Evaluation and
Treatment of Common
Sports Injuries to the
Wrist and Hand
Mary L. Mundrane-Zweiacher,
MPT, ATC, CHT
Most often – You are the Expert!!
First CMC Joint
Extrinsic Hand Muscles: Volar
Aspect

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Palmaris longus
Flexor carpi radialis
Flexor carpi ulnaris
Flexor Pollicis Longus
Flexor Digitorum
Profundus (FDP)
Flexor Digitorum
Superficialis (FDS)
The Extrinsic Hand Muscles:
Volar Aspect


Flexor Digitorum
Profundus (FDP)
Flexor Digitorum
Superficialis (FDS)
Extrinsic Hand Muscles: Dorsal
Aspect





Extensor Pollicis
Longus (EPL)
Extensor Pollicis
Brevis (EPB)
Abductor Pollicis
Longus (APL)
Extensor indicis
Extensor Digitorum
Communis (EDC)
Visible Extensor Mechanism
Extrinsic Hand Muscles: Dorsal
Aspect




Extensor carpi radialis
longus ( ECRL)
Extensor carpi radialis
brevis (ECRB)
Extensor carpi ulnaris
Extensor digiti minimi
The Intrinsic Hand Muscles

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Lumbricales
Dorsal Interossei
Palmar (Volar)
Interossei
Thenar Muscles
Hypothenar Muscles
Adductor Pollicis
Intrinsic Hand Muscles
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
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Lumbricales
Dorsal Interossei
Palmar (Volar)
Interossei
Thenar Muscles
Hypothenar Muscles
Adductor Pollicis
Intrinsic Hand Muscles


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

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Lumbricales
Dorsal Interossei
Palmar (Volar)
Interossei
Thenar Muscles
Hypothenar Muscles
Adductor Pollicis
Volar Plate
Phases of Connective Tissue
Healing



Inflammatory Phase
Fibroplastic Phase
Remodeling Phase
Inflammatory Phase

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vasodilation
hyperemia
increased cell permeability
increased vascularity
cell migration
debris removal
Fibroplastic Phase





re-epithelialization causing wound closure (skin)
fibroplasia – fibroblasts are activated and move along
the fibrin meshwork to generate new collagen, elastin,
GAG’s, proteoglycans, and glycoproteins
neovascularization – regeneration of small blood
vessels
wound contraction
collagen with random alignment
Remodeling Phase



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
consolidation phase
increased wound strength
realignment of collagen
reduction of abnormal cross links
maturation phase – the scar links change
from weak hydrogen bonds to strong covalent
bonds
AROM/PROM/AAROM

Most reliable method for measuring finger/wrist
flexion and extension is the volar/dorsal
technique

Bilateral comparison
Strength/Grip testing


Submax effort can be ruled out with use of
rapid-exchange grip testing and bell curve with
five position grip testing with a Jamar
Five position grip testing can also assist with
your tendon function assessment
Sensibility
Examination/Sensation Testing

Done to screen for nerve compression

Semmes Weinstein light touch threshold is the
most sensitive clinical test for detecting nerve
compression
X-Ray Studies

Variance (assessed on X-Ray with the forearm in
neutral rotation)
Neutral ulnar variance – the head of the distal ulna is
even with the distal end of the radius
 Positive ulnar variance – the head of the ulna
extends distally beyond the distal radius
 Negative ulnar variance – the head of the ulna is
more proximal than the distal radius

Common Finger/Hand Injuries

Mallet Finger – is a disruption of the terminal
aspect of the extensor tendon either because of
laceration, rupture, or avulsion
1. Mechanism – forceful flexion of the dip
joint when the finger is being actively
extended
Mallet finger
Conservative Treatment for acute
mallet finger (less than 3 weeks
old)
Acute Mallet Finger Treatment

a. 0-6 weeks – continual splinting of the dip
joint in 10-15deg hyperextension (volar splints
work best)
- the splint may be removed once a day to
prevent skin breakdown or maceration but
the hyperextension must be maintained
- if the dip joint bends, the splint wearing
time must be started over
Splint choices
Acute Mallet Finger Treatment

after 6 weeks – active AROM at the dip joint is
allowed in a limited range and for limited
sessions each day. The mallet finger splint is
worn outside of exercise. If an extensor lag
develops, AROM sessions are decreased or put
on hold and continual splinting resumed.
Acute Mallet Finger Treatment


at 8 weeks – if no extensor lag, the mallet splint
is discontinued during the day but still worn at
night. Gentle strengthening with putty, hand
exerciser, etc can be added
at 9 weeks – the mallet splint is discontinued if
no lag

no PROM to the dip joint is done with mallet finger,
only active
Chronic Mallet Finger Treatment

