Chapter 24: The Forearm, Wrist,
Hand and Finger
Anatomy of the Forearm
Blood and Nerve Supply
• Most of the flexors are supplied by the
median nerve
• Most of the extensor are controlled by the
radial nerve
• Blood is supplied by the radial and ulnar
arteries
Assessment of the Forearm
• History
– What was the cause?
– What were the symptoms at the time of injury,
did they occur later, were they localized or
diffuse?
– Was there swelling and discoloration?
– What treatment was given and how does it feel
now?
• Observation
– Visually inspect for deformities, swelling and
skin defects
– Range of motion
– Pain w/ motion
• Palpation
– Palpated at distant sites and at point of injury
– Can reveal tenderness, edema, fracture,
deformity, changes in skin temperature, a false
joint, bone fragments or lack of bone continuity
•Palpation: Bony and Soft Tissue
• Proximal head of
radius
• Olecranon process
• Radial shaft
• Ulnar shaft
• Distal radius and ulna
• Radial styloid
• Ulnar head
• Ulnar styloid
•
•
•
•
•
Distal radioulnar joint
Radiocarpal joint
Extensor retinaculum
Flexor retinaculum
Extensor carpi radialis
longus and brevis
• Extensor carpi ulnaris
• Brachioradialis
• Extensor pollicis
longus and brevis
•Palpation (continued)
• Abductor pollicis
longus
• Extensor indicus
supinator
• Flexor carpi radialis
• Palmaris longus
• Flexor digitorum
superficialis
• Flexor digitorum
profundus
• Flexor pollicis longus
• Pronator quadratus
• Pronator teres
Recognition and Management of
Injuries to the Forearm
• Contusion
– Etiology
• Ulnar side receives majority of blows due to arm
blocks
• Can be acute or chronic
• Result of direct contact or blow
– Signs and Symptoms
• Pain, swelling and hematoma
• If repeated blows occur, heavy fibrosis and possibly
bony callus could form w/in hematoma
• Contusion (continued)
– Management
• Proper care in acute stage involves RICE for at least
one hour and followed up w/ additional cryotherapy
• Protection is critical - full-length sponge rubber pad
can be used to provide protective covering
• Forearm Splints
– Etiology
• Forearm strain - most come from severe static
contraction
• Cause of splints - repeated static contractions
• Difficult to manage
– Signs and Symptoms
• Dull ache between extensors which cross posterior
aspect of forearm
• Weakness and pain w/ contraction
• Point tenderness in interosseus membrane
– Management
• Treat symptomatically
• If occurs early in season, strengthen forearm; when
it occurs late in season treat w/ cryotherapy, wraps,
or heat
• Can develop compartment syndrome in forearm as
well and should be treated like lower extremity
• Forearm Fractures
– Etiology
• Common in youth due to falls and direct blows
• Ulna and radius generally fracture individually
• Fracture in upper third may result in abduction
deformity due pull of pronator teres
• Fracture in lower portion will remain relatively
neutral
• Older athlete may experience greater soft tissue
damage and greater chance of paralysis due to
Volkman’s contracture
– Signs and Symptoms
• Audible pop or crack followed by moderate to
severe pain, swelling, and disability
• Edema, ecchymosis w/ possible crepitus
• Management
– Initially
RICE
followed by
splinting
until
definitive
care is
available
– Long term
casting
followed by
rehab plan
• Colles’ Fracture
– Etiology
• Occurs in lower end
of radius or ulna
• MOI is fall on
outstretched hand,
forcing radius and
ulna into
hyperextension
• Less common is the
reverse Colles’
fracture
– Signs and Symptoms
• Forward displacement of radius causing visible
deformity (silver fork deformity)
• When no deformity is present, injury can be passed
off as bad sprain
• Extensive bleeding and swelling
• Tendons may be torn/avulsed and there may be
median nerve damage
– Management
•
•
•
•
Cold compress, splint wrist and refer to physician
X-ray and immobilization
Severe sprains should be treated as fractures
Without complications a Colles’ fracture will keep
an athlete out for 1-2 months
• In children, injury may cause lower epiphyseal
separation
• Madelung Deformity
– Etiology
• Developmental deformity of the wrist
• Associated with changes in radius, ulna and carpal
bone  results in palmar and ulnar wrist
subluxations
• Common in female athletes – particularly gymnasts
• Carpals become wedged between radius and ulna
following epiphyseal plate changes
– Signs and Symptoms
• Bowing of radius and ulna evident on X-ray
• Wrist pain and loss of forearm rotation
• Palmar subluxation with prominence of radius and
ulnar styloid processes
• Madelung Deformity (continued)
– Management
• Therapeutic modalities and NSAID’s for pain
• Wrist can be taped or braced to prevent wrist
extension
• Typically corrected surgically in athletes with
chronic pain and disability
Anatomy of the Wrist, Hand and
Fingers
•Blood and Nerve Supply
• Three major nerves
– Ulnar, median and
radial
• Ulnar and radial
arteries supply the
hand
– Two arterial arches
(superficial and deep
palmar arches)
Assessment of the Wrist, Hand
and Fingers
• History
–
–
–
–
–
–
–
–
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of, pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?
