The Forearm, Wrist, Hand, and Fingers

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The Forearm, Wrist, Hand, and 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, radial
  styloid process, ulnar head, ulnar styloid
• Musculature flexors pronators (lie
  anteriorly. ulnar side), extensors supinators
  (lie posteriorly, medial side)
• Nerve/Blood Supply median and radial nerve and
  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 they
  supinate and pronate
• Palpation
• Special Tests

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Recognition and Management of Forearm Injuries

• Contusion
• Etiologydirect blow
• Why more common to ulna?
• Signs and Symptoms
• Management
• Forearm Splints
• Etiology repeated severe static contraction
• Signs and Symptomsdull ache between extensors,
  interosseous membrane
• Management early season vs late in season?
• Note Acute / Chronic exertional compartment
  syndrome deep compartment most common and
  associated with avulsions, distal radius
  fracture, or crushing injuries management same
  as in lower leg

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• Colles fracture
• Etiology FOA, forces radius and ulna back and up
  hyperextension
• Signs and Symptoms (posterior displacement)
• Management
• Reverse Colles fall on back of hand
• Forearm Fractures
• Etiology
• Signs 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, and
  phalangeal joints
• Ligaments many at each joint in the hand
• TFCC (triangular fibrocartilage complex) b/t
  head of ulna and triquetrial bone
• Musculature many intrinsic and extrinsic
  muscles
• Blood and Nerve Supply ulnar, median, radial
  nerve and radial and ulnar superficial and deep
  palmar arch arteries.

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Assessment of Wrist, Hand, and Finger Injuries

• History
• Observation
• Palpation
• Special Tests Finklesteins test, Tinels Sign,
  Phalens test, valgus and varus stress test,
• Circulatory and Neurological Evaluation
• Allen test
• Functional Evaluation

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Special Tests

• Finklesteins Test
• De Quervains (tenosynovitis)
• Thumb tucked inside fist with ulnar deviation
• Tinels Sign
• Tap over transverse carpal ligament
• Pain numbness and tingling indicates median nerve
  disruption and presence 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 evaluations
• Allen's test test function of radial and ulnar
  arteries
• Athlete makes fist 4-5 times while holding final
  fist, evaluator pinches off both arteries hand
  should be blanched
• Release arties individually

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Recognition and Management of Wrist, Hand, and
Finger Injuries

• Wrist Sprain
• Etiology
• Signs and Symptoms
• Management
• Triangular Fibrocartilage Complex Injury
• Etiologyforced hyperextension or compression of
  radioulnar joint and proximal row of carpals
• Signs and Symptoms
• Management

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• Tenosynovitis
• Etiology repeated wrist acceleration and
  deceleration
• Signs and Symptoms pain w/ passive stretching
• Management may need splinting and strengthening
• Tendinitis
• Etiology repetitive pulling motions and pressure
  on palm of hand
• Signs and Symptomspain with AROM and passive
  stretching
• Management
• Nerve Compression, Entrapment, Palsy
• Etiology median (carpal tunnel) and ulnar
  (pisiform and hamate)
• Signs and Symptomsdeformities(bishops, claw and
  drop wrist)
• Management if chronic, may require surgical
  decompression

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• Carpal Tunnel Syndrome
• Tunnel pink
• Bones white
• Ligament blue
• Carpal tunnel syndrome
• Etiology repeated flexion
• Signs and Symptoms sensory and motor impairment
• Management

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Recognition and Management of Wrist, Hand, and
Finger Injuries

• Dislocation of the Lunate Bone
• Etiologyforced hyperextension of wrist
• Signs and Symptomsdifficulty with wrist and
  finger flexion may have impaired nerves
• Management referral for reduction

• Hamate Fracture
• Etiology contact while holding something(racket)
• Signs and Symptoms
• Management
• Wrist Ganglion(synovial cyst)
• Etiologyherniation of joint capsule or tendon
• Signs and Symptoms
• Management

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• De Quervains Disease
• Etiology tenosynovitis of thumb
• Signs and Symptoms
• Management

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Scaphoid Fracture

• Etiology compression of scaphoid b/t radius and
  ulna
• Concerns portion of scaphoid has decreased
  vascular supply improper healing can occur and
  result in aseptic necrosis of the scaphoid bone
• Signs and Symptoms
• Anatomical snuffbox pain
• Management

