Transcript Wrist and Hand Anatomy

Wrist Anatomy
Bones
 Quiz - What
bones comprise
the wrist?
Joints
 Quiz - What joints
comprise the
wrist?
Carpal Bones and
Articulations
Proximal Row
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Where can you
palpate these?
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Scaphoid
Lunate
Triquetrum
Pisiform
Radiocarpal joint
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Distal Row
Ulnocarpal joint
Intercarpal joints
Where can you
palpate these?
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Trapezium
Trapezoid
Capitate
Hamate
Intercarpal joints
Carpometacarpal
joints (related to
hand)
Articulations and ROM
Distal Radioulnar joint
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Supination and Pronation – 80-90o
Ulna moves posteriorly and laterally with pronation
Radiocarpal joint (and Ulnocarpal joint)
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Flexion (80-90o) and Extension (75-85o)
Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints
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Gliding
Soft tissue of Wrist
Ligaments
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Covered by a fibrous
capsule
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Radial and ulnar
collateral
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limit ulnar and radial
deviation; collectively
limits flexion and
extension
Intercarpal and
Carpometacarpal
Soft tissue of Wrist
Ligaments
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Dorsal – limits flexion
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Dorsal Radiocarpal
Palmar - limit
extension
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Transverse carpal
ligament
Palmar radiocarpal
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Multiple divisions
Palmar ulnocarpal
ligament
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Multiple divisions
Soft tissue of Wrist
Cartilage
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Triangular Fibrocartilage
Complex – TFCC
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“Meniscus” between
ulna and triquetrum
Ulnar collateral ligament
and palmar ulnocarpal
ligaments have
attachments
Compressed with
Pronation and
Extension
Compressed with Ulnar
deviation
Muscle Tissue of Wrist
Extensor muscles
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Extensor
Retinaculum
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What’s its function?
Muscles innervated
by radial nerve
There are 8
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Name them…
Flexor Muscles
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Flexor retinaculum
(aka transverse
carpal ligament)
Two compartments
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Superficial – 4
Deep – 3
Name them…
Innervated by
median and ulnar
nerve
EXTENSORS
FLEXORS
Wrist and Hand Anatomy
Nerves/Vessels
 Radial & ulnar artery and veins
 Radial, ulnar, & median nerves
Carpal Tunnel  Flexor Tendons - 9
 Median Nerve
Wrist Injuries
Strains
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Onset usually acute – FOOSH or Overexertion
S/S: Active ROM limited
Wrist Ganglion
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Herniation of the joint capsule or synovial sheath
of a tendon.
Tx: Bible Therapy
Wrist Injuries
deQuervain’s Disease - thumb/wrist
stenosing tenosynovitis of the extensor
pollicis
brevis and abductor pollicis longus.
 S/S: crepitation, tenderness, strength loss.
 Special Test: = Finkelstein’s test
 Tx: RICE, NSAIDs
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Wrist Injuries
Sprains
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Onset is usually acute – FOOSH or overexertion
Often diagnosed when other injuries are ruled out
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S/S: Laxity, pain, swelling, limited ROM
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Both active and passive ROM are effected
Pain is usually with overstretching
Special Tests: Varus/Valgus, Carpal Glide
PRICE, Rehabilitation, Taping for prevention
Wrist Injuries
Triangular Fibrocartilage Injuries - TFCC
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Onset is usually acute
MOI: Forced hyperextension of wrist with loading
S/S: Pain with pronation/extension and/or ulnar
deviation; Pain with loading; Point tenderness;
Swelling; Altered joint mechanics
Special Test: Valgus test elicits pain but no laxity
and Varus test compresses and causes pain
Immobilization and Surgery are often necessary
Neural Injuries
Carpal Tunnel Syndrome
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Compression of median nerve
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Fibrosis of the synovium of flexor tendons secondary to
tenosynovitis
MOI: Insidious onset with repetitive wrist movement (and
finger movement); Acute onset with trauma; Progressive
degeneration
 S/S: numbness palmar thumb, index,
middle fingers, dull ache, weak finger
flexion (grip). May worsen with sleep.
 Poor posture may predispose.
 Special Tests: Tinel’s sign
and Phalen’s
 Tx: Conservative (PRICE, NSAIDs) and Surgical
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Neural Injuries
Biker’s Palsy
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Ulnar nerve compression
Ulnar nerve passes through tunnel of Guyon between
pisiform and hamate.
MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar
deviation
Tx: Padding (Gloves), Ice, NSAIDs
Drop Wrist Syndrome
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Radial nerve compression at elbow
Inability to extend wrist and fingers
Wrist Injuries
Wrist Fractures
 Distal Radius/Ulna and Forearm Fractures
 Onset is acute
 MOI: Hyperextension or hyperflexion combined
with rotatory motion – FOOSH
 S/S: Deformity felt and observed; Crepitus
 Evaluated Neurovascular status
 Tx: Splint, Ice, Referral
Wrist Injuries
Wrist Fractures
 Distal Radius/Ulna
 Colles’ Fracture
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MOI: hyperextension-fall on outstretched
S/S: “silver fork deformity” - radius & ulna posteriorly
Smith’s Fracture (Reverse Colles)
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MOI: hyperflexed
S/S: “garden spade deformity” - radius
& ulna anteriorly
Wrist Injuries
Wrist Fractures
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Scaphoid - most common carpal
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MOI: fall on outstretched hand
S/S: wrist aches, pain in anatomical
snuff box,
painful handshake or with
overpressure
Tx: Splint, Referral, Ice
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Plain X-rays may not be enough
Immobilization (long and/or short) –
12 weeks
Risk: aseptic necrosis and nonunion fractures
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Preiser’s Disease
Surgery may be necessary
Wrist Injuries
Wrist Dislocations
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Radius or Ulna
Lunate is very common
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MOI: force hyperextension
Dorsal displacement = perilunate dislocation
Palmar displacement (total rupture) = lunate
dislocation
S/S: Deformity, 3rd Knuckle is lower (Murphy’s
sign), Paresthesia of middle finger, weak finger
flexion
Risk: Untreated or repeated trauma
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Kienbock’s Disease
 Decreased grip, pain with ulnar deviation,
weak extension, pain with passive 3rd
finger extension
Immobilization – 6-8 weeks; Surgery may be
necessary
Wrist Injury Prevention
Good technique!
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But…these help
Flexor
tendon
arrangement
Lumbricals
Palmar
Interossei
Dorsal
Interossei
4
3
2
1
Extensor Hood, Long extensor
tendon, and lateral bands
Finger flexor
tendons
Unique finger
Look at pulley
system
Observation
Relaxed position of hand
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Fingers slightly flexed
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Relative shortness of finger flexors
Skin and Nail health
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Discoloration, texture, hair patterns
Finger alignment
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Tips of fingers should align with finger flexion
Hand abnormalities
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Finger and metacarpal positioning
Muscle atrophy
Range of motion
Range of Motion
Carpometacarpal
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Flexion (70-80o)/Extension
Abduction (70-80o)/Adduction
Opposition
Metacarpophalangeal
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Flexion (85-105o)/Extension (20-35o)
Abduction/Adduction (20-25o)
Interphangeal joints
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Thumb flexion (80-90o)
PIP flexion (110-120o)
DIP flexion (80-90o)
Palpation
Metacarpals and joints
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Collateral ligaments of MCPs
Phalanges and joints
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Collateral ligaments of PIPs and DIPs
Thenar compartment
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muscles
Thenar webspace
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muscles
Central compartment
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Palmar fascia and muscles
Hypothenar compartment
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muscles
Pathology
Tendon pathology
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Trigger Finger/Thumb
Mallet Finger
Boutonniere Deformity
Jersey Finger
Dupuytren’s Contracture
Swan Neck Deformity
Dupuytren’s Contracture
Joint pathology
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Sprains
Bony pathology
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Fractures
Dislocations
Swan Neck Deformity
Tendon pathology
Trigger Finger or Thumb
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Etiology
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Repeated motion of fingers may cause irritation, producing
tenosynovitis
Inflammation of tendon sheath (flexor tendons of wrist, fingers and
thumb, abductor pollicis)
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Signs and Symptoms
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Thickening forming a nodule that does not slide easily
Resistance to re-extension, produces snapping that is palpable,
audible and painful
Palpation produces pain and lump can be felt w/in tendon sheath
Management
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Immobilization, rest, cryotherapy and NSAID’s
Ultrasound and ice are also beneficial
Injection
Tendon pathology
Mallet Finger (baseball or basketball finger)
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Etiology
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Signs and Symptoms
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Caused by a blow that contacts tip of finger
avulsing extensor tendon from insertion
Avulses extensor digitorum at distal phalanx
Unable to extend distal end of finger (carrying at 30
degree angle)
Point tenderness at sight of injury
X-ray shows avulsed bone on dorsal proximal distal
phalanx
Management
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RICE and splinting in hyperextension for 6-8
weeks
Tendon pathology
Boutonniere Deformity
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Etiology
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Signs and Symptoms
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Rupture of extensor tendon dorsal to the middle
phalanx – bone passes through central slip
Forces DIP joint into extension and PIP into
flexion
Severe pain, obvious deformity and inability to
extend DIP joint
Swelling, point tenderness
Management
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Cold application, followed by splinting in PIP
extension and DIP flexion
Splinting must be continued for 5-8 weeks
Tendon pathology
Jersey Finger
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Etiology
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Signs and Symptoms
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Rupture of flexor digitorum profundus tendon
from insertion on distal phalanx
Often occurs w/ ring finger when athlete tries to
grab a jersey
DIP can not be flexed, finger remains extended
Pain and point tenderness over distal phalanx
Management
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Must be surgically repaired
Rehab requires 12 weeks and there is often poor
gliding of tendon, w/ possibility of re-rupture
Tendon pathology
Dupuytren’s Contracture
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Etiology
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Nodules develop in palmer aponeurosis,
