© 2011 mcgraw-hill higher education. all rights reserved. chapter 24: the forearm, wrist, hand and...
TRANSCRIPT
© 2011 McGraw-Hill Higher Education. All rights reserved.
Chapter 24: The Forearm, Wrist, Hand and Fingers
Anatomy of the Forearm
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-1
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-2 © 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-2© 2011 McGraw-Hill Higher Education. All rights reserved.
Blood and Nerve Supply
• Most of the flexors are supplied by the median nerve
• Most of the extensor are controlled by the radial nerve
• Blood is supplied by the radial and ulnar arteries
© 2011 McGraw-Hill Higher Education. All rights reserved.
Assessment of the Forearm
• History– What was the cause?– What were the symptoms at the time of
injury, did they occur later, were they localized or diffuse?
– Was there swelling and discoloration?– What treatment was given and how does it
feel now?– Any previous injury to your forearm?
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Observation– Visually inspect for deformities, swelling
and skin defects– Range of motion– Pain w/ motion
• Palpation– Palpated at distant sites and at point of
injury– Can reveal tenderness, edema, fracture,
deformity, changes in skin temperature, a false joint, bone fragments or lack of bone continuity
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation: Bony and Soft Tissue
• Proximal head of radius
• Olecranon process• Radial shaft• Ulnar shaft• Distal radius and
ulna• Radial styloid• Ulnar head• Ulnar styloid
• Distal radioulnar joint
• Radiocarpal joint
• Extensor retinaculum
• Flexor retinaculum
• Extensor carpi radialis longus and brevis
• Extensor carpi ulnaris
• Brachioradialis
• Extensor pollicis longus and brevis
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation (continued)
• Abductor pollicis longus
• Extensor indicus supinator
• Flexor carpi radialis• Palmaris longus• Flexor digitorum
superficialis• Flexor digitorum
profundus
• Flexor pollicis longus
• Pronator quadratus• Pronator teres
© 2011 McGraw-Hill Higher Education. All rights reserved.
Recognition and Management of Injuries to the Forearm
• Contusion– Etiology
• Ulnar side receives majority of blows due to arm blocks
• Can be acute or chronic • Result of direct contact or blow
– Signs and Symptoms• Pain, swelling and hematoma• If repeated blows occur, heavy fibrosis and
possibly bony callus could form w/in hematoma© 2011 McGraw-Hill Higher Education. All rights reserved.
• Contusion (continued)– Management
• Proper care in acute stage involves RICE and followed up w/ additional cryotherapy
• Protection is critical - full-length sponge rubber pad can be used to provide protective covering
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Forearm Splints– Etiology
• Forearm strain - most come from severe static contraction
– Signs and Symptoms• Dull ache between extensors which cross posterior
aspect of forearm• Weakness and pain w/ contraction• Point tenderness in interosseus membrane
– Management• Treat symptomatically• Patient should focus on strengthening forearm• Treat w/ cryotherapy, wraps, or heat if condition
persists• Can develop compartment syndrome in forearm as
well and should be treated like lower extremity© 2011 McGraw-Hill Higher Education. All rights reserved.
• Forearm Fractures– Etiology
• Common in youth due to falls and direct blows
• Ulna and radius generally fracture individually
• Fracture in upper third may result in abduction deformity due pull of pronator teres
• Fracture in lower portion will remain relatively neutral
• Older patients may experience greater soft tissue damage and greater chance of paralysis due to Volkmann's contracture
– Signs and Symptoms• Audible pop or crack followed by moderate to
severe pain, swelling, and disability
• Edema, ecchymosis w/ possible crepitus
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Management– Initially RICE
followed by splinting until definitive care is available
– Long term casting followed by rehab plan
Figure 24-3
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Colles’ Fracture– Etiology
• Occurs in lower end of radius or ulna
• MOI is fall on outstretched hand, forcing radius and ulna into hyperextension
• Less common is the reverse Colles’ fracture (Smith fracture)
– Anterior displacement of distal fragment
• Intraarticular fracture is referred to as a Barton fracture
Figure 24-4© 2011 McGraw-Hill Higher Education. All rights reserved.