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Finger anatomy

• Bones
• Ligaments
• PIP and DIP have the same design
• Collateral ligaments, palmar fibrocartilage, and
  loose posterior capsule or synovial membrane
  (protected by extensor expansion)

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Finger anatomy

• Musculature
• PIP Flex. Digitorium Superficialis
• DIP Flex. Digitorium Profundus
• PIP DIP Exten. Digitorium Longus (becomes
  extensor expansion after MCP)
• Intrinsics
• Dorsal and palmar interosseei
• Lumbricalsvolar surface MCP flex., IP exten.
• Thenar (4 that act on thumb) hypothenar (4 that
  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 nerve
  form pressure
• Signs and Symptomspain, numbness, tingling
• Management pad area, decrease activity surgery
  PRN
• Jersey finger
• EtiologyFDP rupture, grabbing jersey
• Signs and SymptomsDIP cannot flex
• ManagementSURGERY

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• Trigger finger or thumb
• Etiology stenosing tendon by repeated movements
• Signs and Symptoms resistance to re-extension
  after thumb and finger flexed
• Managementpossible injections splinting
• Dupuytrens Contracture
• Etiology idiopathic development of nodules in
  palmer aponeurosis
• Signs and Symptomsflexion deformity cannot
  extend
• Management surgical removal

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Boutonniere deformity

• Etiologyrupture of extensor tendon dorsal to
  middle phalanx trauma to tip of finger causes
  DIP extension and PIP flexion
• Signs and Symptoms cannot extend
• Managementsplint PIP in extension 5-8wks.

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• Swan neck deformity
• AKA Pseudoboutonniere
• Etiologysevere hyperextension injury to volar
  plate
• Signs and Symptoms hyperextension of PIP
• Management splint 20-30 degrees flexion 3 wks

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Mallet Finger

• Etiology strike to tip of finger, jamming and
  avulsing extensor tendon
• Signs and Symptoms unable to extend, may palpate
  avulsed bone
• Managementextension splint 6-8 wks

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• Gamekeepers Thumb
• EtiologyUCL of thumb forced abductions, an
  hyperextension
• Signs and Symptomsinability to pinch pain with
  stress
• Managementsplint 3 weeks protect with activity

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Recognition and Management of Wrist, Hand, and
Finger Injuries

• Sprains, Dislocations, and Fractures
• Etiology
• Signs and Symptoms
• Management
• Sprains PIP and DIP joint
• Etiology
• Signs and Symptoms
• Management

• PIP Doral Dislocation
• Etiologytwist while semiflexed
• Signs and Symptoms
• Managementsplint in ext
• PIP Dorsal dislocation
• Etiologyhyperext.
• Signs and symptomsdeformity inability to move
• Managementreduce and splint 20-30 degrees flex

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Recognition and Management of Wrist, Hand, and
Finger Injuries

• MCP dislocation
• Etiologytwist an shear force
• Signs and Symptomsprox. Phalanx dorsal 60-90
  degrees
• Management reduce splint early ROM
• Metacarpal fracture
• Etiologycompressive axial force
• Signs and Symptomsappear angular or rotated
• Management reduce and splint
• Bennetts Fracture
• Etiologythumb CMC axial and ABD force to thumb
• Signs and Symptomsbase of thumb painful
• Managementrefer to surgeon due to unstable
  nature

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• Distal/Middle/Proximal phalangeal fracture
• Etiologycrushing force direct trauma or twist
• Signs and Symptoms subungual hematoma subungual
  hematoma
• Managementdrain and splint / buddy tape control
  pain
• Fingernail deformity
• Occur for variety of reasons
• Scaling or ridging psoriasis
• Ridging or poor development hyperthyroidism
• Clubbing and cyanosis-chronic respiratory disease
  or heart disorder
• Spooning or depression- chronic alcoholism and
  vitamin deficiencies

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Rehabilitation Principles for the Forearm,
Wrist, Hand, and Fingers

• General Body Conditioning
• Joint Mobilizationtraction and mobilization help
  restore ROM
• Flexibility full ROM is measure of good rehab
• Strengthequal
• Neuromuscular Controlgreat dexterity required
• Return to Activity Goals full dexterity, full
  ROM, full strength