limiting finger extension - ultimately causing
flexion deformity
Signs and Symptoms
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Dupuytren’s Contracture
Often develops in 4th or 5th finger (flexion
deformity)
Management
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Tissue nodules must be removed as they can
ultimately interfere w/ normal hand function
Tendon pathology
Swan Neck Deformity Etiology
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Distal tear of volar plate or finger trauma may cause
Swan Neck deformity
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Signs and Symptoms
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Flexed MCP, extended PIP, and flexed DIP
Pain, swelling w/ varying degrees of hyperextension
Tenderness over volar plate of PIP
Indication of volar plate tear = passive
hyperextension
Management
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RICE and analgesics
Splint in PIP 20-30 degrees of flexion/DIP extension
for 3 weeks; followed by buddy taping
Joint pathology
Sprains Phalanges
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Etiology
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Phalanges are prone to sprains caused by
direct blows or twisting
Signs and Symptoms
Recognition primarily occurs through history
 Sprain symptoms - pain, severe swelling and
hemorrhaging
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Joint pathology
Gamekeeper’s Thumb
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Etiology
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Signs and Symptoms
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Sprain of UCL of MCP joint of the thumb
Mechanism is forceful abduction of proximal phalanx occasionally
combined w/ hyperextension
Pain over UCL in addition to weak and painful pinch
Management
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Immediate follow-up must occur
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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
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Thumb spica should be used following splinting for support
Joint pathology
Sprains of Interphalangeal Joints of Fingers
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Etiology
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Signs and Symptoms
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Can include collateral ligament, volar plate, extensor slip tears
Occurs w/ axial loading or valgus/varus stresses
Pain, swelling, point tenderness, instability
Valgus and varus tests may be possible
Management
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RICE, X-ray examination and possible splinting
Splint at 30-40 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
Joint pathology
PIP Dorsal Dislocation
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Etiology
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Treated w/ RICE, splinting
and analgesics followed by
reduction
After reduction, finger is
splinted at 20-30 degrees
of flexion for 3 weeks -followed by buddy taping
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Caused by twist while it is
semiflexed
Signs and Symptoms
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Pain and swelling over PIP
Obvious deformity,
disability and possible
avulsion
Management
Etiology
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Signs and Symptoms
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Hyperextension that
disrupts volar plate at
middle phalanx
PIP Palmar Dislocation
Pain and swelling over PIP;
point tenderness over
dorsal side
Finger displays angular or
rotational deformity
Management
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Treat w/ RICE, splinting
and analgesics followed by
reduction
Splint in full extension for
4-5 weeks after which it is
protected for 6-8 weeks
during activity
Open Dislocation
Joint pathology
MCP Dislocation
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Etiology
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Caused by twisting or shearing force
Signs and Symptoms
Pain, swelling and stiffness at MCP joint
 Proximal phalanx is angulated at 60-90
degrees
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Management
RICE, following reduction splinting in slight
flexion (3 weeks)
 Buddy taping following splinting
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Bony Pathology
Metacarpal Fracture
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Etiology
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Signs and Symptoms
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Direct axial force or compressive force
Fractures of the 5th metacarpal = Boxer’s
Fracture
Pain and swelling; possible angular or rotational
deformity
Management
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RICE, analgesics are given followed by X-ray
examinations
Deformity is reduced, followed by splinting - 4
weeks of splinting after which therapy starts
Bony pathology
Bennett’s Fracture
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Etiology
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Signs and Symptoms
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Occurs at carpometacarpal joint of the thumb as
a result of an axial and abduction force to the thumb
CMC may appeared to be deformed - X-ray will
indicate fracture
Athlete will complain of pain and swelling over the
base of the thumb
Management
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Structurally unstable and must be referred to an
orthopedic surgeon
Surgery and immobilization – season ending
Bony pathology
Distal Phalangeal Fracture
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Etiology
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Crushing force
Signs and Symptoms
Complaint of pain and swelling of distal phalanx
 Subungual hematoma is often seen in this
condition
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Management
RICE and analgesics are given
 Protective splint is applied as a means for pain
relief
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Bony pathology
Middle Phalangeal Fracture
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Etiology
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Signs and Symptoms
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Occurs from direct trauma or twist
Pain and swelling w/ tenderness over middle
phalanx
Possible deformity; X-ray will show bone
displacement
Management
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RICE and analgesics
No deformity - buddy tape w/ splint for activity
Deformity - immobilization for 3-4 weeks and a
Bony pathology
Proximal Phalangeal Fracture
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Etiology
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May be spiral or angular
Signs and Symptoms
Complaint of pain, swelling, deformity
 Inspection reveals varying degrees of deformity
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Management
RICE and analgesics are given as needed
 Fracture stability is maintained by
immobilization of the wrist in slight
extension, MCP in 70 degrees of flexion and
buddy taping
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Lacerations
Superficial location of tendons and
nerves predisposes athletes to damage
form shallow lacerations.