– Signs and Symptoms• Forward displacement of radius causing visible
deformity (silver fork deformity)• When no deformity is present, injury can be
passed off as bad sprain• Extensive bleeding and swelling• Tendons may be torn/avulsed and there may
be median nerve damage
– Management• Cold compress, splint wrist and refer to
physician• X-ray and immobilization• Severe sprains should be treated as fractures• In children, injury may cause lower epiphyseal
separation
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Madelung Deformity– Etiology
• Developmental deformity of the wrist• Associated with changes in radius, ulna and
carpal bone results in palmar and ulnar wrist subluxations
• Common in females• Carpals become wedged between radius and
ulna following epiphyseal plate changes
– Signs and Symptoms• Bowing of radius and ulna evident on X-ray• Wrist pain and loss of forearm rotation• Palmar subluxation with prominence of radius
and ulnar styloid processes
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Madelung Deformity (continued)– Management
• Therapeutic modalities and NSAID’s for pain
• Wrist can be taped or braced to prevent wrist extension
• Typically corrected surgically in patients with chronic pain and disability
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-5
Anatomy of the Wrist, Hand and Fingers
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-6© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-7
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-8
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-9 A & B
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-9 C© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-10© 2011 McGraw-Hill Higher Education. All rights reserved.
•Blood and Nerve Supply
• Three major nerves– Ulnar, median and
radial
• Ulnar and radial arteries supply the hand– Two arterial arches
(superficial and deep palmar arches)
Figure 24-11
© 2011 McGraw-Hill Higher Education. All rights reserved.
Assessment of the Wrist, Hand and Fingers
• History– Past history– Mechanism of injury– When does it hurt?– Type of, quality of, duration of, pain?– Sounds or feelings?– How long were you disabled?– Swelling?– Previous treatments?
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Observation– Postural deviations– Is the part held still, stiff or protected?– Wrist or hand swollen or discolored?– General attitude– What movements can be performed fully
and rhythmically?– Thumb to finger touching– Color of nail beds
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation: Bony
• Scaphoid• Trapezoid• Trapezium• Lunate• Capitate• Triquetral• Pisiform• Hamate (hook)• Metacarpals 1-5
• Proximal, middle and distal phalanges of the fingers
• Proximal and distal phalanges of the thumb
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation: Soft Tissue
• Triangular fibrocartilage
• Ligaments of the carpals
• Carpometacarpal joints and ligaments
• Metacarpophalangeal joints and ligaments
• Proximal and distal interphalangeal joints and ligaments
• Flexor carpi radialis
• Flexor carpi ulnaris
• Lumbricale muscles
• Flexor digitorum superficialis and profundus
• Palmer interossi
• Flexor pollicis longus and brevis
• Abductor pollicis brevis
• Opponens pollicis
• Opponens digiti minimi
© 2011 McGraw-Hill Higher Education. All rights reserved.
•Palpation: Soft Tissue
• Extensor carpi radialis longus and brevis
• Extensor carpi ulnaris• Extensor digitorum• Extensor indicis• Extensor digiti minimi• Dorsal interossi• Extensor pollicis brevis
and longusAbductor pollicis longus
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Special Tests– Finklestein’s Test
• Test for de Quervain’s syndrome• Athlete makes a fist w/ thumb tucked inside• Wrist is ulnarly deviated• Positive sign is pain indicating stenosising
tenosynovitis• Pain over carpal tunnel could indicate carpal tunnel
syndrome
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-12
• Special Tests– Tinel’s Sign
• Produced by tapping over transverse carpal ligament
• Tingling, paresthesia over sensory distribution of the median nerve indicates presence of carpal tunnel syndrome
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-13
• Phalen’s Test– Test for carpal tunnel
syndrome– Position is held for
approximately one minute
– If test is positive, pain will be produced in region of carpal tunnel
Figure 24-14
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Valgus/Varus and Glide Stress Tests• Tests used to assess ligamentous integrity of
joints in hands and fingers• Valgus and varus tests are used to test
collateral ligaments• Anterior and posterior glides are used to
assess the joint capsule
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-15
• Lunotriquetral Ballottement Test– Stabilize lunate while
sliding the triquetral anteriorly and posteriorly
– Assessing laxity, pain and crepitus
– Positive test indicates instability that often results in dislocation of the lunate
Figure 24-16
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Circulatory and Neurological Evaluation• Hands should be felt for temperature
– Cold hands indicate decreased circulation
• Pinching fingernails can also help detect circulatory problems (capillary refill)
• Allen’s test can also be used – Patient is instructed to clench fist 3-4 times, holding it
on the final time– Pressure applied to ulnar and radial arteries– Patient then opens hand (palm should be blanched)– One artery is released and should fill immediately
(both should be checked)
• Hand’s neurological functioning should also be tested (sensation and motor functioning)
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Functional Evaluation– Range of motion in all movements of wrist
and fingers should be assessed– Active, resistive and passive motions should
be assessed and compared bilaterally• Wrist - flexion, extension, radial and ulnar
deviation• MCP joint - flexion and extension• PIP and DIP joints - flexion and extension• Fingers - abduction and adduction• MCP, PIP and DIP of thumb - flexion and
extension• Thumb - abduction, adduction and opposition• 5th finger - opposition
© 2011 McGraw-Hill Higher Education. All rights reserved.