• Observation
–
–
–
–
–
Postural deviations
Is the part held still, stiff or protected?
Wrist or hand swollen or discolored?
General attitude
What movements can be performed fully and
rhythmically?
– Thumb to finger touching
– Color of nailbeds
•Palpation: Bony
•
•
•
•
•
•
•
•
•
Scaphoid
Trapezoid
Trapezium
Lunate
Capitate
Triquetral
Pisiform
Hamate (hook)
Metacarpals 1-5
• Proximal, middle and
distal phalanges of the
fingers
• Proximal and distal
phalanges of the
thumb
•Palpation: Soft Tissue
• Triangular fibrocartilage
• Ligaments of the carpals
• Carpometacarpal joints
and ligaments
• Metacarpophylangeal
joints and ligaments
• Proximal and distal
interphylangeal joints
and ligaments
• Flexor carpi radialis
• Flexor carpi ulnaris
• Lumbricale muscles
• Flexor digitorum
superficialis and
profundus
• Palmer interossi
• Flexor pollicis longus
and brevis
• Abductor pollicis
brevis
• Opponens pollicis
• Opponens digiti
minimi
•Palpation: Soft Tissue
• Extensor carpi radialis
longus and brevis
• Extensor carpi ulnaris
• Extensor digitorum
• Extensor indicis
• Extensor digiti minimi
• Dorsal interossi
• Extensor pollicis
brevis and longus
Abductor pollicis
longus
• Special Tests
– Finklestein’s Test
•
•
•
•
Test for de Quervain’s syndrome
Athlete makes a fist w/ thumb tucked inside
Wrist is ulnarly deviated
Positive sign is pain indicating stenosising
tenosynovitis
• Pain over carpal tunnel could indicate carpal tunnel
syndrome
– Tinel’s Sign
• Produced by tapping over transverse carpal ligament
• Tingling, paresthesia over sensory distribution of the
median nerve indicates presence of carpal tunnel
syndrome
• Phalen’s Test
– Test for carpal tunnel
syndrome
– Position is held for
approximately one
minute
– If test is positive, pain
will be produced in
region of carpal tunnel
– Valgus/Varus and Glide Stress Tests
• Tests used to assess ligamentous integrity of joints
in hands and fingers
• Valgus and varus tests are used to test collateral
ligaments
• Anterior and posterior glides are used to assess the
joint capsule
• Lunotriquetral
Ballotment Test
– Stabilize lunate while
sliding the triquetral
anteriorly and
posteriorly
– Assessing laxity, pain
and crepitus
– Positive test indicates
instability that often
results in dislocation of
the lunate
– Circulatory and Neurological Evaluation
• Hands should be felt for temperature
– Cold hands indicate decreased circulation
• Pinching fingernails can also help detect circulatory
problems (capillary refill)
• Allen’s test can also be used
– Athlete instructed to clench fist 3-4 times, holding it on the
final time
– Pressure applied to ulnar and radial arteries
– Athlete then opens hand (palm should be blanched)
– One artery is released and should fill immediately (both
should be checked)
• Hand’s neurological functioning should also be
tested (sensation and motor functioning)
• Functional Evaluation
– Range of motion in all movements of wrist and
fingers should be assessed
– Active, resistive and passive motions should be
assessed and compared bilaterally
•
•
•
•
•
•
•
Wrist - flexion, extension, radial and ulnar deviation
MCP joint - flexion and extension
PIP and DIP joints - flexion and extension
Fingers - abduction and adduction
MCP, PIP and DIP of thumb - flexion and extension
Thumb - abduction, adduction and opposition
5th finger - opposition
Recognition and Management of
Injuries to the Wrist, Hand and
Fingers
• Wrist Sprains
– Etiology
• Most common wrist injury
• Arises from any abnormal, forced movement
• Falling on hyperextended wrist, violent flexion or
torsion
• Multiple incidents may disrupt blood supply
– Signs and Symptoms
• Pain, swelling and difficulty w/ movement
– Management
•
•
•
•
Refer to physician for X-ray if severe
RICE, splint and analgesics
Have athlete begin strengthening soon after injury
Tape for support can benefit healing and prevent
further injury
• Triangular Fibrocartilage Complex (TFCC)
Injury
– Etiology