Any laceration to the fascia below the
cutaneous layer should receive a
referral
R/O trauma to tendons and nerves
 Prevent infection
 Suture to ensure minimal scarring
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Finger Nail Pathology
Subungual Hematoma
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MOI: finger caught between two surfaces
Presents with bleeding under nail bed
Draining – Drill or Cauterize
Paronychia
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Infection around fingernail beds
S/S: Redness, pain, drainage
Warm soaks (Betadine), Antibiotic, Referral
Changes in normal appearance - indicative of a number of
different diseases
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Scaling or ridging = psoriasis
Ridging and poor development = hyperthyroidism
Clubbing and cyanosis = congenital heart disorders or chronic
respiratory disease
Spooning or depression = chronic alcoholism or vitamin deficiency
Prevention of Hand
Injuries
Protection
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Gloves, Grips, Braces
Proper Technique
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Sport and Ergonomics
Physical Conditioning
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Reps and Sets for muscles of Hand
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Theraputty, Wrist curls/extensions, Fist pumps
Problem Solving
Putting it together with
Case studies
History
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What is the cause of pain?
Mechanism of injury?
Previous history?
Location, duration and intensity of pain?
Creptitus, numbness, distortion in temperature?
Sounds or sensations?
Technique changes?
Weakness or fatigue?
What provides relief?
Observation
Functional Evaluation
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Range of motion in all movements of wrist should
be assessed
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Wrist “attitude”
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How do the carpals and metacarpals align with the distal
radius and ulna?
Is there symmetry?
How are those tendons looking?
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Active, resistive and passive motions should be
assessed and compared bilaterally
Wrist - flexion, extension, radial and ulnar deviation
Is there a palmaris longus? - 10% of population it is
absent
Become a “palm reader”?
Palpation
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Bony and Soft Tissue Palpation
Are they where they should be?
 Do they feel like they should feel?
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Circulatory and Neurological Evaluation
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Hands should be felt for temperature
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Cold hands indicate decreased circulation
Take pulse – radial artery
 Pinching fingernails can also help detect
circulatory problems (capillary refill)
 Hand’s neurological functioning should also be
tested (sensation and motor functioning)
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Is it nerve?
What other test is
common for nerve
injury?
How else can you
detect a neural injury?
What test is this?
Is it the ligaments or
joints?
Which tests are these?
What are some distinguishing
characteristics of a ligament or joint
injury?
Is it muscle or tendon?
How do you assess the function
of a muscle?
What are some distinguishing
characteristics of a muscle
injury?
What test assesses
these structures?
Is it bone?
What is are distinguishing signs of a potential fractures?
Case study #1
A 28 year old woman complains of pain
in the right hand over the last 3 months.
She reports numerous FOOSH
incidents and currently works as a
cashier at a grocery store. The pain
awakens her at night and is relieved
only by vigorous rubbing of her hand
and motion of the fingers and wrist.
There is some tingling in the index and
middle fingers. What is your
assessment plan?
Case study #2
A 18 year old boy reports with wrist pain and
swelling on the dorsum of his wrist and hand.
He notes the pain is more near the base of
the thumb. He is an active weightlifter. He
says he tripped and experienced a FOOSH
while playing recreational football. He states
that after the injury the wrist hurt, he rested 2
days and iced, the pain decreased, but then
with weightlifting the swelling has developed
the last 5 days. Now it is very swollen and
painful. What is your assessment plan?
Case study #3
A 22 year old golfer comes to you with pain
along his right medial wrist. He reports that
while on spring break he went skiing and had
a FOOSH. The wrist was achy but didn’t
bother after a few hours especially since he
put snow on it for 20 minutes. Now that he
has returned to school and golf practice he is
having trouble controlling his drives and long
iron shots because of pain in his wrist at the
top of the swing. What is your assessment
plan?