Recognition and Management of Injuries to the Wrist, Hand
and Fingers• Wrist Sprains
– Etiology• Most common wrist injury• Arises from any abnormal, forced movement• Falling on hyperextended wrist, violent flexion
or torsion• Multiple incidents may disrupt blood supply
– Signs and Symptoms• Pain, swelling and difficulty w/ movement
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management• Refer to physician for X-ray if severe• RICE, splint and analgesics• Have patient begin strengthening soon after
injury• Tape for support can benefit healing and
prevent further injury
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Triangular Fibrocartilage Complex
(TFCC) Injury– Etiology
• Occurs through forced hyperextension, falling on outstretched hand
• Violent twist or torque of the wrist• Often associated w/ sprain of UCL
– Signs and Symptoms• Pain along ulnar side of wrist, difficulty w/ wrist
extension, possible clicking• Swelling is possible, not much initially• Patient may not report injury immediately
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management• Referred to physician for treatment• Treatment will require immobilization initially for
4 weeks• Immobilization should be followed by period of
strengthening and ROM activities• Surgical intervention may be required if
conservative treatments fail
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Tenosynovitis– Etiology
• Cause of repetitive wrist accelerations and decelerations
• Repetitive overuse of wrist tendons and sheaths
– Signs and Symptoms• Pain w/ use or pain in passive stretching• Tenderness and swelling over tendon
– Management• Acute pain and inflammation treated w/ ice
massage 4x daily for first 48-72 hours, NSAID’s and rest
• When swelling has subsided, ROM is promoted• Ultrasound and phonophoresis can be used• PRE can be instituted once swelling and pain
subsided© 2011 McGraw-Hill Higher Education. All rights reserved.
• Tendinitis– Etiology
• Repetitive pulling movements of (commonly) flexor carpi radialis and ulnaris; repetitive pressure on palms (cycling) can cause irritation of flexor digitorum
• Primary cause is overuse of the wrist– Signs and Symptoms
• Pain on active use or passive stretching• Isometric resistance to involved tendon produces
pain, weakness or both– Management
• Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and rest
• When swelling has subsided, ROM is promoted w/ contrast bath
• PRE can be instituted once swelling and pain subsided (high rep, low resistance)
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Nerve Compression, Entrapment, Palsy– Etiology
• Median and ulnar nerve compression • Result of direct trauma to nerves
– Signs and Symptoms• Sharp or burning pain associated w/ skin sensitivity or
paresthesia• May result in benediction/ bishop’s deformity• (damage to the ulnar nerve) or claw hand deformity
(damage to both nerves)• Palsy of radial nerve produces drop wrist deformity
caused by paralysis of extensor muscles• Palsy of median nerve can cause ape hand (thumb
pulled back in line w/ other fingers)
– Management• Chronic entrapment may cause irreversible damage• Surgical decompression may be necessary
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figures 24-19 to 22
© 2011 McGraw-Hill Higher Education. All rights reserved.
Bishop or Benediction
Hand
Claw Hand
Drop Wrist
Ape Hand
• Carpal Tunnel Syndrome– Etiology
• Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel
• Result of repeated wrist flexion or direct trauma to anterior aspect of wrist
– Signs and Symptoms• Sensory and motor deficits (tingling, numbness and
paresthesia); weakness in thumb
– Management• Conservative treatment - rest, immobilization,
NSAID’s• If symptoms persist, corticosteroid injection may be
necessary or surgical decompression of transverse carpal ligament
© 2011 McGraw-Hill Higher Education. All rights reserved.