0-8 weeks – continual splinting of the dip joint
in 10-15deg hyperextension (sometimes the dip
joint may be pinned)
- the splint may be removed once a day to
prevent skin breakdown or maceration but
the hyperextension must be maintained
-if not pinned and if the dip joint bends, the
splint wearing time must be started over
Chronic Mallet Finger Treatment


after 8 weeks – active AROM at the dip joint is allowed
in a limited range and for limited sessions each day.
The mallet finger splint is worn outside of exercise. If
an extensor lag develops, AROM sessions are decreased
or put on hold and continual splinting resumed.
c. at 9 weeks – if no extensor lag, the mallet splint is
gradually discontinued during the day but still worn at
night. Decreased 1 hour per day is typical. PROM may
be added if the dip extensor lag is < 10deg.
Surgical Treatment for Mallet
Finger (greater than 3 weeks old)


is indicated when the avulsed distal fragment is
50% or greater of the articular surface of the
distal phalanx
surgical procedure – an incision is made along
the area of the distal phalanx and dip joint. The
displaced bone fragment is re-approximated
along the distal phalanx. A k-wire is used to
position the dip joint in extension.
Surgical Candidate for Mallet
Finger
Surgical Treatment for Mallet
Finger


3 days post-up – Dressing is removed and edema
control is begun. A splint is made to protect the
distal tip and pin and worn continually. Pin is
cleaned daily with hydrogen peroxide (depending
on physician)
at 6 weeks – the pin is removed by the physician
with continual splinting of the dip joint except
during exercise sessions

AROM exercises are initiated to the dip joint (6 times a
day for 5-10min)
Surgical Treatment for Mallet Finger




at 7 weeks – active AROM at the dip joint is
allowed in a limited range and for limited
sessions each day. Gentle ROM exercises may
be initiated to the dip joint as long as and
extensor lag is not present at the dip joint.
at 9 weeks – splint wearing time is steadily
decreased usually 1 hour per day
at 10 weeks – discontinue splint during the day
at 12 weeks – discontinue splint at night
Flexor Digitorum
Profundus Injury
versus
Flexor Digitorum
Superficialis Injury
FDS
FDP
Flexor Digitorum Profundus
Rupture or Avulsion
•
Mechanism – a forceful eccentric load on the
FDP can cause an avulsion off the distal
phalanx
•
Called Jersey Finger because this frequently
occurs as a player grabs another player and the
finger becomes caught in their jersey
Forceful extension of the 4th dip
joint
Rupture of the FDP
Flexor Digitorum Profundus
Rupture or Avulsion
Flexor Digitorum Profundus
Rupture or Avulsion

Signs and Symptoms:
swelling and discomfort at the DIP joint
 Patient will not be able to flex the DIP joint actively


Treatment:
-RECOGNITION – often missed if FDS function
is intact
 -Referral to MD (surgery to re-attach tendon)

Flexor Digitorum Superficialis Injury
(to 3rd through 5th fingers)


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Uncommon in athletics
Mechanism – mostly lacerations from sharp
objects
Sign: patient will not be able to flex PIP joint of
fingers with the other two fingers held in full
extension
Treatment:
-referral to MD
Boutonniere Deformity versus
Volar Plate Contracture
Boutonniere Deformity
Boutonniere Deformity –
Extensor tendon injury at Zone 3
and the lateral bands move volar
to the axis of the PIP joint




