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Wrist Anatomy
Bones
Quiz - Whatbones comprisethe wrist?
Joints
Quiz - What jointscomprise the
wrist?
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Carpal Bones and
ArticulationsProximal 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 tohand)
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Articulations and ROM
Distal Radioulnar joint
Supination and Pronation 80-90o
Ulna moves posteriorly and laterally with pronationRadiocarpal joint (and Ulnocarpal joint)
Flexion (80-90o) and Extension (75-85o)
Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints
Gliding
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Soft tissue of Wrist
Ligaments
Covered by a fibrous
capsule
Radial and ulnarcollateral
limit ulnar and radial
deviation; collectively
limits flexion and
extension
Intercarpal and
Carpometacarpal
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Soft tissue of Wrist
Ligaments Dorsal limits flexion
Dorsal Radiocarpal
Palmar - limitextension Transverse carpal
ligament
Palmar radiocarpal
Multiple divisions
Palmar ulnocarpalligament
Multiple divisions
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Soft tissue of Wrist
Cartilage Triangular Fibrocartilage
Complex TFCC
Meniscus betweenulna and triquetrum
Ulnar collateral ligamentand palmar ulnocarpalligaments haveattachments
Compressed withPronation andExtension
Compressed with Ulnardeviation
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Muscle Tissue of Wrist
Extensor muscles
Extensor
Retinaculum Whats 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 ulnarnerve
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FLEXORSEXTENSORS
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Wrist and Hand Anatomy
Nerves/Vessels Radial & ulnar artery and veins
Radial, ulnar, & median nerves
Carpal Tunnel -
Flexor Tendons - 9 Median Nerve
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Wrist Injuries
Strains 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
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Wrist Injuries
deQuervains Disease - thumb/wrist
stenosing tenosynovitis of the extensor
pollicis
brevis and abductor pollicis longus.
S/S: crepitation, tenderness, strength loss.
Special Test: = Finkelsteins test
Tx: RICE, NSAIDs
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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
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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 laxityand Varus test compresses and causes pain
Immobilization and Surgery are often necessary
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Neural Injuries
Carpal Tunnel Syndrome Compression of median nerve
Fibrosis of the synovium of flexor tendons secondary totenosynovitis
MOI: Insidious onset with repetitive wrist movement (andfinger movement); Acute onset with trauma; Progressivedegeneration
S/S: numbness palmar thumb, index,
middle fingers, dull ache, weak finger
flexion (grip). May worsen with sleep. Poor posture may predispose.
Special Tests: Tinels sign
and Phalens
Tx: Conservative (PRICE, NSAIDs) and Surgical
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Neural InjuriesBikers 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
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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
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Wrist InjuriesWrist Fractures
Distal Radius/Ulna
Colles Fracture
MOI: hyperextension-fall on outstretched
S/S: silver fork deformity - radius & ulna posteriorly Smiths Fracture (Reverse Colles)
MOI: hyperflexed
S/S: garden spade deformity - radius
& ulna anteriorly
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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 withoverpressure
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
Preisers Disease
Surgery may be necessary
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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(Murphyssign), Paresthesia of middle finger, weak fingerflexion
Risk: Untreated or repeated trauma Kienbocks Disease
Decreased grip, pain with ulnar deviation,weak extension, pain with passive 3rdfinger extension
Immobilization 6-8 weeks; Surgery may be
necessary
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Wrist Injury Prevention
Good technique!
Butthese help
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Lumbricals
123
4PalmarInterossei
DorsalInterossei
Flexortendonarrangement
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Extensor Hood, Long extensor
tendon, and lateral bands
Finger flexortendons
Unique fingerLook at pulley
system
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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
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Range of Motion
Carpometacarpal Flexion (70-80o)/Extension
Abduction (70-80o)/Adduction
OppositionMetacarpophalangeal Flexion (85-105o)/Extension (20-35o)
Abduction/Adduction (20-25o)
Interphangeal joints Thumb flexion (80-90o)
PIP flexion (110-120o)
DIP flexion (80-90o)
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Palpation
Metacarpals and joints
Collateral ligaments of MCPs
Phalanges and joints Collateral ligaments of PIPs and DIPs
Thenar compartment
muscles
Thenar webspace
musclesCentral compartment
Palmar fascia and muscles
Hypothenar compartment
muscles
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Pathology
Tendon pathology
Trigger Finger/Thumb
Mallet Finger
Boutonniere Deformity Jersey Finger
Dupuytrens Contracture
Swan Neck Deformity
Joint pathology Sprains
Bony pathology
Fractures
Dislocations
Dupuytrens Contracture
Swan Neck Deformity
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Tendon pathology
Trigger Finger or Thumb Etiology
Repeated motion of fingers may cause irritation, producingtenosynovitis
Inflammation of tendon sheath (flexortendons of wrist, fingers andthumb, 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 NSAIDs
Ultrasound and ice are also beneficial
Injection
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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
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Tendon pathology
Boutonniere Deformity Etiology
Rupture ofextensor tendon dorsalto 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
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Tendon pathology
Jersey Finger Etiology
Rupture offlexor 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 poorgliding of tendon, w/ possibility of re-rupture
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Tendon pathology
Dupuytrens Contracture
Etiology
Nodules develop in palmer aponeurosis,limiting finger extension - ultimately causing
flexion deformity
Signs and Symptoms
Often develops in 4th or 5th finger (flexiondeformity)
Management
Tissue nodules must be removed as they can
ultimately interfere w/ normal hand function
Dupuytrens Contracture
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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 = passivehyperextension
