© 2011 mcgraw-hill higher education. all rights reserved. chapter 24: the forearm, wrist, hand and...

© 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 24: The Forearm, Wrist, Hand and Fingers

Anatomy of the Forearm


Figure 24-1


Blood and Nerve Supply

• Most of the flexors are supplied by the median nerve

• Most of the extensor are controlled by the radial nerve

• Blood is supplied by the radial and ulnar arteries


Assessment of the Forearm

• History– What was the cause?– What were the symptoms at the time of

injury, did they occur later, were they localized or diffuse?

– Was there swelling and discoloration?– What treatment was given and how does it

feel now?– Any previous injury to your forearm?


• Observation– Visually inspect for deformities, swelling

and skin defects– Range of motion– Pain w/ motion

• Palpation– Palpated at distant sites and at point of

injury– Can reveal tenderness, edema, fracture,

deformity, changes in skin temperature, a false joint, bone fragments or lack of bone continuity


•Palpation: Bony and Soft Tissue

• Proximal head of radius

• Olecranon process• Radial shaft• Ulnar shaft• Distal radius and

ulna• Radial styloid• Ulnar head• Ulnar styloid

• Distal radioulnar joint

• Radiocarpal joint

• Extensor retinaculum

• Flexor retinaculum

• Extensor carpi radialis longus and brevis

• Extensor carpi ulnaris

• Brachioradialis

• Extensor pollicis longus and brevis


•Palpation (continued)

• Abductor pollicis longus

• Extensor indicus supinator

• Flexor carpi radialis• Palmaris longus• Flexor digitorum

superficialis• Flexor digitorum

profundus

• Flexor pollicis longus

• Pronator quadratus• Pronator teres


Recognition and Management of Injuries to the Forearm

• Contusion– Etiology

• Ulnar side receives majority of blows due to arm blocks

• Can be acute or chronic • Result of direct contact or blow

– Signs and Symptoms• Pain, swelling and hematoma• If repeated blows occur, heavy fibrosis and

possibly bony callus could form w/in hematoma© 2011 McGraw-Hill Higher Education. All rights reserved.

• Contusion (continued)– Management

• Proper care in acute stage involves RICE and followed up w/ additional cryotherapy

• Protection is critical - full-length sponge rubber pad can be used to provide protective covering


• Forearm Splints– Etiology

• Forearm strain - most come from severe static contraction

– Signs and Symptoms• Dull ache between extensors which cross posterior

aspect of forearm• Weakness and pain w/ contraction• Point tenderness in interosseus membrane

– Management• Treat symptomatically• Patient should focus on strengthening forearm• Treat w/ cryotherapy, wraps, or heat if condition

persists• Can develop compartment syndrome in forearm as

well and should be treated like lower extremity© 2011 McGraw-Hill Higher Education. All rights reserved.

• Forearm Fractures– Etiology

• Common in youth due to falls and direct blows

• Ulna and radius generally fracture individually

• Fracture in upper third may result in abduction deformity due pull of pronator teres

• Fracture in lower portion will remain relatively neutral

• Older patients may experience greater soft tissue damage and greater chance of paralysis due to Volkmann's contracture

– Signs and Symptoms• Audible pop or crack followed by moderate to

severe pain, swelling, and disability

• Edema, ecchymosis w/ possible crepitus


• Management– Initially RICE

followed by splinting until definitive care is available

– Long term casting followed by rehab plan

Figure 24-3


• Colles’ Fracture– Etiology

• Occurs in lower end of radius or ulna

• MOI is fall on outstretched hand, forcing radius and ulna into hyperextension

• Less common is the reverse Colles’ fracture (Smith fracture)

