1. Wrist and Forearm Lecture 15

2. The Wrist and Hand
the wrist and hand are used extensively in activities of daily living and in nearly all sports
The anatomy of the wrist is highly complex
injuries to this region are often the result of the natural tendency of the individual to sustain the force of the fall on the hyper-extended wrist
Often seen in ball handling sports

3. Bones and Articulations
the wrist and hand are composed of numerous small bones and articulations, which enable the dexterous movements performed by the hand and wrist both during sports and daily living

4. Distal radioulnar joint between the distal ulna and the radius
allows for pronation and supination of the forearm
triangular fibrocartilage (TFC) is the disc that makes up a portion of the triangular fibrocartilage complex(TFCC) which acts as a stabilizer of the joint
often injured , can lead to serious problems

5. Radiocarpal joint is the major joint of the wrist
condyloid shape where the radius articulates with the scaphoid, lunate and triquetrum allows flex/ext, radial and ulnar deviations and circumduction
volar, dorsal , radial and ulnar collateral ligaments reinforce the radiocarpal joint

6. Carpometacarpel (CM) joint
joint between the carpels and the metacarpels
gliding joint
dorsal , volar and interosseous ligaments

7. l st CM (thumb)
saddle joint

8. Metacarpalphalangeal ( MP)
allows flex/ext , add/ abd
condyloid joints
reinforced by strong collateral ligaments
Interphalangeal (PIP, DIP)
hinge joints
flex/ext
volar, and collateral ligaments

9. Muscle & Tendons of the Hand
given the highly controlled and precise movements that the hand and fingers can perform , there is no surprise that a large number of muscles are responsible
extrinsic muscles ( 9) , originate outside the wrist – cross wrist and insert in hand
intrinsic muscles (10) , originate in the hand or wrist, and insert in hand or wrist

10. Major Actions of the Wrist and Hand
wrist – flex/ext/radial deviation/ulnar deviation/ circumduction
thumb – flexion /extension/ adduction /abduction and opposition
fingers – flex/ext/add/abd/

11. Common Injuries to Wrist and Hand

12. Wrist Sprain result of a single trauma – or repeated stress
usually result of axial loading on the palm during a fall on the outstretched arm
severity depends on
i) magnitude of the force
ii) position of the hand on impact
iii) strength of tissue

13. point tenderness on dorsum of radiocarpal joint , pain increases with passive or active extension
because of the need to perform daily activity these injuries are often not given the time to heal and can lead to chronic instabilities
Rx – PIER, NSAIDS, modalities , immobilization , rule out fractures

14. Wrist Strains usually the result of an overload or over stretching
pain and restricted motion
often occur with a wrist sprain
difficult to distinguish if both are present
Rx – PIER, NSAIDS, modalities , immobilization , rule out fractures

15. Triangular Fibrocartilage Complex
TFCC is located on the ulnar side of the wrist between the ulna and the triquetrum and pisiform
TFCC is a stabilizer of the distal radialulnar joint
Injuries are common but often missed diagnosed

16. Often caused by falling on outstretched hand , forced hyperextension of the wrist
s/s
Pain and swelling on ulnar side of wrist
Point tenderness ( TFCC)
Decreased ROM and strength esp wrist extension and ulnar deviation

18. Scaphoid # most frequently fractured carpel ( 60 - 70%)
usually the result of hyperextension during a fall on the outstretched arm
pain in anatomical snuff box , and pain with wrist extension and radial deviation , possible loss of function
often misdiagnosed due to lack of evidence on xray – re xay in 2 weeks or bone scan

19. CAUTION - scaphoid has poor blood supply distal pole
Rx - PIER – refer to doctor immediately
Casting involves a long process for healing - minimum six weeks and maybe more if not healing properly

23. First Aid
Immediately apply ice with some type of splint that helps to immobilize the wrist
Elevate with use of a sling
Refer for medical attention

24. Colles Fracture
fracture to the distal forearm involving one or both bones (usually the radius)
occurs with in 1 ½ inches of the wrist
results in a fork deformity (distal segment displaces in dorsal and radial direction)