Management
RICE and analgesics
Splint in PIP 20-30 degrees of flexion/DIP extension
for 3 weeks; followed by buddy taping
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Joint pathology
Sprains Phalanges Etiology
Phalanges are prone to sprains caused bydirect blows or twisting
Signs and Symptoms Recognition primarily occurs through history
Sprain symptoms - pain, severe swelling and
hemorrhaging
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Joint pathology
Gamekeepers 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 untilpain free
Splint should extend from wrist to end of thumb in neutral position
Thumb spica should be used following splinting for support
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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 mayassist healing process
Taping can be used for support
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Joint pathology
PIP Dorsal Dislocation Etiology
Hyperextension thatdisrupts volar plate atmiddle phalanx
Signs and Symptoms Pain and swelling over PIP
Obvious deformity,disability and possibleavulsion
Management Treated w/ RICE, splinting
and analgesics followed byreduction
After reduction, finger issplinted at 20-30 degreesof flexion for 3 weeks --followed by buddy taping
PIP Palmar Dislocation Etiology
Caused by twist while it issemiflexed
Signs and Symptoms Pain and swelling over PIP;
point tenderness overdorsal side
Finger displays angular orrotational deformity
Management Treat w/ RICE, splinting
and analgesics followed byreduction
Splint in full extension for4-5 weeks after which it isprotected for 6-8 weeksduring activity
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Open Dislocation
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Joint pathology
MCP Dislocation
Etiology
Caused by twisting or shearing force Signs and Symptoms
Pain, swelling and stiffness at MCP joint
Proximal phalanx is angulated at 60-90
degrees Management
RICE, following reduction splinting in slightflexion (3 weeks)
Buddy taping following splinting
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Bony Pathology
Metacarpal Fracture
Etiology
Direct axial force or compressive force
Fractures of the 5th metacarpal = BoxersFracture
Signs and Symptoms
Pain and swelling; possible angular or rotational
deformity Management
RICE, analgesics are given followed by X-rayexaminations
Deformity is reduced, followed by splinting - 4
weeks of splinting after which therapy starts
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Bony pathology
Bennetts 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 willindicate fracture
Athlete will complain of pain and swelling over the
base of the thumb Management
Structurally unstable and must be referred to anorthopedic surgeon
Surgery and immobilization season ending
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Bony pathology
Distal Phalangeal Fracture
Etiology
Crushing force Signs and Symptoms
Complaint of pain and swelling of distal phalanx
Subungual hematoma is often seen in this
condition 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
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
Deformit - immobilization for 3-4 weeks and a
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Bony pathology
Proximal Phalangeal Fracture
Etiology
May be spiral or angular Signs and Symptoms
Complaint of pain, swelling, deformity
Inspection reveals varying degrees of deformity
Management RICE and analgesics are given as needed
Fracture stability is maintained byimmobilization of the wrist in slight
extension, MCP in 70 degrees of flexion andbudd ta in
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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
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 chronicrespiratory disease
Spooning or depression = chronic alcoholism or vitamin deficiency
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Prevention of Hand
InjuriesProtection
Gloves, Grips, Braces
Proper Technique Sport and Ergonomics
Physical Conditioning
Reps and Sets for muscles of Hand Theraputty, Wrist curls/extensions, Fist pumps
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Problem Solving
Putting it together withCase studies
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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?
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Observation
Functional Evaluation Range of motion in all movements of wrist should
be assessed
Active, resistive and passive motions should beassessed 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 isabsent
Become a palm reader?
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Palpation
Bony and Soft Tissue PalpationAre they where they should be?
Do they feel like they should feel?
Circulatory and Neurological Evaluation Hands should be felt for temperature
Cold hands indicate decreased circulation
Take pulse radial artery
Pinching fingernails can also help detectcirculatory problems (capillary refill)
Hands neurological functioning should also betested (sensation and motor functioning)
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Is it nerve?
What test is this?
What other test is
common for nerve
injury?
How else can you
detect a neural injury?
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Is it the ligaments or
joints?
Which tests are these?
What are some distinguishing
characteristics of a ligament or joint
injury?
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Is it muscle or tendon?
What test assesses
these structures?
What are some distinguishing
characteristics of a muscleinjury?
How do you assess the function
of a muscle?
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Is it bone?
What is are distinguishing signs of a potential fractures?
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Case study #1
A 28 year old woman complains of painin the right hand over the last 3 months.
She reports numerous FOOSHincidents and currently works as acashier at a grocery store. The painawakens her at night and is relieved
only by vigorous rubbing of her handand motion of the fingers and wrist.There is some tingling in the index andmiddle fingers. What is your
assessment plan?
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Case study #2
A 18 year old boy reports with wrist pain andswelling 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. Hesays he tripped and experienced a FOOSHwhile playing recreational football. He statesthat after the injury the wrist hurt, he rested 2
days and iced, the pain decreased, but thenwith weightlifting the swelling has developedthe last 5 days. Now it is very swollen andpainful. What is your assessment plan?
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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 didnt
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 ishaving trouble controlling his drives and long
iron shots because of pain in his wrist at the
top of the swing. What is your assessment