the forearm, wrist, hand, and fingers chapter 24
TRANSCRIPT
The Forearm, Wrist, Hand, and Fingers
Chapter 24
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
Forearm Assessment
HistoryObservation
Visually inspect, including wrsit and elbow
If no deformity present, observe while they supinate and pronate
PalpationSpecial Tests
Recognition and Management of Forearm
Injuries
Contusion Etiology:direct blow
Why more common to ulna? Signs and Symptoms Management
Forearm Splints Etiology: repeated severe static contraction Signs and Symptoms:dull 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
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
Wrist, Hand, and Finger Anatomy
Bones: carpals and metacarpalsJoints: radiocarpal, carpal, metacarpal, and
phalangeal jointsLigaments: “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.
Assessment of Wrist, Hand, and Finger Injuries
HistoryObservationPalpationSpecial Tests: Finklestein’s test,
Tinel’s Sign, Phalen’s test, valgus and varus stress test,
Circulatory and Neurological Evaluation Allen test
Functional Evaluation
Special Tests Finklesteins’ Test
De Quervains (tenosynovitis)Thumb tucked inside fist with ulnar deviation
Tinel’s Sign Tap over transverse carpal ligament Pain numbness and tingling indicates median nerve disruption and
presence of carpal tunnel Phalen’s 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
Recognition and Management of Wrist, Hand, and Finger Injuries
Wrist Sprain Etiology Signs and Symptoms Management
Triangular Fibrocartilage Complex Injury Etiology:forced hyperextension or
compression of radioulnar joint and proximal row of carpals
Signs and Symptoms Management
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 Symptoms:pain with AROM and passive
stretching Management
Nerve Compression, Entrapment, Palsy Etiology: median (carpal tunnel) and ulnar (pisiform
and hamate) Signs and Symptoms:deformities(bishop’s, claw and
drop wrist) Management: if chronic, may require surgical
decompression
Carpal Tunnel Syndrome Tunnel = pink Bones = white Ligament = blue
Carpal tunnel syndrome Etiology: repeated
flexion Signs and Symptoms:
sensory and motor impairment
Management
Recognition and Management of Wrist, Hand, and Finger Injuries
Dislocation of the Lunate Bone Etiology:forced
hyperextension of wrist
Signs and Symptoms:difficulty 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) Etiology:herniation of
joint capsule or tendon
Signs and Symptoms Management
De Quervain’s Disease Etiology:
tenosynovitis of thumb
Signs and Symptoms
Management
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
Finger anatomy
BonesLigaments
PIP and DIP have the same design
Collateral ligaments, palmar fibrocartilage, and loose posterior capsule or synovial membrane (protected by extensor expansion)
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: Lumbricals:volar surface; MCP flex., IP exten.Thenar (4 that act on thumb) & hypothenar
(4 that act on 5th)
Recognition and Management of Wrist, Hand, and Finger Injuries
Contusion to hand and fingers Etiology Signs and Symptoms: fingernail? Management
Bowler’s Thumb Etiology: fibrosis of the ulnar digital nerve
form pressure Signs and Symptoms:pain, numbness, tingling Management: pad area, decrease activity;
surgery PRN Jersey finger
Etiology:FDP rupture, grabbing jersey Signs and Symptoms:DIP cannot flex Management:SURGERY
Trigger finger or thumb Etiology: stenosing tendon by repeated
movements Signs and Symptoms: resistance to re-
extension after thumb and finger flexed Management:possible injections; splinting
Dupuytren’s Contracture Etiology: idiopathic development of nodules
in palmer aponeurosis Signs and Symptoms:flexion deformity;
cannot extend Management: surgical removal
Boutonniere deformity
Etiology:rupture of extensor tendon dorsal to middle phalanx; trauma to tip of finger causes DIP extension and PIP flexion
Signs and Symptoms: cannot extend
Management:splint PIP in extension 5-8wks.
Swan neck deformity
AKA Pseudoboutonniere Etiology:severe
hyperextension; injury to volar plate
Signs and Symptoms: hyperextension of PIP
Management: splint 20-30 degrees flexion 3 wks
Mallet Finger
Etiology: strike to tip of finger, jamming and avulsing extensor tendon
Signs and Symptoms: unable to extend, may palpate avulsed bone
Management:extension splint 6-8 wks
Gamekeepers Thumb Etiology:UCL of
thumb; forced abductions, an hyperextension
Signs and Symptoms:inability to pinch; pain with stress
Management:splint 3 weeks; protect with activity
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 Etiology:twist while
semiflexed Signs and Symptoms Management:splint in
ext PIP Dorsal dislocation
Etiology:hyperext. Signs and
symptoms:deformity; inability to move
Management:reduce and splint 20-30 degrees flex
Recognition and Management of Wrist, Hand, and Finger Injuries
MCP dislocation Etiology:twist an shear force Signs and Symptoms:prox. Phalanx dorsal 60-90
degrees Management: reduce; splint; early ROM
Metacarpal fracture Etiology:compressive axial force Signs and Symptoms:appear angular or rotated Management: reduce and splint
Bennett’s Fracture Etiology:thumb CMC; axial and ABD force to
thumb Signs and Symptoms:base of thumb painful Management:refer to surgeon due to unstable
nature
Distal/Middle/Proximal phalangeal fracture Etiology:crushing force; direct trauma or twist Signs and Symptoms: subungual hematoma
subungual hematoma Management:drain 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
Rehabilitation Principles for the Forearm, Wrist, Hand, and
FingersGeneral Body Conditioning Joint Mobilization:traction and mobilization
help restore ROM
Flexibility: full ROM is measure of good rehab
Strength:equal
Neuromuscular Control:great dexterity required
Return to Activity: Goals: full dexterity, full ROM, full strength