WRIST AND HAND INJURIES

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WRIST AND HAND INJURIES
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OBJECTIVES WEEK 10

• OBJECTIVES
• 1. Review anatomy of the wrist and hand.
• 2. Describe the signs and symptoms of acute and
  chronic injuries to the wrist and hand.
• 3. Identify common functional and structural
  issues related to the wrist and hand.
• 4. Perform objective tests on the wrist and
  hand.
• 5. Perform examination on wrist and hand using
  goniometers, and systematic checklists for exam.
• 6. Review of other syndromes and disorders.

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WRIST INJURIES

• ANATOMY
• Wrist/hand has 27 bones and more than 20 joints.
• Anatomical snuffbox (scaphoid bone) is found
  between the extensor pollicis tendon and extensor
  pollicis brevis tendon. Most commonly injured
  wrist bone.
• 5 muscles affect the wrist Flexor carpi
  radialis, palmaris longus (12 of population
  doesnt have one), flexor carpi ulnaris perform
  flexion. Extensor carpi radialis longus and
  Extensor carpi ulnaris perform extension.
• 3 extrinsic muscles affect fingers Extensor
  Digitorum, Flexor digitorum superficialis and
  profundus. 2 smaller ones are the Extensor
  indicis and digiti minimi.
• 11 intrinsic muscles affect fingers
  Lumbricales, 4 dorsal and 3 palmar interossei.
• 8 muscles control the thumb Extensor pollicis
  longus, extensor pollicis brevis, abductor
  pollicis longus/brevis and flexor pollicis
  longus/brevis, opponens pollicis, and adductor
  pollicis.
• 3 muscles affect the little finger Abductor
  digiti minimi, flexor digiti minimi brevis, and
  adductor digiti minimi.

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ACUTE INJURIES

• CONTUSIONS
• Occur commonly but pain and symptoms usually
  subside in a few days.
• SPRAINS
• With so many joints sprains are common usually
  resulting from extended or flexing of the wrist
  beyond normal ROM, falling, jamming wrist on
  blocking or vaulting activities, and twisting
  mechanics. Excessive ulnar and radial deviation
  will also cause injury to ligaments.
• Symptoms include pain, swelling, pt.
  tenderness, pain with active and passive ROM,
  muscular weakness, instability or deformity.
• Gamekeepers thumb or Skiers thumb Involves
  the Collateral ligament of the MCP joint in the
  thumb.
• Occurs with forced abduction and hyperextension
  of the thumb.
• Signs and symptoms include pain, pt.
  tenderness, selling, instability, and weakness
  when gripping
• EXAM Valgus/Varus stress tests
• STRAINS
• Occurs most often in the tendon areas.

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• TENDON AVULSIONS
• Jersey Finger
• Flexion tendon injury to the Flexor Digitorum
  Profundus.
• Caused by forced extension of distal phalanx when
  finger is in flexion. This happens in football
  players when the finger gets caught in a
  jersey.
• Signs and Symptoms immediate pain, swelling and
  point tenderness over the attachment of the
  distal segment. If complete rupture, the finger
  will not flex.
• Mallet Finger (baseball finger)
• Extension tendon injury when the distal end of
  the finger is suddenly forced into flexion.
• Common when catching a ball at the of the finger,
  rupture can happen.
• Signs and symptoms pain, point tenderness,
  flexion deformity, inability to flex the distal
  phalange.
• Boutonniere Deformity
• Flexion of the PIP joint and hyperextension of
  the DIP joint.
• Usually involves the Extensor Digitorum tendon at
  the middle phalanx.
• Forced flexion at the PIP joint is most common
  injury.
• Signs and Symptoms pain at PIP joint, swelling
  and weakness at PIP joint.
• FRACTURES
• Colles fracture occurs at distal radius and
  ulna by a fall on outstretched arm, displacement
  is dorsal.
• Smiths fracture same as Colles fracture but
  displacement is volar, caused by fall on
  hyperflexed wrist.
• Bennetts Fracture occurs at base of 1st
  metacarpal caused by a striking object.

