1. Hand and Wrist Evaluation

2. History How did this injury occur (mechanism)
When did you hurt your wrist/thumb?
Where does it hurt?
Did you hear any sounds or feel a pop?
Any previous history?
Pain Levels & Types of Pain
Training Methods
What activities recreates the pain?
Did you continue activity after injury?

3. Observation Obvious Deformities Discoloration / ecchymosis Swelling
Attitude of hand
Slightly flex at all joints when at rest
Bilateral Comparison of wrist/hand
Palmar surface, dorsal surface, knuckles, finger nails

4. Palpation Boney Radius Ulna Anatomical Snuffbox Metacarpals Phalanges
Carpal Bones

5. Palpation Continued Soft Tissue Tunnels 1 - 6 Carpal Tunnel
Tunnel of Guyon
Thenar eminence
Hypothenar eminence
Palmar aponeurosis

6. Tunnels of the Wrist

7. Carpal Tunnel

8. Tunnel of Guyon Structures in the Tunnel of Guyon
Ulnar nerve and Ulnar artery
The nerve and artery runs right between the Hook of the Hamate and the pisiform

9. Thenar Eminence Thenar Eminence Supplied by Median Nerve Observations
Located under the thumb
Made up of 3 muscles
More developed on dominant hand
Supplied by Median Nerve
Observations
Size
Shape
Consistancy
Atrophy or Hypertrophy

10. Hypothenar Eminence Hypohenar Eminence Supplied by the Ulnar nerve
Runs from Pinkie to Pisiform
Made up of 3 muscles
More developed on dominant hand
Supplied by the Ulnar nerve
Observations
Size
Shape
Consistency
Atrophy or hypertrophy

11. Palmar Aponeurosis Center of the hand Shape of a Triangle
Finger Flexors run through this
Unable to palpate muscles due to thick fibrous tissue

12. Conditions found in the Wrist/Hand
Ganglion Cyst
DeQuervain’s Disease
Fractured Bone (Scaphoid)
Carpal Tunnel Syndrome
Joint Capsular Contractures (DIP, PIP, MP joint, CMC)
Colles’ Fracture
Dupuytren Contracture
Trigger Finger
Subungual Hematoma
Swan neck Deformity
Boutonniere deformity
Mallet finger deformity
Bowler’s Thumb
Jersey Finger
Handlebar Palsy

13. Ganglion Cyst Herniation of joint capsule or tendon sheath
Usually found on the back of the wrist but can found anywhere a tendon is in the hand
May feel soft, rubbery, or very hard
Pain with the appearance of a lump
TX includes intense pressure or aspiration followed by a compression pad

14. DeQuervain’s Disease
Tenosynovitis or inflammation of the tendon sheath in the wrist.
Occurs in Tunnel 1
Tunnel narrows and pain is felt when the abductor pollicis longus and extensor pollicis brevis moves in the tunnel
Seen in athletes whose sport requires great deal of wrist ROM
Pain is an achy pain which radiates into forearm or hand
Special Test: Finklestein’s test TX
Immobilization, rest, cryotherapy, and antiinflammatory medication

15. DeQuervain’s Disease

16. Fractured Scaphoid Falling on an outstretched hand
At risk for avascular necrosis
Loss of blood supply
Often misdiagnosised as a wrist sprain
Requires immediate immobilization

17. Carpal Tunnel Syndrome
Structures found in CT
8 long finger flexor tendons
Their synovial sheath
The median nerve
Inflammation of tendons and sheath
Leads to compression of median nerve
Occurs in athletes who perform repeated wrist flexion or direct trauma to tunnel SX
Tingling, numbness in the thumb, index finger, middle finger and palm of the hand
Atrophy of the thenar eminence
Weakness in thumb movement
Possitive Tinnel sign and Phalens test TX
Rest, immobilization, and NSAIDS
Can lead to injections of Corticosteriod and possible surgical intervention

18. Colles Fracture
Fracture of the Head of the Radius with or without the a fracture in the ulna
Displacement is usually dorsal TX
Closed reduction and immobilization

19. Dupuytren’s Contracture
Nodules form in palmer aponeurosis
Limits extension
Causes Flexion
Flexion deformity usually found in ring and little finger
Surgery is required

20. Trigger Finger / Thumb Nodule forms on the Tendon due to overuse
Tenosynovitis
Pain and funny clicking sound with extension
Snapping is both palpable and audible
Lump can be felt at the end of the sheath TX
Immobilization, rest, cryotherapy, and antiinflammatory medication
Steroid injections
Last option splinting finger in extension

