1. HuP 191B – Advanced Assessment of Upper Extremity Injuries
Wrist, Hand and Finger Evaluation and Pathologies

2. History

3. History Location of pain Mechanism of injury/etiology
Unusual sounds/sensations
Onset/duration and description of symptoms
Prior history/general health concerns

4. Location of Pain
Generally, local injury represented by local symptoms – sometimes difficult to identify specific structure/s
Must be aware of possible referred pain from cervical, shoulder and/or elbow pathologies

5. Mechanism of Injury Direct trauma
Hyperextension/hyperflexion injuries of wrist and/or fingers
Insiduous onset increases likelihood of chronic conditions
Identify factors which increase or decrease symptoms

6. Unusual Sounds or Sensations
Numbness/tingling indicative of neurological pathology – must establish if local or referred
Fractures, dislocations and tendon ruptures often accompanied by “popping” sensation
Some overuse conditions (tendonitis) may present with “snapping” sensation

7. Onset/Duration and Description of Symptoms
Type of pain (ache, throb, etc.)
Intensity of pain (objectify)
Immediate vs. gradual onset of symptoms
Changes in symptoms (better, worse)

8. Prior History and General Health Concerns
Any previous injury, especially if neurological in nature, may have lasting effect on function, etc.
Hand is typically first part of body to be affected by:
Arthritis
Peripheral vascular disease (PVD)
Insufficient vascular structures to provide adequate circulation
Raynaud’s phenomenon
Reaction to cold temps – alternating bouts of pallor and cyanosis (vascular responses)

9. Inspection/Observation

10. Inspection/Observation
General inspection
Inspection of wrist and hand
Inspection of thumb and fingers

11. General Inspection Hand posture Gross deformity Palmar creases
Relaxed normal hand is slightly flexed with subtle palmar arch
Gross deformity
Associated with fractures and/or dislocations
Palmar creases
May not be visible if severe swelling
Cuts, scars, lacerations
Superficial nature of neurovascular structures makes them susceptible to injury even with superficial wounds

12. Inspection of Wrist and Hand
Distal radioulnar continuity
Carpal and metacarpal continuity/contour
MP joint alignment
Depressed knuckle = Boxer’s fracture
Wrist and hand posturing
Neurovascular conditions may prompt abnormalities (drop wrist, Volkmann’s ischemic contracture)

13. Inspection of Wrist and Hand
Ganglion cyst
Defined as benign collection of thick fluid within a tendinous sheath or joint capsule
Most commonly found in wrist and hand
Painful with motions that impinge upon when symptomatic

14. Inspection of Thumb and Fingers
Skin and fingernails
Subungual hematoma
Paronychia – infection at nail periphery
Felon – infection/abscess at or distal to DIP
Finger alignment and deformity
If finger out of alignment, may be spiral fracture of phalanx/metacarpal
Secondary to fracture, dislocation or tendon injury

15. Skin and Fingernail Conditions

16. Palpation

17. Palpation Wrist and finger flexors Wrist and finger extensors
Bony anatomy
Non-carpal bones
Carpal bones
Ligamentous and intrinsic muscular structures

18. Wrist and Finger Flexors
Flexor carpi ulnaris tendon
Flexor carpi radialis tendon
Tendons of finger flexors
Superficialis vs. profundus
Palmaris longus tendon

19. Wrist and Finger Extensors
Extensor digitorum tendons
Anatomical snuffbox
Extensor pollicis longus – medial (ulnar) border
Abductor pollicis longus and extensor pollicis brevis – lateral (radial) border
Scaphoid - floor

20. Anatomic Snuffbox

21. Non-Carpal Bony Anatomy
Distal radius/radial styloid process
Lister’s tubercle (dorsal and distal radius)
Ulnar head/ulnar styloid process
Metacarpals
Phalanges

22. Carpal Bony Anatomy Scaphoid Lunate Triquetrum Pisiform
Floor of snuffbox, easier with ulnar deviation
Lunate
Typically aligned with 3rd metacarpal, distal to Lister’s tubercle and flex wrist
Triquetrum
Just distal to ulnar styloid process
Pisiform
Small, rounded prominence at proximal aspect of hypothenar eminence in palm

