a fall on the outstretched hand

36. Point tender in anatomical snuff box Decreased Range of Motion
Signs and Symptoms
Pain
Swelling
Point tender in anatomical snuff box
Decreased Range of Motion
Positive Pinch Test
Anatomical snuff box=spread all your fingers as far as possible...the depression between two thumb tendons (ext.pollicislongus and abd.pollicis brevis)
Pinch test = hold a piece of paper with thumb and index finger only, spread the other 3 fingers. Pull out paper and have the athlete try to hold on to it. If it is painful in anatomical snuff box or paper slips out, send to physician

37. Treatment
Splint, ice, and send to physician
A weird thing about a scaphoid fracture is that it does not show on x-rays for the first 7-10 days ... Usually physicians cast it for 10 days if they suspect a fracture and then x-ray again

38. Other fractures
Signs and Symptoms
Pain
Deformity
Limited Range of Motion
Swelling

40. Treatment
Splint, Ice, and send to physician