– Anterior displacement of distal fragment

• Intraarticular fracture is referred to as a Barton fracture


– Signs and Symptoms• Forward displacement of radius causing visible

deformity (silver fork deformity)• When no deformity is present, injury can be

passed off as bad sprain• Extensive bleeding and swelling• Tendons may be torn/avulsed and there may

be median nerve damage

– Management• Cold compress, splint wrist and refer to

physician• X-ray and immobilization• Severe sprains should be treated as fractures• In children, injury may cause lower epiphyseal

separation


• Madelung Deformity– Etiology

• Developmental deformity of the wrist• Associated with changes in radius, ulna and

carpal bone results in palmar and ulnar wrist subluxations

• Common in females• Carpals become wedged between radius and

ulna following epiphyseal plate changes

– Signs and Symptoms• Bowing of radius and ulna evident on X-ray• Wrist pain and loss of forearm rotation• Palmar subluxation with prominence of radius

and ulnar styloid processes


• Madelung Deformity (continued)– Management

• Therapeutic modalities and NSAID’s for pain

• Wrist can be taped or braced to prevent wrist extension

• Typically corrected surgically in patients with chronic pain and disability


Figure 24-5

Anatomy of the Wrist, Hand and Fingers


Figure 24-7


Figure 24-8


Figure 24-9 A & B


•Blood and Nerve Supply

• Three major nerves– Ulnar, median and

radial

• Ulnar and radial arteries supply the hand– Two arterial arches

(superficial and deep palmar arches)

Figure 24-11


Assessment of the Wrist, Hand and Fingers

• History– Past history– Mechanism of injury– When does it hurt?– Type of, quality of, duration of, pain?– Sounds or feelings?– How long were you disabled?– Swelling?– Previous treatments?


• Observation– Postural deviations– Is the part held still, stiff or protected?– Wrist or hand swollen or discolored?– General attitude– What movements can be performed fully

and rhythmically?– Thumb to finger touching– Color of nail beds


•Palpation: Bony

• Scaphoid• Trapezoid• Trapezium• Lunate• Capitate• Triquetral• Pisiform• Hamate (hook)• Metacarpals 1-5

• Proximal, middle and distal phalanges of the fingers

• Proximal and distal phalanges of the thumb


•Palpation: Soft Tissue

• Triangular fibrocartilage

• Ligaments of the carpals

• Carpometacarpal joints and ligaments

• Metacarpophalangeal joints and ligaments

• Proximal and distal interphalangeal joints and ligaments

• Flexor carpi radialis

• Flexor carpi ulnaris

• Lumbricale muscles

• Flexor digitorum superficialis and profundus

• Palmer interossi

• Flexor pollicis longus and brevis

• Abductor pollicis brevis

• Opponens pollicis

• Opponens digiti minimi


•Palpation: Soft Tissue

• Extensor carpi radialis longus and brevis

• Extensor carpi ulnaris• Extensor digitorum• Extensor indicis• Extensor digiti minimi• Dorsal interossi• Extensor pollicis brevis

and longusAbductor pollicis longus


• Special Tests– Finklestein’s Test

• Test for de Quervain’s syndrome• Athlete makes a fist w/ thumb tucked inside• Wrist is ulnarly deviated• Positive sign is pain indicating stenosising

tenosynovitis• Pain over carpal tunnel could indicate carpal tunnel

syndrome


Figure 24-12

• Special Tests– Tinel’s Sign

• Produced by tapping over transverse carpal ligament

• Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome


Figure 24-13

• Phalen’s Test– Test for carpal tunnel

syndrome– Position is held for

approximately one minute

– If test is positive, pain will be produced in region of carpal tunnel

Figure 24-14


– Valgus/Varus and Glide Stress Tests• Tests used to assess ligamentous integrity of

joints in hands and fingers• Valgus and varus tests are used to test

collateral ligaments• Anterior and posterior glides are used to

assess the joint capsule


Figure 24-15

• Lunotriquetral Ballottement Test– Stabilize lunate while

sliding the triquetral anteriorly and posteriorly

– Assessing laxity, pain and crepitus

– Positive test indicates instability that often results in dislocation of the lunate

Figure 24-16


– Circulatory and Neurological Evaluation• Hands should be felt for temperature

– Cold hands indicate decreased circulation

• Pinching fingernails can also help detect circulatory problems (capillary refill)

• Allen’s test can also be used – Patient is instructed to clench fist 3-4 times, holding it

on the final time– Pressure applied to ulnar and radial arteries– Patient then opens hand (palm should be blanched)– One artery is released and should fill immediately

(both should be checked)