• de Quervain’s Disease (Hoffman’s disease)– Etiology
• Stenosing tenosynovitis in thumb (extensor pollicis brevis and abductor pollicis longus
• Constant wrist movement can be a source of irritation
– Signs and Symptoms• Aching pain, which may radiate into hand or
forearm• Positive Finklestein’s test• Point tenderness and weakness during thumb
extension and abduction; painful catching and snapping
© 2011 McGraw-Hill Higher Education. All rights reserved.
• de Quervain’s Disease (Hoffman’s disease)– Management
• Immobilization, rest, cryotherapy and NSAID’s• Ultrasound and ice are also beneficial• Joint mobilizations have been recommended to
maintain ROM
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Dislocation of Lunate Bone– Etiology
• Forceful hyperextension or fall on outstretched hand
– Signs and Symptoms• Pain, swelling, and difficulty executing wrist and finger
flexion• Numbness/paralysis of flexor muscles due to
pressure on median nerve
– Management• Treat as acute, and sent to physician for reduction• If not recognized, bone deterioration could occur,
requiring surgical removal• Usual recovery is 1-2 months
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-24
• Kienböck's Disease– Etiology
• Loss of blood supply to lunate bone resulting in osteonecrosis
– Signs and Symptoms• Pain, swelling, with decreases in ROM
• Decreased grip strength
• Tenderness over the bone (middle of the dorsum of the wrist)
– Management• Early treatment involves immobilization and
NSAID’s
• Operative treatment may be required if conservative treatment fails
– May involve wrist bone fusion or bone removal
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Scaphoid Fracture– Etiology
• Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones
• Often fails to heal due to poor blood supply
– Signs and Symptoms• Swelling, severe pain in
anatomical snuff box
• Presents like wrist sprain
• Pain w/ radial flexion
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-25
• Scaphoid Fracture– Management
• Must be splinted and referred for X-ray prior to casting
• Immobilization lasts 6 weeks and is followed by strengthening and protective tape
• Wrist requires protection against impact loading for 3 additional months
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-25
• Hamate Fracture– Etiology
• Occurs as a result of a fall or more commonly from contact while athlete is holding an implement
– Signs and Symptoms• Wrist pain and weakness, along w/ point
tenderness• Pull of muscular attachment can cause non-
union
– Management• Casting wrist and thumb is treatment of choice• Hook of hamate can be protected w/ doughnut
pad to take pressure off area
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Hamate Fracture– Management
• Casting wrist and thumb is treatment of choice
• Hook of hamate can be protected w/ doughnut pad to take pressure off area
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-26
• Wrist Ganglion– Etiology
• Synovial cyst (herniation of joint capsule or synovial sheath of tendon)
• Generally appears following wrist strain
– Signs and Symptoms• Appear on back of wrist generally• Occasional pain w/ lump at site• Pain increases w/ use• May feel soft, rubbery or very hard
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Wrist Ganglion– Management
• Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing
• New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad
• Ultrasound can be used to reduce size
• Surgical removal is most effective treatment method
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-27
• Contusion and Pressure Injuries of Hand and Fingers– Etiology
• Result of blow or compression of bones w/in hand and fingers
– Signs and Symptoms• Pain and swelling of soft tissue
– Management• Cold compression until hemorrhaging has ceased• Follow w/ gradual warming - soreness may still be
present -- padding may also be necessary• Bruising of distal phalanx can result in subungual
hematoma - extremely painful due to build-up of pressure under nail
– Pressure must be released once hemorrhaging has ceased
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-28© 2011 McGraw-Hill Higher Education. All rights reserved.
