Wrist, Hand, & Fingers Injury Assessment

1. Wrist, Hand, & FingersInjury Assessment HEAT 4685 Chapter 15, p.519

2. Clinical AnatomyP. 519 • Bony Anatomy • Radius • styloid process • Ulna • styloid process • ulnar head • Carpals (8) • Proximal row: N, L,T, P • Distal row: T,T,C,H • Metacarpals (5)

3. Clinical Anatomy p.520 • Ligamentous Anatomy • Radial collateral ligament • limits ulnar deviation • taut in full flexion & extension • Ulnar collateral ligament • limits radial deviation • taut in full flexion & extension

4. Clinical Anatomy p. 520 • Ligamentous Anatomy • Palmar radio-carpal ligament complex • limits wrist hyperextension • Dorsal radiocarpal ligament • only major dorsal ligament • limits wrist flexion • Palmar ulnocarpal ligament • limits hyperextension • Intercarpal ligaments • maintains alignment of carpals

5. Clinical Anatomy p. 528 • Carpal Tunnel • Fig. 15-8, p. 528 • Transverse ligament • 10 structures pass through tunnel

6. Evaluation: History p.528 • Location of pain • localized pain? • radiating pain? • referred pain? • Mechanism of injury • acute vs.. chronic pain • hyperflexion vs. hyperextension • Sounds & sensations • pops/snaps/crepitus • numbness/tingling/burning

7. History--p. 528 • PMH • systemic disease (diabetes, rheumatoid arthritis, etc) • other upper extremity/cervical spine injury?

8. Observation/Inspection--p. 530 • Posturing of the hand-- • tendon avulsions/neuro. Injuries • Pathological Postures—p.531 • Obvious deformity in fingers/wrist-- • dislocations/fractures • alignment, knuckles, with/without motion • Murphy’s sign • Boxer’s fracture

9. Observation/Inspection--p. 530 • Palmar creases-- • lost with edema • decreased with Down’s Syndrome • Lacerations/scars--superficial structures easily damaged • Ganglion cysts • Thenar/hypothenar eminence (p. 535)

10. Finger Inspection—p.532 • Felon • Infection distal to DIP joint • Inflammation of distal phalanx • Treat with antibiotics • Subungual Hematoma • Entrapped hematoma • Lumina present? • Treat quickly to reduce pain • Paronychia • Peripheral nailbed infection • Inflammation with possible drainage • Treat with antibiotics and warm soaks

11. Palpation-- p. 533, 536-537 • pisiform (5th) • hook of the hamate (4th) • palmaris longus • p. 533, fig. 15-14 • present? • scaphoid • navicular • “anatomical snuffbox”—p.535, fig. 15-16 • lunate (dorsal--3rd)

12. Functional Tests--p. 537 • Wrist ROM—Box 15-3, p. 538 • flexion>extension • ulnar deviation>radial deviation • Thumb ROM—p.543 • flexion/extension • abduction/adduction • opposition • Finger ROM—Box 15-4, p. 539 • flexion/extension • abduction/adduction

13. Pathologies • Wrist/Hand • Fingers • Thumb

14. Wrist/Hand Pathologies

15. Wrist/Hand Sprains--p.553 , Table 15-5 • History: • acute onset (FOOSH) • excessive ROM • Observation • occasional localized edema • limited AROM in flex/ext (?) • (-) x-rays • Palpation: • localized tenderness • usually no deformity or crepitus • Examination: • all other pathologies r/o • Overpressure in PROM • no specific laxity testing

16. Collateral Ligament Sprains--p.548 • History: • acute onset (FOOSH) • excessive ROM • Observation • occasional localized edema • limited AROM in flex/ext (?) • (-) x-rays • Palpation: • localized tenderness • usually no deformity or crepitus • Examination: • Glide test • Box 15-10, p.550 • Varus/valgus testing • fig. 15-9, p. 549

17. Triangular Fibrocartilage Complex Sprains--(TFCC)—553& Table 15-6, p. 554 • History: • acute onset • wrist hyperext. Mechanism • often accompanies UCL injury • pain inc. with activity • Observation: • diffuse swelling • persistent nagging injury • Palpation: • Medial jointline tenderness • possible UCL tenderness • limited extension (AROM & PROM) • Examination: • (+) valgus stress test • (+) glide test