• Hand’s neurological functioning should also be tested (sensation and motor functioning)


• Functional Evaluation– Range of motion in all movements of wrist

and fingers should be assessed– Active, resistive and passive motions should

be assessed and compared bilaterally• Wrist - flexion, extension, radial and ulnar

deviation• MCP joint - flexion and extension• PIP and DIP joints - flexion and extension• Fingers - abduction and adduction• MCP, PIP and DIP of thumb - flexion and

extension• Thumb - abduction, adduction and opposition• 5th finger - opposition


Recognition and Management of Injuries to the Wrist, Hand

and Fingers• Wrist Sprains

– Etiology• Most common wrist injury• Arises from any abnormal, forced movement• Falling on hyperextended wrist, violent flexion

or torsion• Multiple incidents may disrupt blood supply

– Signs and Symptoms• Pain, swelling and difficulty w/ movement


– Management• Refer to physician for X-ray if severe• RICE, splint and analgesics• Have patient begin strengthening soon after

injury• Tape for support can benefit healing and

prevent further injury


• Triangular Fibrocartilage Complex

(TFCC) Injury– Etiology

• Occurs through forced hyperextension, falling on outstretched hand

• Violent twist or torque of the wrist• Often associated w/ sprain of UCL

– Signs and Symptoms• Pain along ulnar side of wrist, difficulty w/ wrist

extension, possible clicking• Swelling is possible, not much initially• Patient may not report injury immediately


– Management• Referred to physician for treatment• Treatment will require immobilization initially for

4 weeks• Immobilization should be followed by period of

strengthening and ROM activities• Surgical intervention may be required if

conservative treatments fail


• Tenosynovitis– Etiology

• Cause of repetitive wrist accelerations and decelerations

• Repetitive overuse of wrist tendons and sheaths

– Signs and Symptoms• Pain w/ use or pain in passive stretching• Tenderness and swelling over tendon

– Management• Acute pain and inflammation treated w/ ice

massage 4x daily for first 48-72 hours, NSAID’s and rest

• When swelling has subsided, ROM is promoted• Ultrasound and phonophoresis can be used• PRE can be instituted once swelling and pain

subsided© 2011 McGraw-Hill Higher Education. All rights reserved.

• Tendinitis– Etiology

• Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris; repetitive pressure on palms (cycling) can cause irritation of flexor digitorum

• Primary cause is overuse of the wrist– Signs and Symptoms

• Pain on active use or passive stretching• Isometric resistance to involved tendon produces

pain, weakness or both– Management

• Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and rest

• When swelling has subsided, ROM is promoted w/ contrast bath

• PRE can be instituted once swelling and pain subsided (high rep, low resistance)


• Nerve Compression, Entrapment, Palsy– Etiology

• Median and ulnar nerve compression • Result of direct trauma to nerves

– Signs and Symptoms• Sharp or burning pain associated w/ skin sensitivity or

paresthesia• May result in benediction/ bishop’s deformity• (damage to the ulnar nerve) or claw hand deformity

(damage to both nerves)• Palsy of radial nerve produces drop wrist deformity

caused by paralysis of extensor muscles• Palsy of median nerve can cause ape hand (thumb

pulled back in line w/ other fingers)

– Management• Chronic entrapment may cause irreversible damage• Surgical decompression may be necessary


Figures 24-19 to 22


Bishop or Benediction

Hand

Claw Hand

Drop Wrist

Ape Hand

• Carpal Tunnel Syndrome– Etiology

• Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel

• Result of repeated wrist flexion or direct trauma to anterior aspect of wrist

– Signs and Symptoms• Sensory and motor deficits (tingling, numbness and

paresthesia); weakness in thumb

– Management• Conservative treatment - rest, immobilization,

NSAID’s• If symptoms persist, corticosteroid injection may be

necessary or surgical decompression of transverse carpal ligament


• de Quervain’s Disease (Hoffman’s disease)– Etiology

• Stenosing tenosynovitis in thumb (extensor pollicis brevis and abductor pollicis longus

