KIN 191B – Advanced KIN 191B – Advanced Assessment of Upper Assessment of Upper

Extremity InjuriesExtremity Injuries

Wrist, Hand and Finger Evaluation and Pathologies

HistoryHistory

HistoryHistory

Location of painMechanism of injury/etiologyUnusual sounds/sensationsOnset/duration and description of

symptomsPrior history/general health concerns

Location of PainLocation 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

Mechanism of InjuryMechanism 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

Unusual Sounds or SensationsUnusual 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

Onset/Duration and Description Onset/Duration and Description of Symptomsof Symptoms

Type of pain (ache, throb, etc.)

Intensity of pain (objectify)

Immediate vs. gradual onset of symptoms

Changes in symptoms (better, worse)

Prior History and General Prior History and General Health ConcernsHealth 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)

Inspection/ObservationInspection/Observation

Inspection/ObservationInspection/Observation

General inspection

Inspection of wrist and hand

Inspection of thumb and fingers

General InspectionGeneral Inspection

Hand posture– 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

Inspection of Wrist and HandInspection of Wrist and Hand

Distal radioulnar continuityCarpal and metacarpal continuity/contourMP joint alignment

– Depressed knuckle = Boxer’s fractureWrist and hand posturing

– Neurovascular conditions may prompt abnormalities (drop wrist, Volkmann’s ischemic contracture)

Inspection of Wrist and HandInspection 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

Inspection of Thumb and FingersInspection 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

Skin and Fingernail Skin and Fingernail ConditionsConditions

PalpationPalpation

PalpationPalpation

Wrist and finger flexors

Wrist and finger extensors

Bony anatomy– Non-carpal bones– Carpal bones

Ligamentous and intrinsic muscular structures

Wrist and Finger FlexorsWrist and Finger Flexors

Flexor carpi ulnaris tendon

Flexor carpi radialis tendon

Tendons of finger flexors– Superficialis vs. profundus

Palmaris longus tendon

Wrist and Finger ExtensorsWrist 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

Anatomic SnuffboxAnatomic Snuffbox

Non-Carpal Bony AnatomyNon-Carpal Bony Anatomy

Distal radius/radial styloid process

Lister’s tubercle (dorsal and distal radius)

Ulnar head/ulnar styloid process

Metacarpals

Phalanges

Carpal Bony AnatomyCarpal Bony Anatomy

Scaphoid– 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

Carpal Bony AnatomyCarpal Bony Anatomy

Trapezium– 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 proximal hypothenar eminence on palm

Ligamentous and Intrinsic Ligamentous and Intrinsic Muscular AnatomyMuscular 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 eminenceHypothenar eminence

Range of MotionRange of Motion

Range of MotionRange 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

Wrist Ranges of MotionWrist Ranges of Motion

Flexion – normally 80-90 degrees, firm end feel

Extension – normally 75-85 degrees, firm end feel

Radial deviation – normally 20 degrees, hard end feel (scaphoid on radial styloid)

Ulnar deviation – normally 35 degrees, firm end feel

Wrist Ranges of MotionWrist Ranges of Motion

Thumb Ranges of MotionThumb Ranges of Motion

Flexion – normally 60-70 degrees, soft end feel

Extension – 0 degrees, firm end feel

Abduction – 70-80 degrees, firm end feel

Adduction – 0 degrees, soft end feel

Opposition – flexion/adduction/rotation, touch thumb to little finger, firm end feel

Thumb MotionsThumb Motions

Finger Ranges of MotionFinger Ranges of Motion

MP joints– Flexion – 85-105 degrees, hard end feel (proximal

phalanges on distal metacarpal)– Extension – 20-30 degrees, firm end feel– Abduction/adduction – total of 20-25 degrees, firm end

feel IP/PIP/DIP joints

– Flexion – IP: 80-90 degrees, PIP: 110-120 degrees, DIP: 80-90 degrees, firm end feels except PIP is hard end feel (middle phalanges on proximal phalanges)

– Extension – 0 degrees, firm end feels

Ligamentous/Capsular TestingLigamentous/Capsular Testing

Ligamentous/Capsular TestingLigamentous/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

Neurovascular EvaluationNeurovascular Evaluation

Neurological EvaluationNeurological Evaluation

Peripheral nerve distributions– Median, ulnar and radial nerve sensory and

motor functions

Nerve root level distributions– Dermatomes and myotomes

Vascular EvaluationVascular Evaluation

Radial artery

Capillary refill

Skin temperature and color

Allen test?