23. Carpal Bony Anatomy Trapezium Trapezoid Capitate Hamate
Between scaphoid and 1st metacarpal
Trapezoid
Base of 2nd metacarpal
Capitate
Move toward thumb from hamate, base of 3rd metacarpal
Hamate
“hook” of hamate is large prominence at distal hypothenar eminence on palm

24. Ligamentous and Intrinsic Muscular Anatomy
Radial collateral ligaments
Radiocarpal joint, MP/IP/PIP/DIP joints
Ulnar collateral ligaments
Ulnocarpal joint, MP/IP/PIP/DIP joints
Carpal tunnel (transverse carpal ligament)
Thenar eminence
Hypothenar eminence

25. Range of Motion

26. Range of Motion Active/passive/resistive Wrist
Flexion/extension, ulnar/radial deviation
Thumb (carpometacarpal joint)\
Flexion/extension, abduction/adduction, opposition
Fingers
MP joints: flexion/extension, abduction/adduction
IP/PIP/DIP joints: flexion/extension

27. Wrist Ranges of Motion Flexion – normally 80-90 degrees, firm end feel
Extension – normally degrees, firm end feel
Radial deviation – normally 20 degrees, hard end feel (scaphoid on radial styloid)
Ulnar deviation – normally 35 degrees, firm end feel

28. Wrist Ranges of Motion

29. Thumb Ranges of Motion Flexion – normally 60-70 degrees, soft end feel
Extension – 0 degrees, firm end feel
Abduction – degrees, firm end feel
Adduction – 0 degrees, soft end feel
Opposition – flexion/adduction/rotation, touch thumb to little finger, firm end feel

30. Thumb Motions

31. Finger Ranges of Motion
MP joints
Flexion – degrees, hard end feel (proximal phalanges on distal metacarpal)
Extension – degrees, firm end feel
Abduction/adduction – total of degrees, firm end feel
IP/PIP/DIP joints
Flexion – IP: degrees, PIP: degrees, DIP: degrees, firm end feels except PIP is hard end feel (middle phalanges on proximal phalanges)
Extension – 0 degrees, firm end feels

32. Ligamentous/Capsular Testing

33. Ligamentous/Capsular Testing
Carpal glide tests
Attempts to elicit abnormal glide of carpal bones
Varus/valgus stress tests (do at multiple joint positions)
Wrist
UCL limits radial deviation and flexion/extension
RCL limits ulnar deviation and flexion/extension
Can also assess with glide between radius/ulna and proximal row of carpal bones
MP/IP/PIP/DIP joints
Thumb UCL is common injury site

34. Neurovascular Evaluation

35. Neurological Evaluation
Peripheral nerve distributions
Median, ulnar and radial nerve sensory and motor functions
Nerve root level distributions
Dermatomes and myotomes

36. Vascular Evaluation Radial artery Capillary refill
Skin temperature and color
Allen test?

37. Pathologies

38. Pathologies Wrist injuries Hand injuries Finger injuries
Thumb injuries

39. Wrist Injuries Wrist sprains
Triangular fibrocartilage complex (TFCC) injury
Carpal tunnel syndrome
Wrist fractures
Scaphoid fractures
Lunate/perilunate dislocations
Neurological injuries

40. Wrist Sprains
Most common etiology is hyperflexion or hyperextension (fall on outstretched arm)
Must rule out carpal fracture, neurological injury and TFCC injury before assessing as wrist sprain
Most common presentation involves limited ROM to all wrist movements due to pain, usually also presents with weakness – assess with radiocarpal and carpal glide tests - treated conservatively in nearly all cases

41. TFCC Injury
Sprain to ligamentous structures on dorsal and medial aspect of wrist – injury occurs acutely, but often not reported until later
Most common etiology is hyperextension with ulnar deviation
Presents with tenderness to dorsal medial wrist distal to ulna, limited ROM (especially radial and ulnar deviation), possibility of avulsion fracture
Must be referred to MD – often surgically repaired

42. TFCC Injury

43. Carpal Tunnel Syndrome
Compression of median nerve in carpal tunnel – must be able to differentiate from nerve root injury
Typically secondary to overuse conditions (tendonitis, etc.) but may be due to acute trauma
Most common presentation is neurological deficit/symptoms to median nerve distribution (sensory and motor)

