Wrist and Hand Conditions
Chapter 16
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Anatomy
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Wrist Articulations
• Radiocarpal joint
– Radius with scaphoid, lunate, and triquetrum
– Condyloid joint
– Sagittal plane motions (i.e., flexion, extension,
and hyperextension)
– Frontal plane motions (i.e., radial deviation and
ulnar deviation)
– Circumduction
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Wrist Articulations (cont.)
• Intercarpal joints
– Gliding joints
– Minimal contribution to wrist movement
• Distal radioulnar joint
– Immediately adjacent to radiocarpal joint
– TFCC – stabilizer
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Hand Articulations
• Carpometacarpal joints (CM)
– Thumb
• Saddle joint
– Fingers
• Gliding joints
• Intermetacarpal joints (IM)
• Metacarpophalangeal joints (MP)
– Condyloid joints
• Interphalangeal joints (IP)
– PIP and DIP hinge joints
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Muscles
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Muscles (cont.)
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Muscles (cont.)
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Muscles (cont.)
• Tendon sheaths
– Level of the metacarpal heads – point where flexor
tendons enter a flexor tendon sheath
– Annular pulleys
• Keep flexor tendons and sheath closely applied to
phalanges
– Cruciate pulleys
• Collapse to allow full digital flexion
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Nerves
• Median nerve
• Radial nerve
• Ulnar nerve
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Blood Vessels
• Radial artery
• Ulnar artery
• Numerous divisions
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Kinematics
• Wrist movements
– Flexion
– Extension/ hyperextension
– Radial deviation
– Ulnar deviation
– Circumduction
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Kinematics (cont.)
• CM
– Thumb – flexion, extension, abduction, adduction
• MP – fingers
– Fingers – minimal motion
– Flexion
– Extension
– Abduction
– Adduction
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Kinematics (cont.)
• MP – thumb
– Flexion
– Extension
• IP
– Flexion
– Extension
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Kinematics (Cont’d)
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Kinetics
• Wrist flexors of hand are 2× stronger than extensor muscles
• Grips
– Power
– Precision
– Lateral pinch; fencing
– Maximum grip strength – exerted with wrist in ulnar
deviation and slight hyperextension
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Prevention of Injuries
• Protective equipment
– Pads and gloves
• Physical conditioning
– Strength and flexibility
– Exercises for wrist and elbow
• Proper skill technique
– Instruction on falling
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Contusions and Skin Wounds
• Always important to consider an underlying fracture
• Contusion S&S: pain & discoloration
• Skin wounds – typically abrasions and lacerations
• Management
– Standard acute for closed wound & open wound
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Sprains
• Wrist
– Mechanism: axial loading on proximal palm
during fall on outstretched hand
– S&S
• Standard – sprain
• Specific
 Point tenderness on dorsum of radiocarpal
joint
 ↑ Pain with active or passive extension
– Need to rule out fracture, especially scaphoid fx
– Management: standard acute; NSAIDs
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Sprains (cont.)
• Gamekeeper’s thumb
– Tear of the UCL of the MP joint
– Mechanism: MP in extension and forceful abduction
– S&S
• Palmar aspect of joint – pain; swelling
• + abduction stress
– Management: standard acute; instability: spica
cast for 3-6 weeks; severe: surgical repair
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Sprains (cont.)
• IP sprains
– Excessive valgus and varus: collateral ligaments
– Hyperextension stress: volar plate
– S&S
• Rapid swelling; masks condition
– X-ray: rule out fracture and dislocation
– Management: standard acute; “buddy” taping
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Dislocations
• Distal radioulnar joint (DRUJ)
– Isolated or with radial fracture
– Mechanism: hyperextension
• With hyperpronation: ulna dorsal dislocation; with
hypersupination: ulna volar dislocation
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Dislocations (cont.)
– S&S
• Pain; deformity; extensive swelling
• Dorsal dislocation – ulnar head prominent dorsally;
volar dislocation – wrist appears narrow (result of
overlap of the distal radius and ulna)
• elbow flexion and extension – normal unless
fracture present; pronation and supination of
forearm – limited
– Management: immobilization of limb in vacuum
splint; immediate transportation to physician
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Dislocations (cont.)
• Lunate
– Axial loading displaces in volar direction
– S&S
• Point tenderness – dorsum of hand just distal to
radius
• Thickened area on the palm palpable just distal to
end of radius (proximal to the third metacarpal)
• Passive and active motion may not be painful
– Caution: bone into carpal tunnel – compression of
median nerve
– Management: immobilization of limb in vacuum splint;
immediate transportation to physician
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Dislocations (cont.)
