1. Wrist and Hand

2. Wrist and Hand Bones Wrist (Carpals) Hand Scaphoid (Navicular) Lunate
Triquetral
Pisiform
Trapezium
Trapezoid
Capitate
Hamate
Hand
Phalanges
Thumb
Proximal and distal
Fingers
DIP
PIP
MIP

4. Wrist Joints/Ligaments
Radial Carpal Joint
Radius and carpal bones
Triangular Fibrocartilage
Medial side
Ulnar Collateral Ligament
Radial Collateral Ligament
Lateral side
Intercarpal joints
Between the wrist bones
Carpal Metacarpal Joint of Thumb

6. Finger Ligaments
Collateral Ligaments
At each joint of the finger

8. Muscles Palmar Interossei (3) Palmar muscles Palmar muscles
Lumbricales
Origin: tendon of flexor digitorum profundus
Insertion: Tendons of the extensor digitorum communis
Action
flexes the metacarpophalangeal joints
Extends the interphanlangeal joints
Dorsal Interossei (4)
Origin: Adjacent sides of all the metacarpals
Insertion:Proximal phalanx of 2nd, 3rd and 4th fingers
Abducts the fingers from the middle finger
Palmar Interossei (3)
Origin: medial side of the 2nd metacarpal and lateral side of the 4th and 5th metacarpals
Insertion: Proximal phalanx of the same finger
Action
Adducts the fingers toward the middle finger

9. Muscles Flexor Pollicis Brevis Abductor Pollicis Brevis
Thenar muscles
Thenar Muscles
Flexor Pollicis Brevis
Origin: trapezium and 1st metacarpal
Insertion: base of the proximal phalanx of the thumb
Action
Flexes and adducts the thumb
Adductor Pollicis
Origin: capitate and 2-3rd metacarpals
Insertion: proximal phalanx of thumb
Adducts the thumb
Abductor Pollicis Brevis
Origin: scaphoid and trapezium
Insertion: proximal phalanx of the thumb
Action
Abducts the thumb
Opponens Pollicis
Origin: trapezium
Insertion: latearl border of the metacarpal of the thumb
Pulls the thumb in front of the palm to meet the little finger

10. Muscles Palmaris Brevis Abductor digiti minimi
Hypothenar Muscles
Hypothenar Muscles
Palmaris Brevis
Origin: Flexor retinaculum
Insertion: Skin on the ulnar border of the hand
Action
Pulls the skin toward the middle of the palm
Abductor digiti minimi
Origin: pisiform
Insertion: base of little finger
Abducts the little finger
Flexor digiti minimi brevis
Origin: hamate
Insertion: base of little finger
Action
Flexes little finger
Opponens digiti minimi
Insertion: metacarpal of little finger
Brings the little finger out to meet the thumb

13. Blood and Nerve Supply Three major nerves
Ulnar, median and radial
Ulnar and radial arteries supply the hand
Two arterial arches (superficial and deep palmar arches)

15. Special Tests

16. Finklestin’s Test Test for de Quervain’s syndrome
Athlete makes a fist w/ thumb tucked inside
Wrist is ulnarly deviated
Positive sign is pain indicating stenosising tenosynovitis
Pain over carpal tunnel could indicate carpal tunnel syndrome

17. Tinel’s Sign Produced by tapping over transverse carpal ligament
Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome

18. Phalen’s Test Test for carpal tunnel syndrome
Position is held for approximately one minute
If test is positive, pain will be produced in region of carpal tunnel

19. Valgus/Varus and Glide Stress Tests
Tests used to assess ligamentous integrity of joints in hands and fingers
Valgus and varus tests are used to test collateral ligaments
Anterior and posterior glides are used to assess the joint capsule

21. Circulatory and Neurological Evaluation
Hands should be felt for temperature
Cold hands indicate decreased circulation
Pinching fingernails can also help detect circulatory problems (capillary refill)
Hand’s neurological functioning should also be tested (sensation and motor functioning)
Allen’s test can also be used
Patient is instructed to clench fist 3-4 times, holding it on the final time
Pressure applied to ulnar and radial arteries
Patient then opens hand (palm should be blanched)
One artery is released and should fill immediately (both should be checked)