. Mechanism – volar dislocation or subluxation
of the PIP joint.
-because the lateral bands are volar to the
axis, when the extensor contracts, instead of
extending the joint, they flex the PIP joint.
-over time, the extensor force is
concentrated on the DIP joint, causing DIP
hyperextension and loss of DIP flexion.
-in early stages, there is full passive extension
of the PIP joint.
Boutonniere Deformity
Treatment
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KEY – recognition of the injury
Treatment:
possible surgical repair
consult with a hand therapist
continuous splinting in extension, buddy taping
is not sufficient
finger splints are generally accepted by officials
if they are covered with tape.
Splinting for Boutonniere
Deformity
Good
Bad
Boutonniere Deformity
Treatment



when appropriate healing has occurred, early
short-arc motion
exercise where the PIP joint is held in extension
and the DIP is flexed
night splinting may be required for 2 to 3
months, and protective splinting for the
remainder of the season
Volar Plate Contracture

Mechanism - commonly injured with dorsal
dislocation of the PIP joint (hyperextension
injury).
the volar plate is a fibrocartilaginous structure on
the volar aspect of the PIP joint. In response to
injury it can become fibrotic and immobile, thus
limiting PIP joint extension.
 PIP joint extension will be limited actively and
passively

Treatment for the Dorsal PIP
Dislocation



for a grade I– splinted in slight flexion until acute
pain subsides.
b. for a grade II - a dorsal splint with 20deg to
30deg of PIP joint flexion for approximately 7 to 14
days. After immobilization, the finger can be taped
to an adjacent finger for protection. Patient needs
to be watched for a missed Boutonniere.
c. for a grade III - as per grade unless reduction is
not maintained, then surgery is appropriate
Treatment for the Volar Plate
Contracture



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
Modalities to increase mobility of the volar plate
Volar plate mobilization
PIP ext stretches, with cuing to avoid
hyperextension of the DIP joint
Possible night time static splinting in progressive
extension
Possible day time dynamic splinting
Gamekeeper’s Thumb/Skier’s
Thumb

sprain of the Ulnar collateral ligament of
the thumb MP joint (more common than
injury to the radial collateral ligament)
Gamekeeper’s Thumb/Skier’s
Thumb
Gamekeeper’s Thumb/Skier’s
Thumb

Mechanism

Forced radial deviation of the thumb


For radial collateral ligament injury, forced ulnar deviation
Signs and Symptoms
pain and swelling over the collateral ligament
 tenderness
 laxity and pain noted with passive stress test to the
respective ligament
 pinch is often painful and weak

Gamekeeper’s Thumb/Skier’s
Thumb

Treatment- non surgical conservative
 0-4 weeks - thumb short opponens splint –
motion at the mcp joint must be restricted
 splint will need to be remolded as swelling
decreases
 anti-inflammatory modalities
 maintain ROM/function of wrist and
fingers while maintaining thumb stability
Short Opponens Splint
Gamekeeper’s Thumb/Skier’s
Thumb

Treatment- non surgical conservative

4-6 weeks – if the pain is resolving, gentle AROM to
the thumb
Not uncommon for this to be painful and immobilized
for 6 weeks before AROM
 fluido/MHP/etc when no longer acute swelling


6 weeks – if the patient is asymptomatic, unrestricted
AROM to the thumb

The short opponens splint can be worn for comfort and
protection when not exercising
Gamekeeper’s Thumb/Skier’s
Thumb

Treatment- non surgical conservative
 8 weeks – if the patient is not tender along the
collateral ligament
 Splint can be discontinued except for
activities requiring heavy use of the hand
 Strengthening of the hand/wrist but tight,
sustained pinch or gripping with the
hand/thumb must be avoided for 10-12
weeks
Gamekeeper’s Thumb/Skier’s
Thumb

Treatment – surgical
Surgery is indicated to repair the UCL or RCL if the
tear is complete and there is instability of the joint.
 A Stener’s lesion involves complete rupture of the
UCL and the adductor apponeurosis displaces distal
to the rupture causing the ligament to move away
from the insertion. The UCL will not heal properly,
and thus restore joint stability unless it is surgically
restored.

