chpt24forarm fingers

8/13/2019 Chpt24forarm Fingers

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The Forearm Wrist Handand Fingers

Chapter 24


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Forearm Anatomy

Radius and Ulna: Elbow

Joints: radioulnar joint (superior, middle,and distal)

Bone: proximal radial head, olecranon process,radial shaft, ulnar shaft, distal radius, radialstyloid process, ulnar head, ulnar styloid

Musculature: flexors& pronators (lie anteriorly.ulnar side), extensors & supinators (lieposteriorly, medial side)

Nerve/Blood Supply: median and radial nerveand brachial, radial, and ulnar artery


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Forearm Assessment

History

Observation

Visually inspect, including wrsit and elbow

If no deformity present, observe while theysupinate and pronate

PalpationSpecial Tests


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Management of Forearm

Injuries

ContusionEtiology:direct blowWhy more common to ulna?

Signs and SymptomsManagement

Forearm SplintsEtiology: repeated severe static contraction

Signs and Symptoms:dull ache between extensors,

interosseous membraneManagement: early season vs late in season?

Note: Acute / Chronic exertional compartmentsyndrome: deep compartment most common andassociated with avulsions, distal radius fracture, or

crushing injuries; management same as in lower leg


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Colles fractureEtiology: FOA, forces radius and ulna back and up =

hyperextension

Signs and Symptoms (posterior displacement)Management

Reverse Colles = fall on back of hand

Forearm Fractures

EtiologySigns and Symptoms: more common for radius and ulna

to fracture simultaneously

Management


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Wrist, Hand, and Finger

Anatomy

Bones: carpals and metacarpals

Joints: radiocarpal, carpal, metacarpal, andphalangeal joints

Ligaments: many at each joint in the handTFCC (triangular fibrocartilage complex); b/t head of

ulna and triquetrial bone

Musculature: many intrinsic and extrinsicmuscles

Blood and Nerve Supply: ulnar, median, radialnerve and radial and ulnar superficial and deep

palmar arch arteries.


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Assessment of Wrist,

Hand, and Finger Injuries

History

Observation

PalpationSpecial Tests: Finklesteins test, Tinels

Sign, Phalens test, valgus and varusstress test,

Circulatory and Neurological EvaluationAllen test

Functional Evaluation


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Special Tests

Finklesteins TestDe Quervains (tenosynovitis)

Thumb tucked inside fist with ulnar deviation

Tinels Sign Tap over transverse carpal ligament

Pain numbness and tingling indicates median nerve disruption andpresence of carpal tunnel

Phalens Test Carpal tunnel

Bilateral wrist flexion and press them together; pain is positive sign

Valgus/varus at wrist, MCP, and IP joints Circulatory / neurological evaluationsAllen's test: test function of radial and ulnar arteries

Athlete makes fist 4-5 times; while holding final fist, evaluator pinchesoff both arteries; hand should be blanched

Release arties individually


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of Wrist, Hand, and Finger

Injuries

Wrist Sprain

Etiology

Signs and Symptoms

Management Triangular Fibrocartilage Complex Injury

Etiology:forced hyperextension orcompression of radioulnar joint and proximal

row of carpalsSigns and Symptoms

Management


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Tenosynovitis

Etiology: repeated wrist acceleration anddeceleration

Signs and Symptoms: pain w/ passive stretchingManagement: may need splinting and

strengthening

Tendinitis

Etiology: repetitive pulling motions and pressureon palm of hand

Signs and Symptoms:pain with AROM and passivestretching

Management

Nerve Compression, Entrapment, PalsyEtiology: median (carpal tunnel) and ulnar

(pisiform and hamate)

Signs and Symptoms:deformities(bishops, clawand drop wrist)

Management: if chronic, may require surgical


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Carpal Tunnel SyndromeTunnel = pink

Bones = white

Ligament = blue

Carpal tunnel syndrome

Etiology: repeatedflexion

Signs and Symptoms:sensory and motorimpairment

Management

Recognition and Management


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Recognition and Managementof Wrist, Hand, and Finger

Injuries

Dislocation of the LunateBone

Etiology:forcedhyperextension of wrist

Signs andSymptoms:difficultywith wrist and fingerflexion; may haveimpaired nerves

Management: referralfor reduction

Hamate Fracture

Etiology: contact whileholdingsomething(racket)

Signs and Symptoms

Management

Wrist Ganglion(synovialcyst)

