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Wrist and Hand Unit

Wrist and Hand Unit. Anatomy, Injuries, Evaluations, Treatments, and Rehabilitation. Anatomy of wrist. Bones: carpals and metacarpals Joints: radiocarpal, carpal, metacarpal, and phalangeal joints Ligaments: “many at each joint in the hand”

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Wrist and Hand Unit

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  1. Wrist and Hand Unit Anatomy, Injuries, Evaluations, Treatments, and Rehabilitation

  2. Anatomy of wrist • Bones: carpals and metacarpals • Joints: radiocarpal, carpal, metacarpal, and phalangeal joints • Ligaments: “many at each joint in the hand” • Musculature: “many intrinsic and extrinsic muscles” • Blood and Nerve Supply: ulnar, median, radial nerve and radial and ulnar superficial and deep palmar arch arteries

  3. Radiocarpal joints:condyloid jt. Permits flex/ext, abd/add, circum. Carpal joints:gliding jts. Stabilized by ant/post interosseous lig. Metacarpal joints: 5 bones forming the MCP jt Condyloid jt. But the thumb is a saddle jt. Phalangeal joints: interphalangeal is a hinge jt. Ext/flex only Wrist ligaments: Radius=radial collateral lig attaches the radial styloid to the scaphoid Ulna=ulnar collateral lig. Attaches the ulnar styloid to thepisiform and triquetral bone Transverse carpal lig. = roof of the carpal tunnel Phalangeal ligaments: PIP/DIP joint same ligaments as the wrist. Volar plate on the palmar surface of the phalange Extensor expansion= sheath that expands over the dorsal surface of the phalange. Wrist and hand joints

  4. Assessment of Wrist, Hand, and Finger Injuries • History • Observation • Palpation • Special Tests: Finklestein’s test, Tinel’s Sign, Phalen’s test, valgus and varus stress test, Glide test, Lunotriquetral Ballotment test • Circulatory and Neurological Evaluation • Allen test • Functional Evaluation

  5. Carpal Tunnel Syndrome • Carpal tunnel syndrome • Etiology: transverse carpal lig. Is the roof of the tunnel, 8 long flexor tendons and median N pass through this. Over use of wrist flexion and sometimes a direct blow can cause this. • Signs and symptoms: tingling, numbness over the thumb, 2-3 phalanges, and palm of the hand. Also thumb weakness • Management: rest, immobilization, NSAID’s then surgery to relieve the compression by cutting the transverse carpal lig.

  6. Carpal Tunnel

  7. Carpal Tunnel

  8. Injuries of the wrist • Wrist Sprain • Etiology: Falling on hyperextended wrist most common but you can fall on a flexed wrist • Signs and Symptoms: pain, swelling, limited ROM • Management: Severe sprain go for x-ray. For mod/minor injury RICE and start exercise ASAP • Triangular Fibrocartilage Complex Injury (TFCC) • Etiology: fall on an outstretched hand in hyperextension that compresses the TFCC between radioulnar jt and carpals. UCL involved • Signs and Symptoms: pain along the ulnar side of the wrist, swelling and pain in wrist extension • Management: referred to physician. If not properly managed, permanent loss of motion and disability canoccur.

  9. Tenosynovitis • Etiology: occurs to extensor carpi rad. Longus/brevis mainly in wt. Lifters and rowers chronic injury of repetitive use • Signs and Symptoms: pain in passive stretching and swelling and tenderness • Management: RICE and NSAID’s, along with increase ROM exercises in contrast baths. US • Tendinitis • Etiology: common flexor carpi rad./ulnaris= overuse • Signs and Symptoms:pain in active/passive stretching • Management: Same as above

  10. Nerve Compression, Entrapment, Palsy • Etiology:direct blow- median/ulnar nerve is involved. Median N is compressed in the carpal tunnel. Unlar N is compressed in the tunnel of Guyon (pisiform and hook of the hamate • Signs and Symptoms: sharp, burning pain with possibility of numbness. Ulanr N= Bishops/Benediction hand 4/5th finger is flexed • Ulnar/median n= claw hand distal phalanx flexed, median N= drop wrist or ape hand 2-5 distal phalanx flexed and thumb extended • Management: RICE, NSAID’s or surgery for decompression

  11. Fractured wrist

  12. Dislocation of the Lunate Bone • Etiology: Most common of the carpals. Fall on an outstretched hand. Dislocated anteriorly (palmar side) • Signs and Symptoms: pain, swelling, difficult to flex fingers/wrist • Management: send to Dr. to reduce dislocation, 1-2 months recovery.

  13. Scaphoid Fracture • Etiology: most frequent fx. Force on the outstretched hand. • Signs and Symptoms: swelling, pt. Tender over anatomical snuffbox. Pain in radial flexion. • Management: Ice, splint, and early immobilization. If not aseptic necrosis might occur because of very poor blood supply.