22. Functional Evaluation
Functional EvaluationRange of motion in all movements of wrist and fingers should be assessed
Active, resistive and passive motions should be assessed and compared bilaterally
Wrist - flexion, extension, radial and ulnar deviation
MCP joint - flexion and extension
PIP and DIP joints - flexion and extension
Fingers - abduction and adduction
MCP, PIP and DIP of thumb - flexion and extension
Thumb - abduction, adduction and opposition
5th finger - opposition

23. Wrist/Hand/Finger Injuries

24. Wrist Sprains Wrist Sprains Management Etiology Signs and Symptoms
Most common wrist injury
Arises from any abnormal, forced movement
Falling on hyperextended wrist, violent flexion or torsion
Multiple incidents may disrupt blood supply
Signs and Symptoms
Pain, swelling and difficulty w/ movement
Management
Refer to physician for X-ray if severe
RICE, splint and analgesics
Have patient begin strengthening soon after injury
Tape for support can benefit healing and prevent further injury

25. Triangular Fibrocartilage Complex Injury (TFCC)
Etiology
Occurs through forced hyperextension, falling on outstretched hand
Violent twist or torque of the wrist
Often associated w/ sprain of UCL
Signs and Symptoms
Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clicking
Swelling is possible, not much initially
Patient may not report injury immediately

26. Triangular Fibrocartilage Complex Injury (TFCC)
Management
Referred to physician for treatment
Treatment will require immobilization initially for 4 weeks
Immobilization should be followed by period of strengthening and ROM activities
Surgical intervention may be required if conservative treatments fail

27. Tendinitis Etiology Management Signs and Symptoms
Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris;
Repetitive pressure on palms (cycling) can cause irritation of flexor digitorum
Primary cause is overuse of the wrist
Signs and Symptoms
Pain on active use or passive stretching
Isometric resistance to involved tendon produces pain, weakness or both
Management
Acute pain and inflammation treated w/ ice massage 4x daily for first hours, NSAID’s and rest
When swelling has subsided, ROM is promoted w/ contrast bath
PRE can be instituted once swelling and pain subsided (high rep, low resistance)

28. Nerve Compression, Entrapment, Palsy
Etiology
Median and ulnar nerve compression
Result of direct trauma to nerves
Signs and Symptoms
Sharp or burning pain associated w/ skin sensitivity or paresthesia
Management
Chronic entrapment may cause irreversible damage
Surgical decompression may be necessary

29. Bishop/Benediction Hand: results from injury to the ulnar nerve
2. Claw Hand: results from compression of the median and ulnar nerves
3. Drop wrist: results from palsy of the radial nerve
4. Ape Hand: results from palsy of the median nerve

30. Carpal Tunnel Syndrome
Etiology
Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel
Result of repeated wrist flexion or direct trauma to anterior aspect of wrist
Signs and Symptoms
Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb
Management
Conservative treatment - rest, immobilization, NSAID’s
If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament

31. De Quervian’s Disease (Hoffman’s disease)
Etiology
Stenosing tenosynovitis in thumb
(extensor pollicis brevis and abductor pollicis longus
Constant wrist movement can be a source of irritation
Signs and Symptoms
Aching pain, which may radiate into hand or forearm
Positive Finklestein’s test
Point tenderness and weakness during thumb extension and abduction
painful catching and snapping

32. De Quervain’s Disease Management Immobilization rest Cryotherapy
NSAID’s
Ultrasound and ice are also beneficial
Joint mobilizations have been recommended to maintain ROM

33. Scaphoid Fracture Etiology Management
Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones
Often fails to heal due to poor blood supply
Signs and Symptoms
Swelling
Severe pain in anatomical snuff box
Presents like wrist sprain
Pain w/ radial flexion
Management
Must be splinted and referred for X-ray prior to casting
Immobilization lasts 6 weeks and is followed by strengthening and protective tape
Wrist requires protection against impact loading for 3 additional months