21. Subungual Hematoma
Pooling of blood under the nail due to a direct blow TX
Relieve pressure
Drill through nail

22. Swan Neck Deformity
Tearing of volar plate in PIP joint due to severe hyperextension force
Pain and swelling at PIP joint
Passively hyperextended TX
RICE
Splinted at degrees of flexion for 3 weeks
Buddy tape

23. Boutonniere Deformity
Rupture of the extensor tendon dorsal to the middle phalanx
Trauma occurs to tip of the finger
DIP extension
PIP Flexion SX
Severe pain and inability to extend DIP joint
Obvious deformity and swelling TX
PIP is splinted into extension for 5 – 8 weeks
While extended athlete is encouraged to flex DIP

24. Mallet Finger Deformity
AKA baseball or basketball finger
Tearing of extensor tendon at the DIP joint
Ice and splint

25. Bowler’s Thumb
Irritation to the ulnar digital nerve due to pressure from the thumb hole
Causes thickening and decrease sensation in the ulnar digital nerve SX
Pain, tingling during pressure to the irritated area and numbness TX
Padding thumbhole
Decrease amount of bowling

26. Jersey Finger Often occurs in the Distal phalanx of the ring finger
Tearing of the flexor digitorum profundus tendon
Athlete is unable to flex DIP joint
Unable to ever flex DIP without surgery

27. Handlebar Palsy Compression of the Ulnar nerve
From absorption of vibration and shock through the handle bars
Causing numbness, tingling or pain

28. Special Tests Flexor Digitorum Superficialis Test
Flexor Digitorum Profundus Test
Bunnel-Littler Test
Retinacular Test
Allen Test
Finklestein Test
Tinnel Sign for Carpal Tunnel Syndrome
Phalens Test
Referred Pain from shoulder and Elbow

29. Flexor Digitorum Superficialis Test
Tests the Flexor Digitorum Superficialis of the 3rd digit
How to?
Extend all fingers except the one being tested
Then flex the finger in question at the PIP joint
Positive Finding
Unable to flex finger
Means the FDS isn’t intact or is torn

30. Flexor Digitorum Profundus Test
Tests the Flexor Digitorum Profundus of the 3rd digit
How to?
Flex the finger in question at the DIP joint
Positive Finding
Unable to flex finger
Means the FDP isn’t intact or is torn

31. Bunnel-Littler Test
Evaluates the tightness of intrinsic muscles or joint capsular tightness
How?
Hold MP joint in slight extension
Try to flex PIP joint
Positive finding
Unable to bend = tightness in intrinsic muscles

32. Bunnel-Littler Test Slight Extension of MP Joint + Flex PIP joint
Able to flex
Unable to flex
Intrinsic muscles aren’t tight
Slight Flexion of MP Joint + Flex PIP Joint
Able to flex
Unable to flex
Tight Intrinsic muscles
Joint Capsular tightness

33. Retinacular Test Tests Tightness in the Retinacular Ligaments How
Hold PIP in neutral position and try and move the DIP joint
To differentiate between Retinacular lig. Tightness and joint capsular tightness
Flex the PIP joint and repeat test
If DIP then flexes the Retinacular lig. Is tight
If the DIP still doesn’t flex then there is DIP joint capsular tightness

34. Allen Test
Determines whether or not the radial or ulnar arteries are at full capacity
How?
Instruct athlete to open and close his fist quickly several times and then squeeze his fist tightly so that venous blood is forced out of palm
Place thumb over radial artery and index finger over ulnar and press down
Have athlete open hand (palm should be pale)
Release one artery while keeping pressure on the other artery.
The hand should flush immediately
If not part or all of that artery is blocked
Repeat with both arteries.

35. Finklestein Test
Test for Tenosynovitis or Dequervain’s disease in tunnel 1
How?
Tuck thumb in fist
Then ulnar deviate the wrist
Positive finding
Sharp pain in the area of the tunnel

36. Tinnel Sign for Carpal Tunnel Syndrome
Tap on the Transverse (volar) Carpal Ligament
Positive finding
Reoccurrence of symptoms

37. Phalens Test Testing for carpal tunnel syndrome How? Positive Test
Flex patient’s wrists to its maximal degree and hold that position for at least a minute
Positive Test
Tingling of fingers
Pain or numbness