44. Carpal Tunnel Syndrome
Evaluate with Tinel’s sign to carpal tunnel – positive if symptoms reproduced
Evaluate with Phalen’s test – wrist flexion for ~1 minute – positive if symptoms reproduced
Almost always treated conservatively initially with rest, splinting (night), NSAIDs
Failure of conservative measures can lead to surgery – resection of transverse carpal ligament

45. Phalen’s Test

46. Wrist Fractures
Typically occur from fall on outstretched arm – must consider neurovascular implications
Colles’ fracture
Fracture of distal radius proximal to radiocarpal joint with dorsal displacement of fracture
Smith’s fracture (reverse Colles’)
Fracture of distal radius proximal to radiocarpal joint with palmar/volar displacement of fracture

47. Colles’ Fracture

48. Smith’s Fracture

49. Scaphoid Fracture Easily the most commonly fractured carpal bone
Most common etiology is hyperextension
Blood supply comes from distal aspect and fracture in mid-substance often compromises proximal blood supply – high incidence of non-union/malunion fractures

50. Scaphoid Fracture

51. Scaphoid Fracture
Common presentation is pain/tenderness to snuffbox, limited ROM due to pain (especially extension/radial deviation), decreased grip strength
Conservative management involves immobilization of wrist/thumb/forearm for 6-8 weeks, then progressive ROM/strengthening exercises
Surgical intervention occasionally done in acute situation, but usually after failed conservative approach

52. Perilunate and Lunate Dislocations
Hyperextension is mechanism of injury – leads to 2 dislocation types (progressive severity of injury): perilunate dislocation vs. lunate dislocation
Common presentation is either palmar or dorsal wrist pain/swelling, visible/palpable deformity, 3rd knuckle level with others, neurological symptoms (3rd finger)

53. Perilunate Dislocation
Palmar/volar displacement of proximal row of carpal bones on lunate so that lunate is dorsal to the other bones
Rupture of palmar/volar radiocarpal ligaments and promimal row of carpals “stripped” away from lunate
May spontaneously reduce, but usually remains displaced

54. Perilunate Dislocation

55. Lunate Dislocation
Palmar/volar displacement of lunate relative to carpals (really vice versa – carpals displaced dorsally on lunate)
Further hyperextension forces ruptures dorsal radiocarpal ligaments and the carpals are subsequently displaced
May spontaneously reduce, but usually remains displaced

56. Lunate Dislocation

57. Perilunate and Lunate Dislocations
If closed reduction is stable, immobilized in slight flexion for 6-8 weeks – regular re-evaluation to maintain reduction stability
Requires surgical stabilization if closed reduction not stable acutely or if conservative attempts fail

58. Neurological Injuries
Median nerve – carpal tunnel syndrome
Ulnar nerve
Passes in tunnel of Guyon between hook of hamate and pisiform, can be compressed
Radial nerve
Drop wrist syndrome from inability to extend wrist/fingers if radial nerve injured

59. Hand and Finger Injuries
Metacarpal fractures
Collateral ligament injuries
Posturing and deformities
Finger fractures
Dislocations

60. Metacarpal Fractures
Etiology is direct trauma – injury to 4th and 5th are most common
Boxer’s fracture: 5th metacarpal fracture with “depression or shortening” of knuckle
Often reports of hearing/feeling “pop or snap” at time of injury
Common presentation is localized tenderness/swelling/crepitus, possible displacement, abnormal hand ROM, weakness to affected area

61. Boxer’s Fracture

62. Metacarpal Fractures

63. Metacarpal Fractures
If no displacement, treat with cast immobilization for 4-6 weeks followed by progressive ROM/flexibility/strengthening
If displacement and/or fragmented, surgical intervention necessary to re-establish normal anatomical positioning – then treated same as conservative approach

64. Collateral Ligament Injuries
Etiology is acute force application
Present with localized pain/swelling, ROM limited due to pain/swelling
Varus and valgus stress tests often not informative unless 3rd degree injury
Generally conservatively managed with splint and symptomatic treatment

65. Posturing and Deformities
Ape hand
Bishop’s deformity
Claw hand
Dupuytern’s contracture
Swan neck deformity
Volkmann’s ischemic contracture
Boutonniere deformity
Trigger finger

