Wrist Anatomy

BonesQuiz - What

bones comprise the wrist?

JointsQuiz - What joints

comprise the wrist?

Carpal Bones and Articulations

Proximal Row Where can you

palpate these? Scaphoid Lunate Triquetrum Pisiform

Radiocarpal joint Ulnocarpal joint

Intercarpal joints

Distal Row Where can you

palpate these? Trapezium Trapezoid Capitate Hamate

Intercarpal joints Carpometacarpal

joints (related to hand)

Articulations and ROM

Distal Radioulnar joint Supination and Pronation – 80-90o

Ulna moves posteriorly and laterally with pronation

Radiocarpal joint (and Ulnocarpal joint) Flexion (80-90o) and Extension (75-85o) Radial (20o) and Ulnar (35o) Deviation

Intercarpal joints Gliding

Soft tissue of WristLigaments Covered by a fibrous

capsule Radial and ulnar

collateral limit ulnar and radial

deviation; collectively limits flexion and extension

Intercarpal and Carpometacarpal

Soft tissue of Wrist

Ligaments Dorsal – limits flexion

Dorsal Radiocarpal Palmar - limit

extension Transverse carpal

ligament Palmar radiocarpal

Multiple divisions Palmar ulnocarpal

ligament Multiple divisions

Soft tissue of Wrist

Cartilage Triangular Fibrocartilage

Complex – TFCC “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 Extensor

Retinaculum What’s its function?

Muscles innervated by radial nerve

There are 8 Name them…

Flexor Muscles Flexor retinaculum

(aka transverse carpal ligament)

Two compartments Superficial – 4 Deep – 3 Name them…

Innervated by median and ulnar nerve

FLEXORSEXTENSORS

Wrist and Hand AnatomyNerves/Vessels Radial & ulnar artery and veins Radial, ulnar, & median nerves

Carpal Tunnel - Flexor Tendons - 9 Median NerveMedian Nerve

Wrist InjuriesStrains Onset usually acute – FOOSH or Overexertion S/S: Active ROM limited

Wrist Ganglion Herniation of the joint capsule or synovial sheath

of a tendon.

Tx: Bible Therapy

Wrist InjuriesdeQuervain’s Disease - thumb/wriststenosing tenosynovitis of the extensor

pollicis

brevis and abductor pollicis longus.S/S: crepitation, tenderness, strength loss. Special Test: = Finkelstein’s testTx: RICE, NSAIDs

Wrist Injuries

Sprains Onset is usually acute – FOOSH or overexertion Often diagnosed when other injuries are ruled out

Both active and passive ROM are effected

S/S: Laxity, pain, swelling, limited ROM Pain is usually with overstretching

Special Tests: Varus/Valgus, Carpal Glide PRICE, Rehabilitation, Taping for prevention

Wrist Injuries

Triangular Fibrocartilage Injuries - TFCC 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 InjuriesCarpal Tunnel Syndrome Compression of median nerve

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

Neural InjuriesBiker’s Palsy 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 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 InjuriesWrist Fractures Distal Radius/Ulna

Colles’ Fracture MOI: hyperextension-fall on outstretched S/S: “silver fork deformity” - radius & ulna posteriorly

Smith’s Fracture (Reverse Colles) MOI: hyperflexed S/S: “garden spade deformity” - radius

& ulna anteriorly

Wrist Injuries

Wrist Fractures Scaphoid - most common carpal

MOI: fall on outstretched hand S/S: wrist aches, pain in anatomical

snuff box,

painful handshake or with overpressure

Tx: Splint, Referral, Ice Plain X-rays may not be enough Immobilization (long and/or short) –