• Constant wrist movement can be a source of irritation

– Signs and Symptoms• Aching pain, which may radiate into hand or

forearm• Positive Finklestein’s test• Point tenderness and weakness during thumb

extension and abduction; painful catching and snapping


• de Quervain’s Disease (Hoffman’s disease)– Management

• Immobilization, rest, cryotherapy and NSAID’s• Ultrasound and ice are also beneficial• Joint mobilizations have been recommended to

maintain ROM


• Dislocation of Lunate Bone– Etiology

• Forceful hyperextension or fall on outstretched hand

– Signs and Symptoms• Pain, swelling, and difficulty executing wrist and finger

flexion• Numbness/paralysis of flexor muscles due to

pressure on median nerve

– Management• Treat as acute, and sent to physician for reduction• If not recognized, bone deterioration could occur,

requiring surgical removal• Usual recovery is 1-2 months


Figure 24-24

• Kienböck's Disease– Etiology

• Loss of blood supply to lunate bone resulting in osteonecrosis

– Signs and Symptoms• Pain, swelling, with decreases in ROM

• Decreased grip strength

• Tenderness over the bone (middle of the dorsum of the wrist)

– Management• Early treatment involves immobilization and

NSAID’s

• Operative treatment may be required if conservative treatment fails

– May involve wrist bone fusion or bone removal


• Scaphoid Fracture– Etiology

• Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones

• Often fails to heal due to poor blood supply

– Signs and Symptoms• Swelling, severe pain in

anatomical snuff box

• Presents like wrist sprain

• Pain w/ radial flexion


Figure 24-25

• Scaphoid Fracture– Management

• Must be splinted and referred for X-ray prior to casting

• Immobilization lasts 6 weeks and is followed by strengthening and protective tape

• Wrist requires protection against impact loading for 3 additional months


Figure 24-25

• Hamate Fracture– Etiology

• Occurs as a result of a fall or more commonly from contact while athlete is holding an implement

– Signs and Symptoms• Wrist pain and weakness, along w/ point

tenderness• Pull of muscular attachment can cause non-

union

– Management• Casting wrist and thumb is treatment of choice• Hook of hamate can be protected w/ doughnut

pad to take pressure off area


• Hamate Fracture– Management

• Casting wrist and thumb is treatment of choice

• Hook of hamate can be protected w/ doughnut pad to take pressure off area


Figure 24-26

• Wrist Ganglion– Etiology

• Synovial cyst (herniation of joint capsule or synovial sheath of tendon)

• Generally appears following wrist strain

– Signs and Symptoms• Appear on back of wrist generally• Occasional pain w/ lump at site• Pain increases w/ use• May feel soft, rubbery or very hard


• Wrist Ganglion– Management

• Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing

• New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad

• Ultrasound can be used to reduce size

• Surgical removal is most effective treatment method


Figure 24-27

• Contusion and Pressure Injuries of Hand and Fingers– Etiology

• Result of blow or compression of bones w/in hand and fingers

– Signs and Symptoms• Pain and swelling of soft tissue

– Management• Cold compression until hemorrhaging has ceased• Follow w/ gradual warming - soreness may still be

present -- padding may also be necessary• Bruising of distal phalanx can result in subungual

hematoma - extremely painful due to build-up of pressure under nail

– Pressure must be released once hemorrhaging has ceased


• Trigger Finger or Thumb– Etiology

• Repeated motion of fingers may cause irritation, producing tenosynovitis

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

• Thickening occurs w/in the sheath, 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• Same treatment as de Quervain’s disease -- if

unsuccessful, injection and splinting are last options


• Extensor Tendon Avulsion (Mallet Finger)– Etiology

• Caused by a blow to tip of finger avulsing extensor tendon from insertion

• Also referred to as baseball or basketball finger

– Signs and Symptoms• Pain at DIP; X-ray shows

avulsed bone on dorsal proximal distal phalanx

• Unable to extend distal end of finger (carrying at 30 degree angle)

• Point tenderness at sight of injury

– Management• RICE and splinting for 6-8 weeks


Figure 24-29

• Boutonniere Deformity– Etiology

• Rupture of extensor expansion dorsal to the middle phalanx

• Tendon slides below axis of PIP jointForces DIP joint into extension and PIP into flexion