• Occurs through forced hyperextension, falling on
outstretched hand
• Violent twist or torque of the wrist
• Often associated w/ sprain of UCL
– Signs and Symptoms
• Pain along ulnar side of wrist, difficulty w/ wrist
extension, possible clicking
• Swelling is possible, not much initially
• Athlete may not report injury immediately
– Management
• Referred to physician for treatment
• Treatment will require immobilization initially for 4
weeks
• Immobilization should be followed by period of
strengthening and ROM activities
• Surgical intervention may be required if
conservative treatments fail
• Tenosynovitis
– Etiology
• Cause of repetitive wrist accelerations and
decelerations
• Repetitive overuse of wrist tendons and sheaths
– Signs and Symptoms
• Pain w/ use or pain in passive stretching
• Tenderness and swelling over tendon
– Management
• Acute pain and inflammation treated w/ ice massage
4x daily for first 48-72 hours, NSAID’s and rest
• When swelling has subsided, ROM is promoted w/
contrast bath
• Ultrasound and phonphoresis can be used
• PRE can be instituted once swelling and pain
subsided
• Tendinitis
– Etiology
• Repetitive pulling movements of (commonly) flexor
carpi radialis and ulnaris; repetitive pressure on
palms (cycling) can cause irritation of flexor
digitorum
• Primary cause is overuse of the wrist
– Signs and Symptoms
• Pain on active use or passive stretching
• Isometric resistance to involved tendon produces
pain, weakness or both
– Management
• Acute pain and inflammation treated w/ ice massage
4x daily for first 48-72 hours, NSAID’s and rest
• When swelling has subsided, ROM is promoted w/
contrast bath
• PRE can be instituted once swelling and pain
subsided (high rep, low resistance)
• Nerve Compression, Entrapment, Palsy
– Etiology
• Median and ulnar nerve compression
• Result of direct trauma to nerves
– Signs and Symptoms
• Sharp or burning pain associated w/ skin sensitivity
or paresthesia
• May result in benediction/ bishop’s deformity
• (damage to the ulnar nerve) or claw hand deformity
(damage to both nerves)
• Palsy of radial nerve produces drop wrist deformity
caused by paralysis of extensor muscles
• Palsy of median nerve can cause ape hand (thumb
pulled back in line w/ other fingers)
– Management
• Chronic entrapment may cause irreversible damage
• Surgical decompression may be necessary
• Carpal Tunnel Syndrome
– Etiology
• Compression of median nerve due to inflammation
of tendons and sheaths of carpal tunnel
• Result of repeated wrist flexion or direct trauma to
anterior aspect of wrist
– Signs and Symptoms
• Sensory and motor deficits (tingling, numbness and
paresthesia); weakness in thumb
– Management
• Conservative treatment - rest, immobilization,
NSAID’s
• If symptoms persist, corticosteroid injection may be
necessary or surgical decompression of transverse
carpal ligament
• de Quervain’s Disease (Hoffman’s disease)
– Etiology
• Stenosing tenosynovitis in thumb (extensor pollicis
brevis and abductor pollicis longus
• Constant wrist movement can be a source of
irritation
– Signs and Symptoms
• Aching pain, which may radiate into hand or
forearm
• Positive Finklestein’s test
• Point tenderness and weakness during thumb
extension and abduction; painful catching and
snapping
• de Quervain’s Disease (Hoffman’s disease)
– Management
• Immobilization, rest, cryotherapy and NSAID’s
• Ultrasound and ice are also beneficial
• Joint mobilizations have been recommended to
maintain ROM
• Dislocation of Lunate Bone
– Etiology
• Forceful hyperextension or fall on outstretched hand
– Signs and Symptoms
• Pain, swelling, and difficulty executing wrist and
finger flexion
• Numbness/paralysis of flexor muscles due to
pressure on median nerve
– Management
• Treat as acute, and sent to physician for reduction
• If not recognized, bone deterioration could occur,
requiring surgical removal
• Usual recovery is 1-2 months
• Scaphoid Fracture
– Etiology
• Caused by force on outstretched hand, compressing