  14. Scaphoid Fracture

  15. Hamate Fracture • Etiology: direct contact to the wrist while holding a a sports implement: tennis racket, bat, golf club. • Signs and Symptoms: wrist pain, weakness, pt. Tender over hamate. • Management: cast.

  16. Wrist Ganglion • Etiology: synovial cyst, most commonly on the back of the wrist • Signs and Symptoms: occasional pain, lump, • Management: direct pressure, US, or surgery

  17. Mallet Finger • Etiology: blow to the tip of the finger rupturing the extensor tendon. • Signs and Symptoms: pain about the DIP jt. Unable to extend the finger. • Management: RICE splinted in extension.

  18. Mallet finger

  19. Boutonnière Deformity • Boutonniere deformity • Etiology:rupture of the extensor tendon dorsal to the middle phalanx. Direct blow to an ext. DIP/ flexed PIP joint • Signs and Symptoms: inability to to extend PIP joint. • Management: splint the PIP in extension. Ice applied

  20. Boutonnière

  21. Gamekeeper’s thumb • Etiology: sprain of the ulnar collateral lig. MCP jt. Forceful abduction • Signs and Symptoms: pain over the MCP, unable to pinch • Management: refer to orthopedist, splint, ice, possible surgery.

  22. Gamekeeper’s thumb

  23. Collateral Lig. Sprain, volar plate rupture, central slip tear • Etiology: PIP/DIP sprains, volar plate rupture, central slip tear • Signs and Symptoms: pain, loss of function, swelling, deformity • Management: RICE, x-ray, splinting, taping later

  24. PIP Dorsal dislocation • Etiology: Hyperext. With volar plate rupture direct blow to finger • Signs and Symptoms: deformity, pain, swelling • Management: Rice, Dr for reduction, splinting of 20-30 degrees of flexion for three weeks. Then buddy taping

  25. MCP dislocation • Etiology: twisting or shear force • Signs and Symptoms: pain, swelling, and stiffness of the MCP joint and prox. Phalanx is dorsally angulated 60-90 degrees • Management: Rice, splinting, Dr. reduced, buddy taped and given early ROM

  26. Metacarpal fracture • Etiology: axial loading, fifth MC from boxing • Signs and Symptoms: pain deformity, angular/rotational deformity • Management: RICE splinting, Dr. splint for 4 weeks • Bennett’s Fracture • Etiology: Carpometacarpal CMC jt. Of the thumb. • Signs and Symptoms: pain swelling over the base of the thumb • Management: referred to orthopedic surgeon, ice, splint

  27. De Quervain’s Disease( Hoffman’s disease) • Etiology: stenosing tenosynovitis in the thumb. First tunnel of the wrist narrows and inflamed synovial lining. Muscle involved would be the extensor pollicis brevis and abductor pollicis longus. Constant wrist movement can be a source of irritation • Signs and Symptoms: aching pain that radiates into the hand or forearm. Movement of the wrist causes pain. (+)Finklestein test. Muscle weakness of the thumb extensors and abduction. Possible snapping/catching of the tendons during movement • Management: immobilization,rest, cryotherapy, and NSAID’s. US and Ice massage

  28. Dupuytren’s Contracture • Etiology: Unknown how it happens. Nodules develop over the palmar aponeurosis that limit finger extension and cause a flexion deformity • Signs and Symptoms: 4th/5th finger stays in flexion • Management: nodules removed surgically

  29. Trigger finger or thumb • Etiology:repeated movement of tendons causes tenosynovitis. Common areas involve the ext. carpi ulnaris, ext. pollicis longus/brevis, abductor pollicis longus. • Signs and Symptoms: pain while flexing thumb or finger. In ability to extend finger or thumb produces a snapping sensation. • Management: same as Dequervain’s disease, steroid injection or splinting last resort.

  30. Trigger finger

  31. Swan neck deformity • Etiology: The volar plate of the PIP jt. Is most commonly injured from a severe hyperextension force. • Signs and Symptoms: pain, swelling at PIP jt and volar plate. More movement of hyperextension of the PIP jt compared to others • Management: Rice, splinting at 20-30 degrees of flexion for 3 weeks

  32. Swan neck deformity

  33. Jersey finger • Etiology: rupture of flexor digitorum profundus. From grabbing a jersey. 4th phalange most commonly injured • Signs and Symptoms: pain, pt tenderness, unable to flex distal phalanx • Management: splint and surgery.

  34. Fingernail deformity • Scaling or ridging= psoriasis • Ridging and poor development= hyperthyroidism • Clubbing and cyanosis= congenital heart disorders or chronic respiratory disease • Spooning or depression= chronic alcoholism or vitamin deficiencies

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