18. Carpal Tunnel Syndrome--p. Table 15-7, p. 554 • History: • usually slow onset • usually repetitive stress mechanism • c/o tingling & numbness into hand • Observation: • generalized palmar edema • symptoms dec. with altered activity • Palpation: • generalized palmar tenderness • dec. sensation along median nerve dermatome • dec. wrist AROM/PROM • weakened thumb ABD • Examination: • (+) Tinel sign at carpal tunnel • (+) Phalen’s test • fig. 15-13, p. 555

19. Lunate dislocation--Table 15-10, p. 558 • History: • forced hyperextension (FOOSH) • hears/feels a “pop” • c/o pain at lateral wrist/hand • possible paresthesia • Observation: • (+) Murphy sign • obvious bulge dorsal or palmar • Palpation: • obvious deformity • possible crepitus • scaphoid fx? • Examination: • Palpation • x-ray to r/o scaphoid fx

20. Wrist Fractures--p. 555 • History: • FOOSH injury • distal radius/ulna pain • heard/felt pop • immediate loss of function • Observation: • obvious deformity • Colles fx--distal radius moves dorsally • Smith’s fx--distal radius moves palmarly • Rapid swelling • Palpation: • obvious deformity • Probable crepitus • Examination: • x-ray referral

21. Navicular/scaphoid fracture--p.556 • History: • hyperextension mechanism • pain at snuffbox • possible crepitus • Observation: • false (+) x-ray • often no significant deformity • Palpation: • pain at anatomical snuffbox • reduced wrist ext. (pain) • crepitus possible • Examination: • x-rays • snuffbox tenderness • percussion test of thumb--> snuffbox pain • monitor for necrosis

22. Navicular/scaphoid fracture--p.556

23. Metacarpal fx--p.559 & Table 15-11, p. 560 • Compression mechanism • pop with immediate pain • immediate localized swelling/deformity • AROM may be possible! • (+) percussion test

24. Finger Pathologies--p.560

25. Boutonniere deformity--p.560 • History: • mechanism: longitudinal force to phalanx • acute or chronic • inability to extend PIP • Observation: • obvious deformity at PIP • maintained DIP extension with PIP flexion • Palpation: • click/pop with AROM at PIP • tenderness at dorsal PIP

26. Finger Fractures--p.561 • Mallet finger-- • dorsal PIP avulsion fx • forced flexion from ext. • inability to actively ext. PIP • Jersey finger • palmar PIP avulsion fx • forced ext. from flexion • inability to actively flex PIP

27. Dislocations--p.551, Box 15-11 • History-- • longitudinal/varus/ valgus stress • felt a pop • obvious deformity • Observation: • obvious deformity at IP joint • immediate swelling • possible fx seen on x-ray • Palpation: • possible crepitus with AROM & PROM • tender at jointline • Examination: • (+) varus or valgus stress test

28. IP Dislocations--

29. Thumb Pathologies--p.562

30. Bennett’s fx--p. 563 • History: • similar to other metacarpal fx • fx at articular surface of CMC • Observation: • limited AROM • fx seen on x-ray • severe loss of function • Palpation: • Tender at CMC jointline • Possible crepitus • Examination: • (+) percussion test • May need surgical fixation

31. deQuervain’s syndrome--Table 15-12, p. 562 • History: • gradual onset • repetitive stress • c/o pain at radial styloid and thenar eminence radiating into forearm • Observation: • lateral forearm edema (distal radius) • dec. AROM at wrist & thumb--esp. deviation • Palpation: • tenderness at abductor tendons of thumb • possible crepitus with radial deviation • Examination • Finklestein’s test • Box 1514, p. 563

32. Thumb sprains--p.562 & Table 15-13, p. 564 • History: • Gamekeeper’s thumb/skier’s thumb • UCL sprain • hyperabduction or hyperextension mech. • acute or gradual onset • c/o medial thumb pain • Observation: • thenar eminence edema • guarded presentation (in adduction) • Palpation: • possible crepitus with AROM/PROM • tenderness at ulnar border of thumb • extreme weakness in ADDuction • Examination: • hyperabduction • (+) pinch test • x-rays • Possible Sx

33. Thumb sprains--