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
History Observation
Visually inspect, including wrsit and elbow If no deformity present, observe while they supinate and pronate

Palpation Special Tests

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 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.

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

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

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(bishops, claw and drop wrist) Management: if chronic, may require surgical

 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 Quervains 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
Bones Ligaments
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 Bowlers 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 reextension after thumb and finger flexed Management:possible injections; splinting Dupuytrens 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 58wks.

 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 Bennetts 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 Fingers

General 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