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CHRONIC INJURIES

• DUPUYTRENS CONTRACTURE
• Flexion of the MCP and PIP joints on 4th or 5th
  fingers. Usually occurs in older adults and
  cause is unknown. You may palpate thickening of
  the palmar fascia.
• WRIST GANGLION
• Herniation of the synovial fluid through the
  joint capsule. Overuse issue that can present on
  the volar or dorsal side of the wrist.
• Observation will show a deformity/mass over
  wrist. May have pain or limited ROM but not
  always.
• DE QUERVAINS DISEASE
• Inflammation of the sheath around the abductor
  pollicis longus and extensor pollicis brevis
  tendons.
• Caused by gripping with hand in ulnar deviation.
  Symptoms will include pain and crepitus at base
  of the thumb, weakness in extension and abduction
  of the thumb.
• TRIGGER FINGER
• Inflammation of the flexor tendons usually over
  3rd and 4th digits.
• Caused by repetitive stress of flexor tendons.
  As this occurs restriction or stenosis of the
  canal happens.
• When finger is flexed it will snap or sound like
  a trigger being pulled.

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NERVE INJURIES TO ELBOW, WRIST AND HAND

• ELBOW
• Ulnar nerve compression
• Located between the medial epicondyle and
  olecranon
• Radial nerve compression
• Located between the posterior humerus and lateral
  epicondyle
• Median nerve compression (Pronator teres
  syndrome)
• Found between the two heads of the pronator teres
  muscle and due to muscle hypertrophy. Found in
  weight lifters, rowers, golfer, etc.
• WRIST
• Carpal Tunnel Syndrome
• Compression of the median nerve as it passes
  through the carpal tunnel.
• Causes are overuse from repetitive activities,
  boney protrusion into the tunnel, and fluid
  retention.
• Found mostly in women and adults. Found in
  individuals who perform excessive typing. Wrist
  flexion in typing and sleeping can cause
  symptoms.
• Symptoms include pain, tenderness, sensory
  changes, motor weakness. Numbness, tingling,
  muscle atrophy in severe cases.
• EXAM includes Tinels test, Phalens test
• Ulnar Nerve Compression Occurs in cyclists due
  to the increased pressure on the thenar eminence.
• The ulnar nerve runs between the pisiform and
  hamate bone in the Guyons canal.
• Signs and Symptoms include pain, tingling,
  numbness into 4th and 5th fingers, motor weakness.

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• Radial Nerve Palsy
• Wrist drop occurs because the extensors are
  involved.
• HAND
• Claw hand deformity
• When the ulnar and median nerves are injured.
• Signs are hyperextension at MCP joint and flexion
  at PIP and DIP joints.

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TREATMENT AND PREVENTION OF WRIST AND HAND
INJURIES

• Rest and ice
• Splinting if necessary
• Stretching the flexors/extensors of wrist and
  fingers, intrinsic muscles of fingers
• Resistive exercises for the wrist in flexion,
  extension, ulnar and radial deviation.
• Resistive exercises for pronation and supination.
• Putty exercises for fingers
• Gripping exercises using putty, balls, hand
  grips, etc.
• Plyometric activities for the fingers and hand
  using small medicine balls.

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OTHER SYNDROMES
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• FIBROMYALGIA
• Anatomy No obvious cause of pain. Pain is
  located in the low back, shoulders, neck, back of
  head, chest, arms, hands, thighs, legs, TMJ, and
  anterior chest. A lack of Serotonin in the body
  can increase pain.
• Description A painful non-articular rheumatic
  condition of at least three months duration,
  characterized by widespread muscular achiness and
  specifically the palpation of tender points at 11
  of 18 prescribes locations on the body (Clinical
  Massage Therapy, Fiona Rattray and Linda Ludwig)
• Symptoms
• Overexertion
• Lack of exercise
• Stress/anxiety
• Depression
• Insomnia/poor sleep
• Trauma
• Extreme temperatures
• Infections
• More often women than men (14)
• Exam
• See handout on trigger point locations (18
  points)
• Treatment
• Massage
• Low impact aerobic exercise
• High reps and low weight strength training

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• OSTEOARTHRITIS
• Description A degenerative chronic condition
  that affects the joints, specifically the
  articular cartilage and subchondral bone.
• Symptoms
• Idiopathic
• Altered biomechanics
• Immobilization
• Trauma
• Pathology
• Seen in adults 25-34, but mostly over 70 years of
  age
• Pain can be unilateral or bilateral
• In later stages, pain at night, loss of strength
  and ROM, muscle spasm, swelling, and loss of
  mobility
• Exam
• Found in the hands, spine, hip, and knee
• Treatment/Prevention
• Rest
• Massage
• Stretching
• Low impact possibly water exercises