– Signs and Symptoms• Severe pain, obvious deformity and inability to

extend DIP joint• Swelling, point tenderness


• Boutonniere Deformity– Management

• Cold application, followed by splinting• Splinting must be continued for 5-8 weeks• Athlete is encouraged to flex distal phalanx


Figure 24-30

• Flexor Digitorum Profundus Rupture (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


• Dupuytren’s Contracture– Etiology

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

– Signs and Symptoms• Often develops in 4th or 5th

finger (flexion deformity)

– Management• Tissue nodules must be

removed as they can ultimately interfere w/ normal hand function


Figure 24-32

• 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

Figure 24-33


– 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• If a complete tear occurs, surgical repair is

necessary to allow normal function to return


• Sprains of Interphalangeal Joints – Etiology

• Can include collateral ligament, volar plate, extensor expansion tears

• Occurs w/ axial loading or valgus/varus stresses

– Signs and Symptoms• Pain, swelling, point tenderness, instability• Valgus and varus tests may be positive

– 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


• Swan Neck Deformity and PsuedoBoutonniere Deformity– Etiology

• Distal tear of volar plate may cause Swan Neck deformity; proximal tear may cause PsuedoBoutonniere deformity

– 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 20-30 degrees of flexion for 3 weeks; followed by buddy taping and then PRE


• 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 digit 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


• 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, splinting following reduction• Buddy taping and given early ROM following

splinting


• Metacarpal Fracture– Etiology

• Direct axial force or compressive force• Fractures of the 5th metacarpal are associated

w/ boxing or martial arts (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 ROM is carried out


Figure 24-36


• 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• Patient will complain of pain and swelling over

the base of the thumb

– Management• Structurally unstable and must be referred to an

orthopedic surgeon


• 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• Subungual hematoma is drained


• 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/ thermoplastic splint for activity

• Deformity - immobilization for 3-4 weeks and a protective splint for an additional 9-10 weeks during activity


• 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 by

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


• PIP Fractures and Dislocation– Etiology

• Combination of fracture and dislocation is the result of an axial load on a partially flexed finger

– Signs and Symptoms• Condition causes pain and swelling in the region

of the PIP joint• Localized tenderness over the PIP

– Management• RICE, analgesics, followed by reduction of the

fracture• If there is a small fragment, buddy taping is used• Large fragments - splint at 30-60 degrees of

flexion


• Fingernail Deformities– Changes in normal

appearance of the fingernail can be indicative of a number of different diseases

• Scaling or ridging = psoriasis• Ridging and poor development =

nutritional deficiencies• Clubbing and cyanosis =

congenital heart disorders or chronic respiratory disease

• Spooning or depression = thyroid problems, iron deficiency anemia


Figure 24-37

Rehabilitation of the Forearm, Wrist, Hand and Fingers

• General Body Conditioning– Must maintain pre-injury level of

conditioning– Cardiorespiratory, strength, flexibility and

neuromuscular control– Many exercise options (particularly lower

extremity)

• Joint Mobilizations– Wrist and hand respond to traction and

mobilization techniques


• Joint Mobilization (cont.)– Can be used to increase specific ranges of

motion


Figure 24-38

• Flexibility– Full pain free ROM is a major goal of

rehabilitation– The program should include active

assisted and active pain free stretching

• Strength– Exercises should not aggravate condition

or disrupt healing process– A variety of exercises are available for

strength (wrist and hand)


Flexibility Exercises

Figure 24-39


Flexibility Exercises

Figure 24-40


Neural Tension Exercises

Figure 24-41


Figure 24-44 & 45


• Neuromuscular Control– Hand and fingers require restoration of

dexterity• Pinching, fine motor activities (buttoning

buttons, tying shoes, and picking up small objects)

– It is important to incorporate functional activities designed to restore patient’s ability to perform daily activities



• Return to Activity– Grip strength must be equal bilaterally, full

range of motion and dexterity– Thumb has unique strength requirements– A variety of customizable bracing and

splinting devices are available to protect injured wrist and hand

Figure 24-46, 47, 48

© 2011 mcgraw-hill higher education. all rights reserved. chapter 24: the forearm, wrist, hand and...

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