Stener’s Lesion
Gamekeeper’s Thumb/Skier’s
Thumb

Treatment – surgical
 10-14 days postop
 Edema control
 Forearm based thumb splint with the ip
joint free, worn continually (splint should
be molded to support the mcp joint well
 4 weeks postop
 Pin is removed
Thumb Spica Splint
Gamekeeper’s Thumb/Skier’s
Thumb

Treatment – surgical

6 weeks postop


AROM/AAROM to emphasize thumb/wrist flexion and
extension, and thumb
adduction/abduction/circumduction
7 weeks postop
Splint revised to a short opponens splint
 PROM exercises begun to the thumb
 Dynamic splints are sometimes used to restore mcp and
ip thumb motion but care needs to be taken to avoid
stressing collaterals

Gamekeeper’s Thumb/Skier’s
Thumb

Treatment – surgical

8 weeks postop
Splint-wearing may be decreased to only times of heavy
lifting and activities requiring a right, sustained pinch
 Dexterity and Progressive strengthening exercise as
tolerated (putty and hand exerciser)


10-12 weeks postop

General unrestricted use of the hand in most activities
except for weighted resistance or sustained power
pinching (that can be resumed at >er 14 weeks)
Radial Collateral Ligament Injury

Adductor Pollicis
makes this injury
significant
Colles/Distal Radius Fracture
Barton’s Fracture
Zone Examination of
the Wrist
Radial dorsal zone
Central dorsal zone
Ulnar dorsal zone
Radial volar zone
Ulnar volar zone
Radial Dorsal Zone
Structures to palpate:
 Radial styloid
 Scaphoid
 Scaphotrapezial joint
 Trapezium
 Base of the first met
 1st MCP joint
The Extrinsic Hand Muscles:
Dorsal Aspect
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
Extensor Pollicis Longus
(EPL)
Extensor Pollicis Brevis
(EPB)
Abductor Pollicis
Longus (APL)
Extensor indicis
Extensor Digitorum
Communis (EDC)
Radial styloid tenderness may
indicate:



Contusion
Fracture
If tenderness is accentuated with radial deviation
(RD) – radioscaphoid arthritis
Scaphoid tenderness in the
snuffbox may indicate:



scaphoid fracture
scaphoid non-union
scaphoid instability
Scaphoid Non-Union
Scaphoid and trapezium
tenderness may indicate:



scaphoid instability
ST arthritis
if accompanied by central dorsal complaints, see
section III B4
First CMC joint tenderness may
indicate:


with a (+) Grind test (pain with axial compression of
the 1st met with rotation) – 1st CMC joint
degenerative arthritis
with a (+) instability/laxity test (more laxity is
present when the 1st met is distracted and moved side
to side or RU direction while the trapezium is stabilized
versus on the uninjured side) – 1st CMC joint
instability or laxity
Instability/Laxity Test
st
1
CMC Splint
Extensor pollicis brevis (EPB)
and abductor pollicis longus
(APL) tenderness may indicate:

with a (+) Finkelstein’s test (pain localized
to the radial aspect of the wrist when thumb
flexion is combined with UD of the wrist) –
de Quervain’s tenosynovitis
st
1
 1st
CMC DJD versus
deQuervain’s
CMC DJD can be confused
with deQuervain’s
tenosynovitis so a Grind test
should also be done
deQuervain’s Tenosynovitis
•
•
Stenosing tenosynovitis of the
APL and EPB tendons in the
sheath
Anatomy – the APL and EPB
tendons pass through the first
dorsal compartment of the extensor
retinaculum. There is a synovial
sheath under the retinaculum
encasing the tendons
deQuervain’s Tenosynovitis

Etiology –
Microtrauma – forceful, sustained, or repetitive
thumb abduction and simultaneous wrist UD. Some
MD’s feel that RD with pinch is the most stressful
because the APL and EPB tendons are taut and
sharply angulated at the wrist and trapeziometacarpal
joint
 Acute trauma – sudden wrenching of the wrist and
thumb while trying to restrain an object or person or
a fall

deQuervain’s Tenosynovitis

Signs and Symptoms
radial-sided wrist pain over the 1st dorsal
compartment
 pain can radiate to the thumb
 increased pain with increased tensile load on the
EPB or APL
 (+) Finkelstein’s test
 wrist flexion will intensify the pain and extension
should relieve it