Etiology:herniation ofjoint capsule or tendon

Signs and Symptoms

Management


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De Quervains Disease

Etiology:tenosynovitis of

thumbSigns and

Symptoms

Management


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Scaphoid FractureEtiology: compression of scaphoid

b/t radius and ulna

Concerns: portion of scaphoid hasdecreased vascular supply; improperhealing can occur and result in asepticnecrosis of the scaphoid bone

Signs and SymptomsAnatomical snuffbox pain

Management


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Finger anatomy

Bones

LigamentsPIP and DIP have the same

design

Collateral ligaments,palmar fibrocartilage, andloose posterior capsule orsynovial membrane(protected by extensorexpansion)
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Finger anatomy

MusculaturePIP: Flex. Digitorium Superficialis

DIP: Flex. Digitorium Profundus

PIP & DIP: Exten. Digitorium Longus (becomesextensor expansion after MCP)

Intrinsics:

Dorsal and palmar interosseei:

Lumbricals:volar surface; MCP flex., IP exten.

Thenar (4 that act on thumb) & hypothenar (4that act on 5th)


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Recognition and Management of

Wrist, Hand, and Finger Injuries Contusion to hand and fingers

Etiology

Signs and Symptoms: fingernail?

Management

Bowlers Thumb

Etiology: fibrosis of the ulnar digital nerveform pressure

Signs and Symptoms:pain, numbness, tingling

Management: pad area, decrease activity;

surgery PRN Jersey finger

Etiology:FDP rupture, grabbing jersey

Signs and Symptoms:DIP cannot flex

Management:SURGERY


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Trigger finger or thumb

Etiology: stenosing tendon by repeatedmovements

Signs and Symptoms: resistance to re-extension after thumb and finger flexed

Management:possible injections; splinting

Dupuytrens Contracture

Etiology: idiopathic development of nodules inpalmer aponeurosis

Signs and Symptoms:flexion deformity; cannotextend

Management: surgical removal


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Boutonniere deformity Etiology:rupture of

extensor tendondorsal to middlephalanx; trauma to tipof finger causes DIPextension and PIPflexion

Signs and Symptoms:

cannot extendManagement:splint

PIP in extension 5-8wks.


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Swan neck deformityAKA

Pseudoboutonniere

Etiology:severehyperextension;injury to volar plate

Signs andSymptoms:hyperextension of

PIPManagement:

splint 20-30degrees flexion 3wks


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Gamekeepers Thumb

Etiology:UCL ofthumb; forced

abductions, anhyperextension

Signs andSymptoms:inabilityto pinch; pain with

stressManagement:splint

3 weeks; protectwith activity


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Recognition and Management of

Wrist, Hand, and Finger Injuries

Sprains, Dislocations, andFractures

Etiology

Signs and SymptomsManagement

Sprains PIP and DIP joint

Etiology

Signs and Symptoms

Management

PIP Doral Dislocation

Etiology:twist whilesemiflexed

Signs and Symptoms

Management:splint inext

PIP Dorsal dislocation

Etiology:hyperext.

Signs and

symptoms:deformity;inability to move

Management:reduceand splint 20-30degrees flex

R iti d M t f W i t


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Recognition and Management of Wrist,

Hand, and Finger Injuries MCP dislocation

Etiology:twist an shear force

Signs and Symptoms:prox. Phalanx dorsal 60-90degrees

Management: reduce; splint; early ROM

Metacarpal fracture

Etiology:compressive axial forceSigns and Symptoms:appear angular or rotated

Management: reduce and splint

Bennetts Fracture

Etiology:thumb CMC; axial and ABD force to thumbSigns and Symptoms:base of thumb painful

Management:refer to surgeon due to unstablenature


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Distal/Middle/Proximal phalangeal fracture

Etiology:crushing force; direct trauma or twist

Signs and Symptoms: subungual hematoma subungualhematoma

Management:drain and splint / buddy tape; control pain Fingernail deformity

Occur for variety of reasons:Scaling or ridgingpsoriasis

Ridging or poor developmenthyperthyroidism

Clubbing and cyanosis-chronic respiratory disease or heart disorderSpooning or depression- chronic alcoholism and vitamin

deficiencies

R h bilit ti P i i l f


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Rehabilitation Principles for

the Forearm, Wrist, Hand, and

FingersGeneral Body Conditioning

Joint Mobilization:traction and mobilization helprestore ROM

Flexibility: full ROM is measure of good rehab

Strength:equal

Neuromuscular Control:great dexterity required

Return to Activity: Goals: full dexterity, fullROM, full strength

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