• Fingers
– Can involve collateral ligaments and volar plate
– MCP
• Rare, but easily recognizable
• Hyperextension or shear
– PIP
• Hyperextension and axial loading (e.g., ball
striking extended finger)
– DIP
• Usually occur dorsally
• Individual often reduces injury on their own
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Dislocations (cont.)
– S&S: swollen, painful finger
– Management: immobilization; ice; immediate
physician referral
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Dislocations (cont.)
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Strains
• Jersey finger
– Rupture of flexor digitorum profundus from distal
phalanx
– Mechanism: rapid extension (from active flexion)
– S&S
• Unable to flex the DIP
• Palpate tendon in proximal aspect of finger
• Hematoma formation along the entire flexor
tendon sheath
– Management: standard acute; physician referral
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Strains (cont.)
• Mallet finger
– Rupture of extensor
tendon from distal
phalanx
– Mechanism: forceful
flexion of PIP
– S&S
• Pain, swelling
• Lack of extension at
DIP
– Management: standard
acute; physician referral
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Strains (cont.)
• Boutonnière deformity
– Rupture of central slip of extensor tendon at the
middle phalanx
– Mechanism: rapid forceful flexion of PIP
– Result: hyperextension at MCP, flexion of PIP,
hyperextension of DIP
– S&S
• No active extension
• Deformity usually not present immediately, but
develops over 2-3 weeks
– Management: standard acute; injury that limits PIP
extension to <30º: immediate physician referral
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Strains (cont.)
• Tendinopathies
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Strains (cont.)
• Tendinopathies
– Trigger finger
• Finger flexors contract but are unable to re-extend
• Due to a nodule within tendon sheath or sheath too
constricted to allow free motion
• S&S
 Locking usually occurs when wakening from sleep
 Painful popping sensation when PIP joint is
passively returned to extension
• Management: NSAIDs, resting finger; splinting when
necessary; possible cortisone injections into the
sheath
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Strains (cont.)
– de Quervain's tenosynovitis
• Stenosing tenosynovitis of APL and EPB
• A forceful grasp, combined with repetitive use of thumb
and ulnar deviation
• S&S
 Pain over radial styloid process ↑ with thumb and
wrist motion
 Point tenderness over the tendons
 Pain with RROM thumb abduction
 + Finkelstein’s test
• Management: standard acute; NSAIDS
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Strains (cont.)
– de Quervain's
tenosynovitis
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Strains (cont.)
• Intersection syndrome
– Tendinitis or friction tendinitis in 1st and 2nd dorsal
compartments of wrist
– Overuse of radial extensors by excessive curling
– S&S
• Point tenderness on the dorsum of the forearm,
2-3 finger breadths proximal to the wrist joint
• Crepitus with AROM or PROM
– Management: ice massage; rest; NSAIDs; splinting;
avoiding exacerbating activities
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Strains (cont.)
• Dupuytren’s contracture
– Nodules develop in palmar aponeurosis that limit finger
extension and cause a flexion deformity
– S&S
• Fixed flexion deformity is visible
• Finger cannot be extended
– Management: surgical repair
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Strains (cont.)
• Gymnast’s wrist
– Stress fracture to distal radial epiphyseal plate
– Mechanism: compression (maximum dorsiflexion)
– S&S:
• Diffuse tenderness – dorsum of midcarpal area
• ↑ pain with extreme motion
– Management: splinting; NSAIDs; activity modification
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Strains (cont.)
• Ganglion cysts
– Benign tumor mass on dorsal aspect of wrist
– Associated with tissue sheath degeneration
– Treatment: symptomatic
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Finger Tip Injuries
• Subungual hematoma
– Blood under fingernail
– Due to direct trauma
– Need to rule out fracture
– Management
• Soak in ice water for 10-15 minutes
• If pain does not diminish, may need to be
drained under supervision of a physician
• Refer to Application Strategy 16.1
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Finger Tip Injuries (cont.)
• Paronychia
– Infection along nail fold
– Fold is red, swollen, and painful; can produce
purulent drainage
– Management
• Warm water soaks and germicide.