deQuervain’s Tenosynovitis

Signs and Symptoms cont’d
painful thumb extension
 MRI may show increased fluid in the 1st extensor
compartment
 rarely pseudotriggering
 can co-exist with or be confused with
trapeziometacarpal arthritis, scaphoid fractures,
scapholunate instability, intersection syndrome,
radial neuritis, and radioscaphoid/scaphotrapezoid
joint problems

deQuervain’s Tenosynovitis

Treatment
splint to minimize UD at wrist and substitutes power
grip for pinch
 anti-inflamatory modalities
 gentle gliding of tendons and gentle AROM
 possible injection into sheath
 after failed conservative management, surgical
release of the 1st dorsal compartment
 Make sure 1st CMC was assessed

EPB and APL muscle belly
tenderness or crepitus may
indicate:

with active thumb movement or friction and
crepitus palpated 4 to 5 cm proximal to the
radial styloid during wrist flexion and
extension with radial deviation -intersection
syndrome
Intersection Point
Intersection Syndrome


stenosing tenosynovitis of the second dorsal
compartment
Anatomy – the intersection where the radial
wrist extensor tendons pass underneath the
muscle bellies of the APL and EPB
approximately 4 cm proximally to Lister’s
tubercle
Intersection Syndrome


Etiology
 repetitive wrist and/or thumb activities
 frequently seen in weight lifters and rowers
 possible bursal inflammation
Signs and Symptoms
 pain and swelling of the overlying muscle bellies of
the APL and EPB muscles
 possible redness
 possible painful crepitus with thumb and wrist
movements
 grip and pinch are often painful and weak
Intersection Syndrome

Treatment
forearm or thumb spica splint
 anti-inflammatory modalities
 gentle gliding of tendons and gentle AROM
 possible injection/possible surgical release

Numbness, tingling, burning,
and pain over the dorsal radial
aspect of the hand may
indicate:


(+) Tinel’s with percussion along the course
of the nerve produces tingling and pain
which may radiate distally – Wartenberg’s
Syndrome or Neuralgia (irritation of the
Dorsal Radial Sensory Nerve)
with more proximal complaints – CN root
irritation?????
Tinel’s Test
Wartenberg’s Syndrome

Anatomy – the dorsal radial sensory nerve
(DRSN) travels along the dorsal radial aspect of
the wrist (very superficial) between the tendons
of the brachioradialis and the ECRL.
Wartenberg’s Syndrome

Etiology – because of the superficial location,
the DRSN is susceptible to compressive forces
(ex. from tight wrist straps). Repetitive
pronation, flexion, and UD (pronation causes
the ECRL tendon to cross under the
brachioradialis tendon and compress the
DRSN).
Wartenberg’s Syndrome

Signs and Symptoms
 flexion and UD puts the nerve on stretch
which increases pain
 numbness, tingling, burning and pain over the
dorsal radial aspect of the hand
 (+) Tinel’s
 possible decreased sensation over the dorsal
web and thumb dorsum
Wartenberg’s Syndrome

Treatment
 anti-inflammatory modalities (phonophoresis)
 heat modalities (not cold)
 gentle stretching
 desensitization
Central Dorsal Zone
Structures to palpate:
 Distal radius (dorsal rim)
 Lister’s tubercle
 Lunate
 Scapholunate interval
 Capitate
 2nd and 3rd metacarpal bases
 2nd – 4th extensor tendons
 Posterior interosseus nerve (PIN)
The Extrinsic Hand Muscles:
Dorsal Aspect





Extensor Pollicis Longus
(EPL)
Extensor Pollicis Brevis
(EPB)
Abductor Pollicis
Longus (APL)
Extensor indicis
Extensor Digitorum
Communis (EDC)
Distal radius dorsal rim
tenderness may indicate:


(-) X-Ray changes – Impingement of the
scaphoid on the radius
(+) X-Ray changes and pain with pressure or
with hyperextension and radial deviation of the
wrist – osteophyte
Lunate tenderness only, may
indicate:

(+) X-Ray changes – Kienbock’s disease
(avascular necrosis of the lunate)
Scapholunate interval tenderness
may indicate:


patient history of recurrent nodular swelling in the
wrist dorsum and complaints of pain with deep
palpation that may not be detected by clinical exam
– dorsal wrist ganglion (***tenderness may be
present with wrist flexion or extension secondary to
compression of the ganglion)
with localized non- nodular swelling –
scapholunate ligament injury
Scapholunate interval tenderness
may indicate:

with localized non-nodular swelling and a (+) finger
extension test (pain in the scapholunate region
with resisted finger extension with the wrist in
flexion) – dorsal wrist syndrome or scapholunate
synovitis
Finger Extension Test
Scaphoid (in the snuffbox) and
scaphotrapezial-trapezoid joint
tenderness with synovitis may
indicate:

and dorsal scapholunate synovitis, and (+)
finger extension test, and a positive
Watson/scaphoid shift test (reproduction
of the patient’s symptoms and usually a
painful clunk when the examiner applies
pressure over the volar prominence of the
scaphoid as the wrist is moved from UD to
RD with slight flexion)– scaphoid rotary
subluxation
Watson/Scaphoid Shift Test
Watson Shift Test Moving into
RD and Flexion
Terry Thomas Sign
SLAC Wrist – ScaphoLunate
Advanced Collapse
2nd and 3rd metacarpal base and
CMC tenderness may indicate:



with a bony prominence at the 2nd and 3rd metacarpal
bases – carpal boss
and/or a (+) Linscheid test (pain localized to the
CMC joint area when the metacarpal heads are moved
in a palmar and dorsal direction on one another) – 2nd
and/or 3rd CMC ligament injury or instability
and/or a (+) metacarpal stress test (pain at the CMC
joint when the MCP joint is fully flexed and the
metacarpal is pronated and supinated) – CMC joint
injury
Linscheid’s Test
Metacarpal Stress Test
Ulnar Dorsal Zone
Structures to palpate:
 Ulnar styloid
 Ulnar head
 DRUJ (distal radial ulnar joint)
 TFCC (triangular fibrocartilage complex)
 Hamate
 Triquetrum
 Lunotriquetral interval (LT interval)
 Fourth and fifth CMC joints
 Extensor carpi ulnaris (ECU)
The Extrinsic Hand Muscles:
Dorsal Aspect





Extensor Pollicis Longus
(EPL)
Extensor Pollicis Brevis
(EPB)
Abductor Pollicis
Longus (APL)
Extensor indicis
Extensor Digitorum
Communis (EDC)
Ulnar Dorsal Joint
Ulnar styloid tenderness may
indicate:


ulnar styloid fracture
ulnar fracture nonunion
Ulnar Compression Test
Fovea tenderness may indicate:


with (+) TFCC load test (pain, clicking, or crepitus
and reproduction of the patient’s symptoms when
the wrist is ulnarly deviated and axial loaded, and
then moved volarly and dorsally , or the forearm is
rotated)- Ulnocarpal abutment (ulnar impaction
syndrome) or TFCC tear
with (+) TFCC load test and a (+) relocation test
(pain reduction when the subluxed ulnar carpus is
relocated. The combined movement of pronation,
and anterior to posterior glide of the carpus on the
ulna relocates the carpus into normal alignment–
TFCC tear/ulnocarpal instability
TFCC Load Test
Relocation Test
Triangular Fibrocartilage
Complex Tear
Triangular Fibrocartilage
Complex Tear

Anatomy
 consists of articular disc (triangular
fibrocartilage), meniscus homologue
(lunocarpal), ulnocarpal ligament, dorsal &
volar radioulnar ligament, and ECU sheath
 only the peripheral 15-20% of the TFCC has
a blood supply
Triangular Fibrocartilage
Complex Tear

Function
 TFCC is main stabilizer of distal radioulnar
joint, in addition to contributing to ulnocarpal
stability
 volar TFC prevents dorsal displacement of
ulna and is tight in pronation
 dorsal TFC prevents volar displacement of
ulna and is tight in supination
Triangular Fibrocartilage
Complex Tear

