1. The Forearm, Wrist, Hand, and Fingers Chapter 24

2. Forearm Anatomy zRadius and Ulna: Elbow yJoints: radioulnar joint (superior, middle, and distal) zBone: proximal radial head, olecranon process, radial shaft, ulnar shaft, distal radius, radial styloid process, ulnar head, ulnar styloid zMusculature: flexors& pronators (lie anteriorly. ulnar side), extensors & supinators (lie posteriorly, medial side) zNerve/Blood Supply: median and radial nerve and brachial, radial, and ulnar artery

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7. Forearm Assessment zHistory zObservation yVisually inspect, including wrsit and elbow yIf no deformity present, observe while they supinate and pronate zPalpation zSpecial Tests

8. Recognition and Management of Forearm Injuries zContusion yEtiology:direct blow xWhy more common to ulna? ySigns and Symptoms yManagement zForearm Splints yEtiology: repeated severe static contraction ySigns and Symptoms:dull ache between extensors, interosseous membrane yManagement: early season vs late in season? yNote: Acute / Chronic exertional compartment syndrome: deep compartment most common and associated with avulsions, distal radius fracture, or crushing injuries; management same as in lower leg

9. zColles’ fracture yEtiology: FOA, forces radius and ulna back and up = hyperextension ySigns and Symptoms (posterior displacement) yManagement yReverse Colles’ = fall on back of hand zForearm Fractures yEtiology ySigns and Symptoms: more common for radius and ulna to fracture simultaneously yManagement

12. Wrist, Hand, and Finger Anatomy zBones: carpals and metacarpals zJoints: radiocarpal, carpal, metacarpal, and phalangeal joints zLigaments: “many at each joint in the hand” yTFCC (triangular fibrocartilage complex); b/t head of ulna and triquetrial bone zMusculature: “many intrinsic and extrinsic muscles” zBlood and Nerve Supply: ulnar, median, radial nerve and radial and ulnar superficial and deep palmar arch arteries.

14. Assessment of Wrist, Hand, and Finger Injuries zHistory zObservation zPalpation zSpecial Tests: Finklestein’s test, Tinel’s Sign, Phalen’s test, valgus and varus stress test, zCirculatory and Neurological Evaluation yAllen test zFunctional Evaluation

15. Special Tests zFinklesteins’ Test De Quervains (tenosynovitis) Thumb tucked inside fist with ulnar deviation zTinel’s Sign yTap over transverse carpal ligament yPain numbness and tingling indicates median nerve disruption and presence of carpal tunnel zPhalen’s Test yCarpal tunnel yBilateral wrist flexion and press them together; pain is positive sign zValgus/varus at wrist, MCP, and IP joints zCirculatory / neurological evaluations yAllen's test: test function of radial and ulnar arteries yAthlete makes fist 4-5 times; while holding final fist, evaluator pinches off both arteries; hand should be blanched yRelease arties individually

16. Recognition and Management of Wrist, Hand, and Finger Injuries zWrist Sprain yEtiology ySigns and Symptoms yManagement zTriangular Fibrocartilage Complex Injury yEtiology:forced hyperextension or compression of radioulnar joint and proximal row of carpals ySigns and Symptoms yManagement

17. zTenosynovitis yEtiology: repeated wrist acceleration and deceleration ySigns and Symptoms: pain w/ passive stretching yManagement: may need splinting and strengthening zTendinitis yEtiology: repetitive pulling motions and pressure on palm of hand ySigns and Symptoms:pain with AROM and passive stretching yManagement zNerve Compression, Entrapment, Palsy yEtiology: median (carpal tunnel) and ulnar (pisiform and hamate) ySigns and Symptoms:deformities(bishop’s, claw and drop wrist) yManagement: if chronic, may require surgical decompression

18. z Carpal Tunnel Syndrome yTunnel = pink yBones = white yLigament = blue z Carpal tunnel syndrome yEtiology: repeated flexion ySigns and Symptoms: sensory and motor impairment yManagement

19. Recognition and Management of Wrist, Hand, and Finger Injuries zDislocation of the Lunate Bone yEtiology:forced hyperextension of wrist ySigns and Symptoms:difficulty with wrist and finger flexion; may have impaired nerves yManagement: referral for reduction z Hamate Fracture yEtiology: contact while holding something(racket) ySigns and Symptoms yManagement z Wrist Ganglion(synovial cyst) yEtiology:herniation of joint capsule or tendon ySigns and Symptoms yManagement

20. z De Quervain’s Disease yEtiology: tenosynovitis of thumb ySigns and Symptoms yManagement