12 weeks Risk: aseptic necrosis and non-

union fractures Preiser’s Disease Surgery may be necessary

Wrist Injuries

Wrist Dislocations Radius or Ulna Lunate is very common

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

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!But…these help

Lumbricals

1234

Palmar Interossei

Dorsal Interossei

Flexor tendon arrangement

Extensor Hood, Long extensor tendon, and lateral bands

Finger flexor tendons

Unique finger

Look at pulley

system

Observation

Relaxed position of hand Fingers slightly flexed

Relative shortness of finger flexors

Skin and Nail health Discoloration, texture, hair patterns

Finger alignment Tips of fingers should align with finger flexion

Hand abnormalities Finger and metacarpal positioning Muscle atrophy

Range of motion

Range of Motion

Carpometacarpal Flexion (70-80o)/Extension Abduction (70-80o)/Adduction Opposition

Metacarpophalangeal Flexion (85-105o)/Extension (20-35o) Abduction/Adduction (20-25o)

Interphangeal joints Thumb flexion (80-90o) PIP flexion (110-120o) DIP flexion (80-90o)

Palpation

Metacarpals and joints Collateral ligaments of MCPs

Phalanges and joints Collateral ligaments of PIPs and DIPs

Thenar compartment muscles

Thenar webspace muscles

Central compartment Palmar fascia and muscles

Hypothenar compartment muscles

Pathology

Tendon pathology Trigger Finger/Thumb Mallet Finger Boutonniere Deformity Jersey Finger Dupuytren’s Contracture Swan Neck Deformity

Joint pathology Sprains

Bony pathology Fractures Dislocations

Dupuytren’s Contracture

Swan Neck Deformity

Tendon pathology

Trigger Finger or Thumb Etiology

Repeated motion of fingers may cause irritation, producing tenosynovitis

Inflammation of tendon sheath (flexor tendons of wrist, fingers and thumb, abductor pollicis)

Thickening forming a nodule that does not slide easily Signs and Symptoms

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

Immobilization, rest, cryotherapy and NSAID’s Ultrasound and ice are also beneficial Injection

Tendon pathology

Mallet Finger (baseball or basketball finger) Etiology

Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion

Avulses extensor digitorum at distal phalanx Signs and Symptoms

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

RICE and splinting in hyperextension for 6-8 weeks

Tendon pathology

Boutonniere Deformity Etiology

Rupture of extensor tendon dorsal to the middle phalanx – bone passes through central slip

Forces DIP joint into extension and PIP into flexion Signs and Symptoms

Severe pain, obvious deformity and inability to extend DIP joint

Swelling, point tenderness Management

Cold application, followed by splinting in PIP extension and DIP flexion

Splinting must be continued for 5-8 weeks

Tendon pathology

Jersey Finger Etiology

Rupture of flexor digitorum profundus tendon from insertion on distal phalanx

Often occurs w/ ring finger when athlete tries to grab a jersey

Signs and Symptoms DIP can not be flexed, finger remains extended Pain and point tenderness over distal phalanx

Management 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 ContractureEtiology

Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity

Signs and SymptomsOften develops in 4th or 5th finger (flexion deformity)

ManagementTissue nodules must be removed as they can

ultimately interfere w/ normal hand function

Dupuytren’s Contracture

Tendon pathology

Swan Neck Deformity Etiology Distal tear of volar plate or finger trauma may cause

Swan Neck deformity Flexed MCP, extended PIP, and flexed DIP

Signs and Symptoms Pain, swelling w/ varying degrees of hyperextension Tenderness over volar plate of PIP Indication of volar plate tear = passive hyperextension

Management RICE and analgesics Splint in PIP 20-30 degrees of flexion/DIP extension for

3 weeks; followed by buddy taping

Joint pathology

Sprains PhalangesEtiology

Phalanges are prone to sprains caused by direct blows or twisting

Signs and SymptomsRecognition primarily occurs through historySprain symptoms - pain, severe swelling and

hemorrhaging

Joint pathology

Gamekeeper’s Thumb Etiology

Sprain of UCL of MCP joint of the thumb Mechanism is forceful abduction of proximal phalanx occasionally

combined w/ hyperextension Signs and Symptoms

Pain over UCL in addition to weak and painful pinch Management

Immediate follow-up must occur 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 Thumb spica should be used following splinting for support

