Wrist and Hand Unit
Anatomy, Injuries, Evaluations,
Treatments, and Rehabilitation
Anatomy of wrist
Bones: carpals and
metacarpals
Joints: radiocarpal,
carpal, metacarpal, and
phalangeal joints
Ligaments: “many at
each joint in the hand”
Musculature: “many
intrinsic and extrinsic
muscles”
Blood and Nerve Supply:
ulnar, median, radial
nerve and radial and
ulnar superficial and
deep palmar arch
arteries
Wrist and hand joints
Radiocarpal
joints:condyloid jt.
Permits flex/ext,
abd/add, circum.
Carpal joints:gliding
jts.
Stabilized by
ant/post interosseous
lig.
Metacarpal joints:
5 bones forming the
MCP jt
Condyloid jt. But the
thumb is a saddle jt.
Phalangeal joints:
interphalangeal is a
hinge jt. Ext/flex
only
Wrist ligaments:
Radius=radial collateral lig
attaches the radial
styloid to the scaphoid
Ulna=ulnar collateral lig.
Attaches the ulnar styloid
to thepisiform and
triquetral bone
Transverse carpal lig. =
roof of the carpal tunnel
Phalangeal ligaments:
PIP/DIP joint same
ligaments as the wrist.
Volar plate on the palmar
surface of the phalange
Extensor expansion=
sheath that expands over
the dorsal surface of the
phalange.
Assessment of Wrist, Hand, and
Finger Injuries
History
Observation
Palpation
Special Tests: Finklestein’s test, Tinel’s Sign,
Phalen’s test, valgus and varus stress test, Glide
test, Lunotriquetral Ballotment test
Circulatory and Neurological Evaluation
Allen test
Functional Evaluation
Carpal Tunnel Syndrome
Carpal tunnel syndrome
Etiology: transverse carpal lig. Is the roof of
the tunnel, 8 long flexor tendons and median N
pass through this. Over use of wrist flexion
and sometimes a direct blow can cause this.
Signs and symptoms: tingling, numbness over
the thumb, 2-3 phalanges, and palm of the
hand. Also thumb weakness
Management: rest, immobilization, NSAID’s
then surgery to relieve the compression by
cutting the transverse carpal lig.
Carpal Tunnel
Carpal Tunnel
Injuries of the wrist
Wrist Sprain
Etiology: Falling on hyperextended wrist most common
but you can fall on a flexed wrist
Signs and Symptoms: pain, swelling, limited ROM
Management: Severe sprain go for x-ray. For
mod/minor injury RICE and start exercise ASAP
Triangular Fibrocartilage Complex Injury (TFCC)
Etiology: fall on an outstretched hand in hyperextension
that compresses the TFCC between radioulnar jt and
carpals. UCL involved
Signs and Symptoms: pain along the ulnar side
of the wrist, swelling and pain in wrist extension
Management: referred to physician. If not properly
managed, permanent loss of motion and disability can
occur.
Tenosynovitis
Etiology: occurs to extensor carpi rad.
Longus/brevis mainly in wt. Lifters and rowers
chronic injury of repetitive use
Signs and Symptoms: pain in passive stretching
and swelling and tenderness
Management: RICE and NSAID’s, along with
increase ROM exercises in contrast baths. US
Tendinitis
Etiology: common flexor carpi rad./ulnaris=
overuse
Signs and Symptoms:pain in active/passive
stretching
Management: Same as above
Nerve Compression, Entrapment, Palsy
Etiology:direct blow- median/ulnar
nerve is involved. Median N is
compressed in the carpal tunnel.
Unlar N is compressed in the
tunnel of Guyon (pisiform and hook
of the hamate
Signs and Symptoms: sharp,
burning pain with possibility of
numbness. Ulanr N=
Bishops/Benediction hand 4/5th
finger is flexed
Ulnar/median n= claw hand distal
phalanx flexed, median N= drop
wrist or ape hand 2-5 distal
phalanx flexed and thumb
extended
Management: RICE, NSAID’s or
surgery for decompression
Fractured wrist
Dislocation of the Lunate Bone
Etiology: Most common of the carpals.
Fall on an outstretched hand. Dislocated
anteriorly (palmar side)
Signs and Symptoms: pain, swelling,
difficult to flex fingers/wrist
Management: send to Dr. to reduce
dislocation, 1-2 months recovery.
Scaphoid Fracture
Etiology: most frequent fx. Force on the
outstretched hand.
Signs and Symptoms: swelling, pt.
Tender over anatomical snuffbox. Pain
in radial flexion.
Management: Ice, splint, and early
immobilization. If not aseptic necrosis
might occur because of very poor blood
supply.