• Trigger Finger or Thumb– Etiology
• Repeated motion of fingers may cause irritation, producing tenosynovitis
• Inflammation of tendon sheath (extensor tendons of wrist, fingers and thumb, abductor pollicis)
• Thickening occurs w/in the sheath, forming a nodule that does not slide easily
– Signs and Symptoms• Resistance to re-extension, produces snapping that is
palpable, audible and painful• Palpation produces pain and lump can be felt w/in
tendon sheath
– Management• Same treatment as de Quervain’s disease -- if
unsuccessful, injection and splinting are last options
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Extensor Tendon Avulsion (Mallet Finger)– Etiology
• Caused by a blow to tip of finger avulsing extensor tendon from insertion
• Also referred to as baseball or basketball finger
– Signs and Symptoms• Pain at DIP; X-ray shows
avulsed bone on dorsal proximal distal phalanx
• Unable to extend distal end of finger (carrying at 30 degree angle)
• Point tenderness at sight of injury
– Management• RICE and splinting for 6-8 weeks
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-29
• Boutonniere Deformity– Etiology
• Rupture of extensor expansion dorsal to the middle phalanx
• Tendon slides below axis of PIP jointForces DIP joint into extension and PIP into flexion
– Signs and Symptoms• Severe pain, obvious deformity and inability to
extend DIP joint• Swelling, point tenderness
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Boutonniere Deformity– Management
• Cold application, followed by splinting• Splinting must be continued for 5-8 weeks• Athlete is encouraged to flex distal phalanx
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-30
• Flexor Digitorum Profundus Rupture (Jersey Finger)– Etiology
• Rupture of flexor digitorum profundus tendon from insertion on distal phalanx
• Often occurs w/ ring finger when athlete tries to grab a jersey
– Signs and Symptoms• DIP can not be flexed, finger remains extended• Pain and point tenderness over distal phalanx
– Management• Must be surgically repaired• Rehab requires 12 weeks and there is often
poor gliding of tendon, w/ possibility of re-rupture
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Dupuytren’s Contracture– Etiology
• Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity
– Signs and Symptoms• Often develops in 4th or 5th
finger (flexion deformity)
– Management• Tissue nodules must be
removed as they can ultimately interfere w/ normal hand function
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-32
• Gamekeeper’s Thumb
– Etiology• Sprain of UCL of MCP
joint of the thumb• Mechanism is forceful
abduction of proximal phalanx occasionally combined w/ hyperextension
– Signs and Symptoms• Pain over UCL in addition
to weak and painful pinch
Figure 24-33
© 2011 McGraw-Hill Higher Education. All rights reserved.
– Management• Immediate follow-up must occur• If instability exists, athlete should be referred to
orthopedist• If stable, X-ray should be performed to rule out
fracture• Thumb splint should be applied for protection
for 3 weeks or until pain free • Splint should extend from wrist to end of thumb
in neutral position• Thumb spica should be used following splinting
for support• If a complete tear occurs, surgical repair is
necessary to allow normal function to return
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Sprains of Interphalangeal Joints – Etiology
• Can include collateral ligament, volar plate, extensor expansion tears
• Occurs w/ axial loading or valgus/varus stresses
– Signs and Symptoms• Pain, swelling, point tenderness, instability• Valgus and varus tests may be positive
– Management• RICE, X-ray examination and possible splinting• Splint at 30-40 degrees of flexion for 10 days• If sprain is to the DIP, splinting for a few days in full
extension may assist healing process• Taping can be used for support
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Swan Neck Deformity and PsuedoBoutonniere Deformity– Etiology
• Distal tear of volar plate may cause Swan Neck deformity; proximal tear may cause PsuedoBoutonniere deformity
– Signs and Symptoms• Pain, swelling w/ varying degrees of hyperextension
• Tenderness over volar plate of PIP
• Indication of volar plate tear = passive hyperextension
– Management• RICE and analgesics
• Splint in 20-30 degrees of flexion for 3 weeks; followed by buddy taping and then PRE
© 2011 McGraw-Hill Higher Education. All rights reserved.
• PIP Dorsal Dislocation– Etiology
• Hyperextension that disrupts volar plate at middle phalanx
– Signs and Symptoms• Pain and swelling over PIP• Obvious deformity, disability and possible
avulsion
– Management• Treated w/ RICE, splinting and analgesics
followed by reduction• After reduction, finger is splinted at 20-30
degrees of flexion for 3 weeks -- followed by buddy taping
© 2011 McGraw-Hill Higher Education. All rights reserved.
• PIP Palmar Dislocation– Etiology
• Caused by twist while digit is semiflexed
– Signs and Symptoms• Pain and swelling over PIP; point tenderness
over dorsal side• Finger displays angular or rotational deformity
– Management• Treat w/ RICE, splinting and analgesics
followed by reduction• Splint in full extension for 4-5 weeks after which
it is protected for 6-8 weeks during activity
© 2011 McGraw-Hill Higher Education. All rights reserved.