Function
 during axial loading, the radius carries the
majority of load (82%), and the ulna a smaller
load (18%)
 increasing the ulnar variance to a positive
2.5 mm increases the load transmission
across the TFCC to 42%
 with the TFCC excised, the radial load
increases to 94%;
Triangular Fibrocartilage
Complex Tear

Mechanism
Peripheryl tears are almost always secondary to
ulnar deviation and forearm rotation with
compressive load on the TFCC
 Central tears are associated with degenerative
processes or trauma
 A positive ulnar variance is a predisposing factor

Triangular Fibrocartilage
Complex Tear

Signs and Symptoms
pain with forearm rotation (especially pronation),
ulnar deviation, and gripping
 a painful “click”
 tenderness between the ulna and triquetrum
 (+) TFCC load test
 X-Rays may show an avulsion of the ulnar styloid or
a tilt to the lunate and triquetrum. Ulnar variance
will also be assessed.

Triangular Fibrocartilage
Complex Tear

Signs and Symptoms – diagnostic tests
Triple Injustion Arthrography – study of choice with
tears being revealed as the contrast dye passes thru
the radiocarpal joint and DRUJ
 MRI – a complete tear would show a full thickness
disruption which would extend thru the disc

Triangular Fibrocartilage
Complex Tear

Treatment (depends on location of tear)
 Non-surgical:
 Application of a Sugartong or Muenster splint
that immobilizes the forearm in neutral because
this is the best position to allow the TFCC to heal
 Activity modification
 Steroid injections
 Anti-inflammatory modalities
 Stabilization exercises
Triangular Fibrocartilage
Complex Tear

Treatment (depends on location of tear)
 Surgical:
 Central tears are debrided while peripheryl tears
are repaired.
 Ulnar shortening if there is a positive ulnar
variance
 Wafer procedure
Radial Volar Zone
Structures to palpate:
 Radial styloid
 Scaphoid tuberosity
 STT joint
 Trapezial ridge
 Flexor carpi radialis (FCR)
 Palmaris longus (if present)
 Flexor tendons to the fingers
 Medial nerve
 Radial artery
The Extrinsic Hand Muscles:
Volar Aspect
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Palmaris longus
Flexor carpi radialis
Flexor carpi ulnaris
Flexor Pollicis Longus
Flexor Digitorum
Profundus (FDP)
Flexor Digitorum
Superficialis (FDS)
Radial styloid tenderness may
indicate:


distal radius fracture
with increased pain upon wrist extension and
radial deviation – radiocarpal ligament
injury
Volar scaphoid tenderness may
indicate:

scaphoid disease
Complaints of numbness,
pain, or tingling from the
distal wrist into the
fingers in the median
nerve distribution may
indicate:



with a (+) Tinel’s sign/test (pain and tingling
radiates to the fingers in the median nerve
distribution when the median nerve is gently
percussed at the wrist level – carpel tunnel
syndrome
and/or a (+) Phalen’s test (numbness and tingling
in the distribution of the median nerve with passive
flexion of the wrist for 15 to 60 seconds) – carpel
tunnel syndrome
with a (+) Lumbicale pinch test (reproduction of
the signs and symptoms when the patient is asked to
hold a sheet of paper in a lumbricale pinch – carpel
tunnel caused by a more proximal origin of the
lumbricales
Phalen’s Test
Lumbricale Pinch Test
Carpal Tunnel Syndrome
CRPS
CRPS
Ulnar volar zone
Structures to palpate:
 Pisiform
 TFCC (triangular fibrocartilage complex)
 Hook of the hamate
 Flexor carpi ulnaris (FCU)
 Ulnar nerve
 Ulnar artery
Hook of the hamate tenderness
may indicate:

with pain accentuated with resisted flexion of
the 4th and 5th finger with the wrist in UD –
hamate fracture
Complaints of ulnar-sided pain
and coldness and a (+) Allen’s
test for the ulnar artery may
indicate:

ulnar hammer/hypothenar hammer
syndrome
Complaints of numbness and
paresthesias in the 4th and 5th
fingers and possibly a (+) Tinel’s
sign

cyclist’s palsy (ulnar nerve compression
within Guyon’s Canal)
Case Study
Mid Range Strengthening
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