34. Hamate Fracture Etiology Signs and Symptoms Management
Occurs as a result of a fall
Signs and Symptoms
Wrist pain
Weakness
Point tenderness
Pull of muscular attachment can cause non-union
Management
Casting wrist and thumb is treatment of choice
Hook of hamate can be protected w/ doughnut

35. Extensor Tendon Avulsion (Mallet Finger)
Etiology
Caused by a blow to tip of finger avulsing extensor tendon from insertion
Also referred to as baseball or basketball finger
Signs and Symptoms
Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx
Unable to extend distal end of finger (carrying at 30 degree angle)
Point tenderness at sight of injury
Management
RICE and splinting for 6-8 weeks

36. Boutonniere Deformity
Etiology
Rupture of extensor expansion dorsal to the middle phalanx
Tendon slides below axis of PIP joint
Forces DIP joint into extension and PIP into flexion
Signs and Symptoms
Severe pain
obvious deformity
inability to extend DIP joint
Swelling, point tenderness
Management
Cold application, followed by splinting
Splinting must be continued for 5-8 weeks
Athlete is encouraged to flex distal phalanx

37. Jersey Finger (Flexor Digitorum Profundus Rupture)
Etiology
Rupture of flexor digitorum profundus tendon
Often occurs w/ ring finger when athlete tries to grab a jersey
Signs and Symptoms
DIP can not be flexed
Finger remains extended
Pain and point tenderness over distal phalanx
Management
Must be surgically repaired
Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture

38. Swan Neck Deformity (PsuedoBoutonniere) Etiology Signs and Symptoms
Distal tear of volar plate may cause Swan Neck deformity;
Proximal tear may cause PsuedoBoutonniere deformity
Signs and Symptoms
Pain, swelling w/ varying degrees of hyperextension
Tenderness over volar plate of PIP
Indication of volar plate tear = passive hyperextension
Management
RICE and analgesics
Splint in degrees of flexion for 3 weeks; followed by buddy taping and then PRE

39. Gamekeeper’s Thumb Etiology Signs and Symptoms
Sprain of UCL of MCP joint of the thumb
Mechanism is forceful abduction of proximal phalanx
Occasionally combined w/ hyperextension
Signs and Symptoms
Pain over UCL
Weak and painful pinch

41. Gamekeeper’s Thumb Management Immediate follow-up must occur
If instability exists, athlete should be referred to orthopedist
If stable, X-ray should be performed to rule out fracture
Thumb splint should be applied for protection for 3 weeks or until pain free
Splint should extend from wrist to end of thumb in neutral position
Thumb spica should be used following splinting for support
If a complete tear occurs, surgical repair is necessary to allow normal function to return

42. Sprains of IP Joints Etiology Signs and Symptoms Management
Can include collateral ligament, volar plate, extensor expansion tears
Occurs w/ axial loading or valgus/varus stresses
Signs and Symptoms
Pain, swelling, point tenderness, instability
Valgus and varus tests may be positive
Management
RICE, X-ray examination and possible splinting
Splint at degrees of flexion for 10 days
If sprain is to the DIP, splinting for a few days in full extension may assist healing process
Taping can be used for support

43. Metacarpal Fracture Etiology S/S Management
Direct axial force, compressive force
Being stepped on
S/S
Pain
Swelling
Appear to be an angular or rotational deformity
Management
Rice
X-ray
Reduce
Splinting
Splint 4-6 wks

44. Bennett’s Fracture Etiology S/S Management
1st metacarpal just distal to the CMC joint of the thumb
Axial and abduction force to thumb
S/S
Pain
Swelling over base of thumb
Deformity
Management
Unstable and referred to orthopedic

45. Mallet Finger

46. Boutonniere Deformity

47. Jersey Finger

48. Swan Neck Deformity

49. Bennett’s Fracture