66. Posturing and Deformities
Ape hand
Median nerve inhibition resulting in thenar eminence atrophy – inability to flex and oppose thumb
Bishop’s deformity
Ulnar nerve inhibition resulting in hypothenar eminence, interossei, and medial 2 lumbricale atrophy – 4th and 5th fingers assume flexed posture
Claw hand
Ulnar and median nerve pathology resulting in flexion of PIP and DIP joints with associated extension of MP joints

67. Dupuytren’s Contracture
Flexion contracture of MP and PIP joints from shortening/adhesions in palmar aponeurosis – most common at 4th and 5th fingers

68. Swan-Neck Deformity
Flexion of MP and DIP joints with associated hyperextension of PIP joint – usually due to volar plate injury, but can have many causes

69. Volkmann’s Ischemic Contracture
Flexion contracture of wrist and fingers from decreased blood supply to forearm muscles secondary to fracture, dislocation or compartment syndrome

70. Boutonniere Deformity
Extension of MP and DIP joints with associated flexion of PIP joint – due to rupture of extensor tendon from middle phalanx causing it to slip laterally at PIP joint changing line of pull from extension to flexion

71. Trigger Finger
“Locking” of ROM during finger flexion from adhesions in flexor tendon sheaths
With flexion movements, adhesions require additional effort to allow for flexion ROM
Tendon “release” often presents as an audible “snap” as finger moves into flexion

72. Trigger Finger

73. Finger Fractures
Distal phalanx most commonly fractured due to flexor/extensor tendon attachments (avulsion) and crushing trauma
Middle phalanx uncommonly injured
Proximal phalanx injury usually not isolated and has associated tendon and/or skin injury
Presentation and treatment similar to metacarpal fracture discussion

74. Finger Fracture

75. Finger Fractures Avulsion fractures of the fingers Mallet finger
Avulsion of extensor tendon from distal phalanx, inability to actively extend DIP joint (passive OK), commonly occurs if fingertip hits ball
Jersey finger
Avulsion of profundus tendon from distal phalanx, inability to actively flex DIP joint if PIP joint stabilized, commonly occurs when grabbing jersey and joint forcefully extended against active motion

76. Mallet Finger

77. Jersey Finger

78. Finger Dislocations
Interphalangeal joint dislocations result in obvious deformity
Must rule out associated fracture – refer to MD for imaging prior to reduction
Generally, easy to reduce – must be splinted after reduction

79. Finger Dislocations

80. Thumb Injuries DeQuervain’s syndrome Sprains MP joint dislocations
Fractures

81. DeQuervain’s Syndrome
Tenosynovitis of extensor pollicis brevis and abductor pollicis longus tendons from repetitive stress (radial deviation)
Presents with pain/swelling to proximal thumb/distal radius, pain with radial/ulnar wrist deviation and thumb extension and abduction
Treated conservatively with rest (immobilization), NSAIDs, modalities

82. DeQuervain’s Syndrome

83. Finkelstein’s Test Evaluative for DeQuervain’s syndrome
Thumb flexed across palm and locked in by finger flexion – wrist placed in ulnar deviation – positive if pain reproduced or increased
Can present with false-positive results

84. Finkelstein’s Test

85. Thumb Sprains
Medial (ulnar) collateral ligament of 1st MP joint is easily most commonly injured – must rule out avulsion fracture
May be due to repetitive stress, but typically etiology is acute hyperextension and/or hyperabduction (skiing, etc.) – Gamekeeper’s thumb

86. Thumb Sprains
Commonly presents with localized tenderness/swelling, may see ecchymosis in thenar eminence, inability to pinch or grasp objects, positive valgus stress test
If mild or moderate injury with good end point, often treat conservatively with splint for 4-6 weeks
If rupture, early surgical intervention indicated to provide acceptable joint stability

87. 1st MP Joint UCL Sprain

88. 1st MP Joint Dislocation
Etiology usually hyperextension and/or hyperabduction – may have associated fracture
Rupture of volar (palmar) ligamentous structure
Presents with obvious deformity and inability to perform ROM
Refer to MD for reduction

89. Thumb Dislocation

90. Thumb Fractures 1st metacarpal fractures due to acute trauma
If fracture extends into articular surface (joint space), known as Bennett’s fracture
Bennett’s fracture often requires surgical intervention to fixate fracture segment to allow for normal bony alignment and stability

91. Bennett’s Fracture