• More severe cases, physician referral
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Nerve Entrapment Syndromes
• Median nerve
– Anterior interosseous nerve syndrome
• Following set of strenuous or repetitive elbow motion
exercises
• Affects motor but not sensation
• S&S
• Acute – sudden loss of use of flexor pollicis longus
index finger profundus tendons
• Gradual – weakness becomes apparent during
heavy activity
• + pinch grip test
• Management: splint extremity; avoid heavy activity
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Nerve Entrapment Syndromes (cont.)
– Carpal tunnel syndrome
• Median nerve, finger flexors, and flexor pollicis longus
• Due to direct trauma, repetitive overuse, or anatomic
anomalies
• S&S
 Awakening pain in middle of night; often relieved
by “shaking out their hands”
 Pain, numbness, or tingling sensation only in
fingertips on palmar aspect of thumb, index, and
middle finger
 + Phalen’s maneuver; + Tinel’s sign
 Weak thumb abduction
• Management: physician referral
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Nerve Entrapment Syndromes (cont.)
• Carpal tunnel
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Nerve Entrapment Syndromes (cont.)
• Ulnar nerve entrapment
– Ulnar tunnel syndrome
• Due to repetitive compressive trauma to the palmar
aspect of the hand
• S&S
 Numbness in the ulnar nerve distribution
(especially little finger)
 + Froment’s sign
 Slight weakness in grip strength
 + Tinel’s sign
• Management: splinting, NSAIDs; activity modification
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Nerve Entrapment Syndromes (cont.)
• Ulnar nerve entrapment
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Nerve Entrapment Syndromes (cont.)
– Cyclist's palsy
• Due to leaning on handlebar for extended period; leads
to swelling in hypothenar area
• Symptoms mimic ulnar nerve entrapment syndrome, but
disappear rapidly after end of ride
• Key: proper padding; varying hand position
– Bowler’s thumb
• Compression of ulnar digital sensory nerve
• S&S
 Numbness, tingling, or pain – medial aspect of thumb
• Management: standard acute; NSAIDs; immobilization
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Nerve Entrapment Syndromes (cont.)
• Radial nerve entrapment
– Distal posterior interosseous nerve syndrome
• Due to compression associated with repetitive and
forceful wrist dorsiflexion
• S&S
• Deep, dull ache in wrist, reproduced with:
 Forceful wrist extension
 Deep palpation of forearm with wrist in flexion
• Management: standard acute; activity modification
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Nerve Entrapment Syndromes (cont.)
– Superficial radial nerve entrapment
• Compressed at the wrist
 Aggravated by repeated pronation and supination
 Tight wrist straps
• S&S
 Burning pain and sensory changes in dorsoradial
aspect of wrist, hand, dorsal thumb, and index finger
 + Tinel’s sign
• Management: standard acute; activity modification
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Fractures
• Distal radius/ulna fracture
–
Mechanism: axial loading; fall
on outstretched hand
–
Monteggia’s
• Distal ulna with associated
dislocation of radial head
–
Galeazzi's
• Distal radius with associated
dislocation or subluxation of
distal radioulnar joint
–
Colles’
• Distal metaphysis of radius,
with displacement of distal
fragment dorsally
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Fractures (cont.)
• Distal radius/ulna fracture (cont.)
– Smith’s
• Distal radius, with displacement of distal
fragment toward palmar aspect
– S&S: normal fracture
– Concerns:
• Circulatory impairment
• Nerve damage
– Management: immobilization in a vacuum splint;
immediate physician referral
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Fractures (cont.)
• Forearm fractures
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Fractures (cont.)
• Scaphoid fracture
– S&S
• History of falling on an outstretched hand
• Point tenderness in anatomic snuff box
• Pain with inward pressure along long axis
• ↑ pain with wrist extension and radial deviation
– Management: standard acute; splint; physician referral
– Concern: aseptic necrosis
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Fractures (cont.)
• Lunate fracture
– Rare in sports
– S&S: dorsal wrist pain, swelling, and weakness of wrist
associated with use
– Concern: Kienböck’s disease
– Management: standard acute; splint; physician referral
• Hamate fracture
– Direct impact; when striking a stationary object with a
racquet or club in full swing
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Fractures (cont.)
– S&S
• Tenderness – hypothenar mass
• Painful RROM abduction of the small finger
• ↓ grip strength
– Management: standard acute; splint; physician referral
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Fractures (cont.)