21. Scaphoid Fracture zEtiology: compression of scaphoid b/t radius and ulna yConcerns: portion of scaphoid has decreased vascular supply; improper healing can occur and result in aseptic necrosis of the scaphoid bone zSigns and Symptoms yAnatomical snuffbox pain zManagement

23. Finger anatomy z Bones z Ligaments yPIP and DIP have the same design yCollateral ligaments, palmar fibrocartilage, and loose posterior capsule or synovial membrane (protected by extensor expansion)

24. Finger anatomy zMusculature yPIP: Flex. Digitorium Superficialis yDIP: Flex. Digitorium Profundus yPIP & DIP: Exten. Digitorium Longus (becomes extensor expansion after MCP) yIntrinsics: xDorsal and palmar interosseei: xLumbricals:volar surface; MCP flex., IP exten. xThenar (4 that act on thumb) & hypothenar (4 that act on 5 th )

25. Recognition and Management of Wrist, Hand, and Finger Injuries zContusion to hand and fingers yEtiology ySigns and Symptoms: fingernail? yManagement zBowler’s Thumb yEtiology: fibrosis of the ulnar digital nerve form pressure ySigns and Symptoms:pain, numbness, tingling yManagement: pad area, decrease activity; surgery PRN zJersey finger yEtiology:FDP rupture, grabbing jersey ySigns and Symptoms:DIP cannot flex yManagement:SURGERY

26. zTrigger finger or thumb yEtiology: stenosing tendon by repeated movements ySigns and Symptoms: resistance to re- extension after thumb and finger flexed yManagement:possible injections; splinting zDupuytren’s Contracture yEtiology: idiopathic development of nodules in palmer aponeurosis ySigns and Symptoms:flexion deformity; cannot extend yManagement: surgical removal

27. Boutonniere deformity z Etiology:rupture of extensor tendon dorsal to middle phalanx; trauma to tip of finger causes DIP extension and PIP flexion z Signs and Symptoms: cannot extend z Management:splint PIP in extension 5- 8wks.

28. z Swan neck deformity z AKA Pseudoboutonniere yEtiology:severe hyperextension; injury to volar plate ySigns and Symptoms: hyperextension of PIP yManagement: splint 20-30 degrees flexion 3 wks

29. Mallet Finger yEtiology: strike to tip of finger, jamming and avulsing extensor tendon ySigns and Symptoms: unable to extend, may palpate avulsed bone yManagement:extension splint 6-8 wks

30. z Gamekeepers Thumb yEtiology:UCL of thumb; forced abductions, an hyperextension ySigns and Symptoms:inability to pinch; pain with stress yManagement:splint 3 weeks; protect with activity

31. Recognition and Management of Wrist, Hand, and Finger Injuries zSprains, Dislocations, and Fractures yEtiology ySigns and Symptoms yManagement zSprains PIP and DIP joint yEtiology ySigns and Symptoms yManagement z PIP Doral Dislocation yEtiology:twist while semiflexed ySigns and Symptoms yManagement:splint in ext z PIP Dorsal dislocation yEtiology:hyperext. ySigns and symptoms:deformity; inability to move yManagement:reduce and splint 20-30 degrees flex

32. Recognition and Management of Wrist, Hand, and Finger Injuries zMCP dislocation yEtiology:twist an shear force ySigns and Symptoms:prox. Phalanx dorsal 60-90 degrees yManagement: reduce; splint; early ROM zMetacarpal fracture yEtiology:compressive axial force ySigns and Symptoms:appear angular or rotated yManagement: reduce and splint zBennett’s Fracture yEtiology:thumb CMC; axial and ABD force to thumb ySigns and Symptoms:base of thumb painful yManagement:refer to surgeon due to unstable nature

34. zDistal/Middle/Proximal phalangeal fracture yEtiology:crushing force; direct trauma or twist ySigns and Symptoms: subungual hematoma subungual hematoma yManagement:drain and splint / buddy tape; control pain zFingernail deformity yOccur for variety of reasons: xScaling or ridging – psoriasis xRidging or poor development – hyperthyroidism xClubbing and cyanosis-chronic respiratory disease or heart disorder xSpooning or depression- chronic alcoholism and vitamin deficiencies

35. Rehabilitation Principles for the Forearm, Wrist, Hand, and Fingers zGeneral Body Conditioning zJoint Mobilization: traction and mobilization help restore ROM zFlexibility: full ROM is measure of good rehab zStrength: equal zNeuromuscular Control :great dexterity required zReturn to Activity: Goals: full dexterity, full ROM, full strength