• MCP Dislocation– Etiology
• Caused by twisting or shearing force
– Signs and Symptoms• Pain, swelling and stiffness at MCP joint• Proximal phalanx is angulated at 60-90
degrees
– Management• RICE, splinting following reduction• Buddy taping and given early ROM following
splinting
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Metacarpal Fracture– Etiology
• Direct axial force or compressive force• Fractures of the 5th metacarpal are associated
w/ boxing or martial arts (boxer’s fracture)
– Signs and Symptoms• Pain and swelling; possible angular or
rotational deformity
– Management• RICE, analgesics are given followed by X-ray
examinations• Deformity is reduced, followed by splinting - 4
weeks of splinting after which ROM is carried out
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-36
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Bennett’s Fracture– Etiology
• Occurs at carpometacarpal joint of the thumb as a result of an axial and abduction force to the thumb
– Signs and Symptoms• CMC may appeared to be deformed - X-ray will
indicate fracture• Patient will complain of pain and swelling over
the base of the thumb
– Management• Structurally unstable and must be referred to an
orthopedic surgeon
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Distal Phalangeal Fracture– Etiology
• Crushing force
– Signs and Symptoms• Complaint of pain and swelling of distal phalanx• Subungual hematoma is often seen in this
condition
– Management• RICE and analgesics are given• Protective splint is applied as a means for pain
relief• Subungual hematoma is drained
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Middle Phalangeal Fracture– Etiology
• Occurs from direct trauma or twist
– Signs and Symptoms• Pain and swelling w/ tenderness over middle
phalanx
• Possible deformity; X-ray will show bone displacement
– Management• RICE and analgesics
• No deformity - buddy tape w/ thermoplastic splint for activity
• Deformity - immobilization for 3-4 weeks and a protective splint for an additional 9-10 weeks during activity
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Proximal Phalangeal Fracture– Etiology
• May be spiral or angular
– Signs and Symptoms• Complaint of pain, swelling, deformity• Inspection reveals varying degrees of deformity
– Management• RICE and analgesics are given as needed• Fracture stability is maintained by
immobilization of the wrist in slight extension, MCP in 70 degrees of flexion and buddy taping
© 2011 McGraw-Hill Higher Education. All rights reserved.
• PIP Fractures and Dislocation– Etiology
• Combination of fracture and dislocation is the result of an axial load on a partially flexed finger
– Signs and Symptoms• Condition causes pain and swelling in the region
of the PIP joint• Localized tenderness over the PIP
– Management• RICE, analgesics, followed by reduction of the
fracture• If there is a small fragment, buddy taping is used• Large fragments - splint at 30-60 degrees of
flexion
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Fingernail Deformities– Changes in normal
appearance of the fingernail can be indicative of a number of different diseases
• Scaling or ridging = psoriasis• Ridging and poor development =
nutritional deficiencies• Clubbing and cyanosis =
congenital heart disorders or chronic respiratory disease
• Spooning or depression = thyroid problems, iron deficiency anemia
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-37
Rehabilitation of the Forearm, Wrist, Hand and Fingers
• General Body Conditioning– Must maintain pre-injury level of
conditioning– Cardiorespiratory, strength, flexibility and
neuromuscular control– Many exercise options (particularly lower
extremity)
• Joint Mobilizations– Wrist and hand respond to traction and
mobilization techniques
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Joint Mobilization (cont.)– Can be used to increase specific ranges of
motion
© 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-38
• Flexibility– Full pain free ROM is a major goal of
rehabilitation– The program should include active
assisted and active pain free stretching
• Strength– Exercises should not aggravate condition
or disrupt healing process– A variety of exercises are available for
strength (wrist and hand)
© 2011 McGraw-Hill Higher Education. All rights reserved.
Flexibility Exercises
Figure 24-39
© 2011 McGraw-Hill Higher Education. All rights reserved.
Flexibility Exercises
Figure 24-40
© 2011 McGraw-Hill Higher Education. All rights reserved.
Neural Tension Exercises
Figure 24-41
© 2011 McGraw-Hill Higher Education. All rights reserved.
Strengthening Exercises
Figure 24-43 © 2011 McGraw-Hill Higher Education. All rights reserved.
Figure 24-44 & 45
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Neuromuscular Control– Hand and fingers require restoration of
dexterity• Pinching, fine motor activities (buttoning
buttons, tying shoes, and picking up small objects)
– It is important to incorporate functional activities designed to restore patient’s ability to perform daily activities
© 2011 McGraw-Hill Higher Education. All rights reserved.
© 2011 McGraw-Hill Higher Education. All rights reserved.
• Return to Activity– Grip strength must be equal bilaterally, full
range of motion and dexterity– Thumb has unique strength requirements– A variety of customizable bracing and
splinting devices are available to protect injured wrist and hand
Figure 24-46, 47, 48