Scaphoid Fracture
Hamate Fracture
Etiology: direct contact to the wrist
while holding a a sports implement:
tennis racket, bat, golf club.
Signs and Symptoms: wrist pain,
weakness, pt. Tender over hamate.
Management: cast.
Wrist Ganglion
Etiology: synovial cyst, most commonly on the
back of the wrist
Signs and Symptoms: occasional pain, lump,
Management: direct pressure, US, or surgery
Mallet Finger
Etiology: blow to the tip of the finger
rupturing the extensor tendon.
Signs and Symptoms: pain about the
DIP jt. Unable to extend the finger.
Management: RICE splinted in extension.
Mallet finger
Boutonnière Deformity
Boutonniere deformity
Etiology:rupture of the
extensor tendon dorsal
to the middle phalanx.
Direct blow to an ext.
DIP/ flexed PIP joint
Signs and Symptoms:
inability to to extend
PIP joint.
Management: splint
the PIP in extension.
Ice applied
Boutonnière
Gamekeeper’s thumb
Etiology: sprain of the ulnar collateral
lig. MCP jt. Forceful abduction
Signs and Symptoms: pain over the
MCP, unable to pinch
Management: refer to orthopedist,
splint, ice, possible surgery.
Gamekeeper’s thumb
Collateral Lig. Sprain, volar
plate rupture, central slip tear
Etiology: PIP/DIP sprains, volar plate
rupture, central slip tear
Signs and Symptoms: pain, loss of
function, swelling, deformity
Management: RICE, x-ray, splinting,
taping later
PIP Dorsal dislocation
Etiology: Hyperext. With volar plate rupture
direct blow to finger
Signs and Symptoms: deformity, pain, swelling
Management: Rice, Dr for reduction, splinting
of 20-30 degrees of flexion for three weeks.
Then buddy taping
MCP dislocation
Etiology: twisting or shear force
Signs and Symptoms: pain, swelling, and
stiffness of the MCP joint and prox.
Phalanx is dorsally angulated 60-90
degrees
Management: Rice, splinting, Dr.
reduced, buddy taped and given early
ROM
Metacarpal fracture
Etiology: axial loading, fifth MC from boxing
Signs and Symptoms: pain deformity,
angular/rotational deformity
Management: RICE splinting, Dr. splint for 4
weeks
Bennett’s Fracture
Etiology: Carpometacarpal CMC jt. Of
the thumb.
Signs and Symptoms: pain swelling over
the base of the thumb
Management: referred to orthopedic
surgeon, ice, splint
De Quervain’s Disease( Hoffman’s disease)
Etiology: stenosing tenosynovitis in the thumb. First
tunnel of the wrist narrows and inflamed synovial lining.
Muscle involved would be the extensor pollicis brevis and
abductor pollicis longus. Constant wrist movement can be
a source of irritation
Signs and Symptoms: aching pain that radiates into the
hand or forearm. Movement of the wrist causes pain.
(+)Finklestein test. Muscle weakness of the thumb
extensors and abduction. Possible snapping/catching of
the tendons during movement
Management: immobilization,rest, cryotherapy, and
NSAID’s. US and Ice massage
Dupuytren’s Contracture
Etiology: Unknown
how it happens.
Nodules develop over
the palmar aponeurosis
that limit finger
extension and cause a
flexion deformity
Signs and Symptoms:
4th/5th finger stays in
flexion
Management: nodules
removed surgically
Trigger finger or thumb
Etiology:repeated movement
of tendons causes
tenosynovitis. Common
areas involve the flexor
tendons of the phalanges.
Signs and Symptoms: pain
while flexing thumb or
finger. Inability to extend
finger or thumb produces a
snapping sensation.
Management: same as
Dequervain’s disease, steroid
injection or splinting last
resort.
Trigger finger
Swan neck deformity
Etiology: The volar plate of the PIP jt. Is
most commonly injured from a severe
hyperextension force.
Signs and Symptoms: pain, swelling at PIP jt
and volar plate. More movement of
hyperextension of the PIP jt compared to
others
Management: Rice, splinting at 20-30 degrees
of flexion for 3 weeks
Swan neck deformity
Jersey finger
Etiology: rupture of flexor digitorum
profundus. From grabbing a jersey. 4th
phalange most commonly injured
Signs and Symptoms: pain, pt
tenderness, unable to flex distal phalanx
Management: splint and surgery.
Fingernail deformity
Scaling or ridging= psoriasis
Ridging and poor development=
hyperthyroidism
Clubbing and cyanosis= congenital
heart disorders or chronic respiratory
disease
Spooning or depression= chronic
alcoholism or vitamin deficiencies