27. First Aid
Immediately apply ice with some type of splint that helps to immobilize the wrist
Elevate with use of a sling
Refer for medical attention
Treat for shock

28. Skier’s or Gamekeeper’s Thumb
thumb is exposed to more force than fingers due to its position on the hand
integrity of the ulnar collateral ligament of the thumb is crucial for normal hand functions

29. UCL of thumb stabilizes the joint as the thumb is pushed against the index and middle fingers while performing pinching and grasping motions
usually occurs when MP joint is near full extension and thumb is forcibly abducted away from the hand
palmer aspect of the hand is swollen, bruising may be visible , point tenderness on UCL ( inside of the thumb) , instability and pain on stressing of the ligament
Rx – PIER , refer to doctor - severe cases may require surgical repair

30. Dislocations lunate is prone to dislocate during axial loading
dorsum of hand tender with a thickened area distal to radius on the palm, swelling
most common dislocation occurs at the PIP or DIP joints, may be associated with open wounds
usually the result of hyperextension and axial compression , such as a ball hitting the end of a finger

31. obvious deformity ,pain , loss of function
immediate treatment – reduction of finger by trained individual
Rx- PIER - xray – protection may take awhile to heal

34. Carpal Tunnel Syndrome
caused by direct trauma or repetitive overuse
condition is three times more common in women , with right hand usually more common
this is due to the more repetitive tasks that women’s occupation usually involve (keyboard)

35. the carpel tunnel runs between the floor of the wrist and the transverse retinacular ligament that runs from the hamate and pisiform on the medial side to the trapezium and scaphoid on the lateral side
this tunnel accommodates the medial nerve, the flexors of the fingers and flexor pollicis longus
swelling of these tendons puts pressure on the median nerve

36. pain that wakes them at night , numbness, decreased grip strength
symptoms reproduced with pressure over the carpel tunnel
Rx - PIER - immobilization refer to doctor chronic conditions often end up with surgery

37. Mallet Finger Rx- PIER and immobilize joint in hyperextended position
occurs when an object hits the end of a finger while the extensor tendon is taut
the resulting force avulses the lateral bands of the extensor mechanism from its distal attachment
obvious deformity , pain - check for fractures
Rx- PIER and immobilize joint in hyperextended position

40. Jersey Finger
This injury typically occurs when an individual grips an opponent’s jersey while the opponent is twists to get away
This ruptures the flexor digitorum profundus tendon from its attachment on the distal phalanx

41. Ring finger is the most commonly injured
Individual will be unable to flex the DIP joint
Rx- PIER and refer to doctor , surgery most likely will need to be performed

42. Boutonniere Deformity
caused by a blunt trauma to the dorsal aspect of the PIP joint
the central slip extensor tendon is ruptured at the middle phalanx, leaving the extensor mechanism intact over the PIP joint

43. this results in hyperextension at the MCP joint , flexion at the PIP joint and hyperextension at the DIP joint
Rx – PIER - needs to be referred to a doctor may need surgery

44. Ganglion Cysts
are begin tumour masses typically seen on the dorsal aspect of the wrist
associated with tissue sheath degeneration
contains fluid and is palpable between the extensors tendons
localised tenderness and some aggravation with wrist flexion
Rx – symptomatic – aspiration or injection , or surgical removal of the cyst

45. Ganglion Cysts
contains fluid and is palpable between the extensors tendons
localised tenderness and some aggravation with wrist flexion
Rx – symptomatic – aspiration or injection , or surgical removal of the cyst

46. Metacarpal Fractures
fractures usually result in sever pain, dorsal swelling and deformity
i) Bennets's # – articular fracture to the proximal end of the first metacarpal
usually occurs during axial compression as in when a punch is thrown with a closed fist
ii) Boxer's # - fracture of the 5th metacarpal

47. Rx – PIER – refer to doctor , may need closed or possibly open reduction depending on alignment

49. Subungual Hematoma direct trauma to the nail bed
capillaries burst from trauma and blood gets trapped under the finger nail
pressure builds and pain results
soak for 10 to 15 minutes in ice water
Rx - may need to drain the hematoma to reduce the pressure