PathologiesPathologies

PathologiesPathologies

Wrist injuries

Hand injuries

Finger injuries

Thumb injuries

Wrist InjuriesWrist Injuries

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

Wrist SprainsWrist 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

TFCC InjuryTFCC 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

TFCC InjuryTFCC Injury

Carpal Tunnel SyndromeCarpal 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)

Carpal Tunnel SyndromeCarpal 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

Phalen’s TestPhalen’s Test

Wrist FracturesWrist 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

Colles’ FractureColles’ Fracture

Smith’s FractureSmith’s Fracture

Scaphoid FractureScaphoid 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

Scaphoid FractureScaphoid Fracture

Scaphoid FractureScaphoid 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

Perilunate and Lunate Perilunate and Lunate DislocationsDislocations

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)

Perilunate DislocationPerilunate 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

Perilunate DislocationPerilunate Dislocation

Lunate DislocationLunate 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

Lunate DislocationLunate Dislocation

Perilunate and Lunate Perilunate and Lunate DislocationsDislocations

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

Neurological InjuriesNeurological 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

Hand and Finger InjuriesHand and Finger Injuries

Metacarpal fractures

Collateral ligament injuries

Posturing and deformities

Finger fractures

Dislocations

Metacarpal FracturesMetacarpal 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

Boxer’s FractureBoxer’s Fracture

Metacarpal FracturesMetacarpal Fractures

Metacarpal FracturesMetacarpal 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

Collateral Ligament InjuriesCollateral Ligament Injuries

Etiology is acute force applicationPresent with localized pain/swelling, ROM

limited due to pain/swellingVarus and valgus stress tests often not

informative unless 3rd degree injuryGenerally conservatively managed with

splint and symptomatic treatment

Posturing and DeformitiesPosturing and Deformities

Ape hand Bishop’s deformity Claw hand Dupuytern’s contracture Swan neck deformity Volkmann’s ischemic contracture Boutonniere deformity Trigger finger

Posturing and DeformitiesPosturing 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

Dupuytren’s ContractureDupuytren’s Contracture

Flexion contracture of MP and PIP joints from shortening/adhesions in palmar aponeurosis – most common at 4th and 5th fingers

Swan-Neck DeformitySwan-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

Volkmann’s Ischemic ContractureVolkmann’s Ischemic Contracture

Flexion contracture of wrist and fingers from decreased blood supply to forearm muscles secondary to fracture, dislocation or compartment syndrome

Boutonniere DeformityBoutonniere 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

Trigger FingerTrigger 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

Trigger FingerTrigger Finger

Finger FracturesFinger Fractures

Distal phalanx most commonly fractured due to flexor/extensor tendon attachments (avulsion) and crushing trauma

Middle phalanx uncommonly injuredProximal phalanx injury usually not isolated

and has associated tendon and/or skin injuryPresentation and treatment similar to

metacarpal fracture discussion

Finger FractureFinger Fracture

Finger FracturesFinger 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

Mallet FingerMallet Finger

Jersey FingerJersey Finger

Finger DislocationsFinger 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

Finger DislocationsFinger Dislocations

Thumb InjuriesThumb Injuries

DeQuervain’s syndrome

Sprains

MP joint dislocations

Fractures

DeQuervain’s SyndromeDeQuervain’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

DeQuervain’s SyndromeDeQuervain’s Syndrome

Finkelstein’s TestFinkelstein’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

Finkelstein’s TestFinkelstein’s Test

Thumb SprainsThumb 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

Thumb SprainsThumb 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

11stst MP Joint UCL Sprain MP Joint UCL Sprain

11stst MP Joint Dislocation 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

Thumb DislocationThumb Dislocation

Thumb FracturesThumb 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

Bennett’s FractureBennett’s Fracture