• Triquetrum fracture
– Caused by impingement of ulnar styloid into dorsum of
triquetrum
– S&S
• History of acute wrist dorsiflexion injury or direct
trauma
• Pain – dorsal wrist over triquetrum
– Management: standard acute; splint; physician referral
• Metacarpal fracture (typical)
– Mechanism: axial compression
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Fractures (cont.)
– S&S:
• ↑ pain and palpable – palm, directly over involved
metacarpal
• ↑ pain with percussion and compression
– Management: immobilize in position of function; ice
without compression; immediate physician referral
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Fractures (cont.)
• Bennett’s fracture
– Articular fracture – proximal end of first metacarpal
– Mechanism: axial compression
– Pull of APL tendon displaces shaft proximally; deep volar
ligament holds small medial fragment in place →
fracture-dislocation
– S&S
• Localized pain and swelling; ↑ pain with inward
pressure long axis
– Management: standard acute; splint; immediate
physician referral
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Fractures (cont.)
• Rolando fracture
– Similar to Bennett’s fracture
– Intra-articular fracture – proximal end of first
metacarpal; tends to be more comminuted
– S&S: same as Bennett’s, but ↑ deformity
– Management: standard acute; splint; immediate
physician referral
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Fractures (cont.)
• Boxer’s fracture
– Distal metaphysis or neck of fourth or fifth
metacarpals
– Inherently unstable
– S&S
• Sudden pain, inability to grip, rapid swelling, and
deformity
• Point tenderness; crepitus
• ↑ pain with axial compression and percussion
– Management: standard acute; splint; immediate
physician referral
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Fractures (cont.)
• Phalangeal fracture
– Mechanism: compression; hyperextension
– S&S:
• ↑ pain with circulative compression of phalanx
• ↑ pain with percussion and compression (long axis)
– Management: standard acute; splint; immediate
physician referral
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Assessment
• History
• Observation/inspection
– Expose entire arm
• Palpation
– Pain, unable or unwilling to move wrist or hand;
determine the possibility of a fracture or
dislocation before moving the wrist or hand
– Proximal to distal
• Physical examination tests
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Range of Motion (ROM)
• Active range of motion (AROM)
– Forearm pronation/supination
– Wrist
• Flexion/extension
• Radial deviation/ulnar deviation
– Fingers and thumb
• Flexion/extension
• Abduction/adduction
• Opposition of thumb and little finger
• Passive range of motion (PROM)
– Normal end feel – tissue stretch
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ROM (cont.)
• Normal ranges
– Supination: 90°
– Pronation: 90°
– Wrist flexion: 80-90°
– Wrist extension: 70-90°
– Radial deviation: 15°
– Ulnar deviation: 30-45°
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ROM (cont.)
• Resisted range of motion (RROM)
–
Supination
–
Pronation
–
Wrist flexion
–
Wrist extension
–
Ulnar deviation
–
Radial deviation
–
Finger flexion/extension
–
Finger abduction/adduction
–
Thumb flexion/extension
–
Thumb abduction/adduction
–
Opposition
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ROM (cont.)
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ROM (cont.)
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Stress Tests
• Wrist ligamentous instability
tests
– Varus and valgus
• Finger ligamentous instability
tests
– Varus and valgus
– Anterior/posterior glide
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Special Tests
• Finkelstein’s test for de
Quervain’s tenosynovitis
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Special Tests (cont.)
• Flexor digitorum superficialis (test for rupture of
FDS)
• Flexor digitorum profundus
• Extensor tendon rupture
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Special Tests (cont.)
• Carpal tunnel
compression test
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Special Tests (cont.)
• Phalen’s wrist flexion test
• Tinel’s sign
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Special Tests (cont.)
• Pinch-grip test for anterior interosseous nerve entrapment
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Special Tests (cont.)
• Froment’s sign for ulnar
nerve paralysis
• Allen test for circulation
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Fracture Assessment
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Neurologic Tests
• Myotomes
– Scapular elevation - C4
– Shoulder abduction - C5
– Elbow flexion and/or wrist extension - C6
– Elbow extension and/or wrist flexion - C7
– Thumb extension and/or ulnar deviation - C8
– Abduction and/or adduction of fingers - T1
• Reflexes
– Biceps - C5-C6
– Brachioradialis - C6
– Triceps – C7
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Neurologic Tests (cont.)
• Dermatomes
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Rehabilitation
• Restoration of motion
– Concern: joint contractures and stiffness – begin
AROM ASAP
– Use of opposite hand to supply load
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
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