Joint pathology

Sprains of Interphalangeal Joints of Fingers Etiology

Can include collateral ligament, volar plate, extensor slip tears Occurs w/ axial loading or valgus/varus stresses

Signs and Symptoms Pain, swelling, point tenderness, instability Valgus and varus tests may be possible

Management 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 Etiology

Hyperextension that disrupts volar plate at middle phalanx

Signs and Symptoms Pain and swelling over PIP Obvious deformity,

disability and possible avulsion

Management 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

PIP Palmar Dislocation Etiology

Caused by twist while it is semiflexed

Signs and Symptoms Pain and swelling over PIP;

point tenderness over dorsal side

Finger displays angular or rotational deformity

Management 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 DislocationEtiology

Caused by twisting or shearing forceSigns and Symptoms

Pain, swelling and stiffness at MCP jointProximal phalanx is angulated at 60-90 degrees

ManagementRICE, following reduction splinting in slight flexion

(3 weeks)Buddy taping following splintingTherapy

Bony Pathology

Metacarpal Fracture Etiology

Direct axial force or compressive force Fractures of the 5th metacarpal = Boxer’s Fracture

Signs and Symptoms Pain and swelling; possible angular or rotational deformity

Management RICE, analgesics are given followed by X-ray

examinations Deformity is reduced, followed by splinting - 4 weeks of

splinting after which therapy starts Unstable fracture may need to be surgically pinned

Bony pathology

Bennett’s Fracture Etiology

Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb

Signs and Symptoms 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

Structurally unstable and must be referred to an orthopedic surgeon

Surgery and immobilization – season ending

Bony pathology

Distal Phalangeal FractureEtiology

Crushing forceSigns and Symptoms

Complaint of pain and swelling of distal phalanxSubungual hematoma is often seen in this condition

ManagementRICE and analgesics are givenProtective splint is applied as a means for pain reliefSubungual hematoma is drained

Bony pathology

Middle Phalangeal Fracture Etiology

Occurs from direct trauma or twist Signs and Symptoms

Pain and swelling w/ tenderness over middle phalanx Possible deformity; X-ray will show bone displacement

Management RICE and analgesics No deformity - buddy tape w/ splint for activity Deformity - immobilization for 3-4 weeks and a protective

splint for an additional 9-10 weeks during activity

Bony pathology

Proximal Phalangeal FractureEtiology

May be spiral or angularSigns and Symptoms

Complaint of pain, swelling, deformity Inspection reveals varying degrees of deformity

ManagementRICE and analgesics are given as neededFracture stability is maintained by immobilization of

the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping

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 referralR/O trauma to tendons and nervesPrevent infectionSuture to ensure minimal scarring

Finger Nail Pathology

Subungual Hematoma MOI: finger caught between two surfaces Presents with bleeding under nail bed Draining – Drill or Cauterize

Paronychia 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

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

ProtectionGloves, Grips, Braces

Proper TechniqueSport and Ergonomics

Physical ConditioningReps and Sets for muscles of Hand

Theraputty, Wrist curls/extensions, Fist pumps

Problem Solving

Putting it together with

Case studies

History 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 Range of motion in all movements of wrist should be

assessed Active, resistive and passive motions should be assessed

and compared bilaterally Wrist - flexion, extension, radial and ulnar deviation

Wrist “attitude” How do the carpals and metacarpals align with the distal

radius and ulna? Is there symmetry?

How are those tendons looking? Is there a palmaris longus? - 10% of population it is absent

Become a “palm reader”?

Palpation

Bony and Soft Tissue PalpationAre they where they should be?Do they feel like they should feel?

Circulatory and Neurological EvaluationHands should be felt for temperature

Cold hands indicate decreased circulationTake pulse – radial arteryPinching fingernails can also help detect

circulatory problems (capillary refill)Hand’s neurological functioning should also be

tested (sensation and motor functioning)

Is it nerve?

What test is this?

What other test is common for nerve injury?

How else can you detect a neural injury?

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?

What test assesses these structures?

What are some distinguishing characteristics of a muscle injury?

How do you assess the function of a muscle?

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?