scaphoid between radius and second row of carpal
bones
• Often fails to heal due to poor blood supply
– Signs and Symptoms
• Swelling, severe pain in anatomical snuff box
• Presents like wrist sprain
• Pain w/ radial flexion
– Management
• Must be splinted and referred for X-ray prior to
casting
• Immobilization lasts 6 weeks and is followed by
strengthening and protective tape
• Wrist requires protection against impact loading for
3 additional months
• Hamate Fracture
– Etiology
• Occurs as a result of a fall or more commonly from
contact while athlete is holding an implement
– Signs and Symptoms
• Wrist pain and weakness, along w/ point tenderness
• Pull of muscular attachment can cause non-union
– Management
• Casting wrist and thumb is treatment of choice
• Hook of hamate can be protected w/ doughnut pad
to take pressure off area
• Wrist Ganglion
– Etiology
• Synovial cyst (herniation of joint capsule or
synovial sheath of tendon)
• Generally appears following wrist strain
– Signs and Symptoms
•
•
•
•
Appear on back of wrist generally
Occasional pain w/ lump at site
Pain increases w/ use
May feel soft, rubbery or very hard
– Management
• Old method was to first break down the swelling
through distal pressure and then apply pressure pad
to encourage healing
• New approach includes aspiration, chemical
cauterization w/ subsequent pressure from pad
• Ultrasound can be used to reduce size
• Surgical removal is most effective treatment method
• Contusion and Pressure Injuries of Hand
and Fingers
– Etiology
• Result of blow or compression of bones w/in hand
and fingers
– Signs and Symptoms
• Pain and swelling of soft tissue
– Management
• Cold compression until hemorrhaging has ceased
• Follow w/ gradual warming - soreness may still be
present -- padding may also be necessary
• Bruising of distal phalanx can result in subungual
hematoma - extremely painful due to build-up of
pressure under nail
– Pressure must be released once hemorrhaging has ceased
• Bowler’s Thumb
– Etiology
• Perineural fibrosis of subcutaneous ulnar digital
nerve of thumb
• Pressure from bowling ball on thumb
– Signs and Symptoms
• Pain, tingling during pressure on irritated area and
numbness
– Management
• Padding, decrease amount of bowling
• If condition continues, surgery may be required
• Trigger Finger or Thumb
– Etiology
• Repeated motion of fingers may cause irritation,
producing tenosynovitis
• Inflammation of tendon sheath (extensor tendons of
wrist, fingers and thumb, abductor pollicis)
• Thickening occurs w/in the sheath, forming a nodule
that does not slide easily
– Signs and Symptoms
• Resistance to re-extension, produces snapping that is
palpable, audible and painful
• Palpation produces pain and lump can be felt w/in
tendon sheath
– Management
• Same treatment as de Quervain’s disease -- if
unsuccessful, injection and splinting are last options
• Mallet Finger (baseball or basketball finger)
– Etiology
• Caused by a blow that contacts tip of finger avulsing
extensor tendon from insertion
– Signs and Symptoms
• Pain at DIP; X-ray shows avulsed bone on dorsal
proximal distal phalanx
• Unable to extend distal end of finger (carrying at 30
degree angle)
• Point tenderness at sight of injury
– Management
• RICE and splinting for 6-8 weeks
• Boutonniere Deformity
– Etiology
• Rupture of extensor tendon dorsal to the middle
phalanx
Forces DIP joint into extension and PIP into flexion
– Signs and Symptoms
• Severe pain, obvious deformity and inability to
extend DIP joint
• Swelling, point tenderness
– Management
• Cold application, followed by splinting
• Splinting must be continued for 5-8 weeks
• Athlete is encouraged to flex distal phalanx
• Jersey Finger
– Etiology
• Rupture of flexor digitorum profundus tendon from
insertion on distal phalanx
• Often occurs w/ ring finger when athlete tries to
grab a jersey
– Signs and Symptoms
• DIP can not be flexed, finger remains extended
• Pain and point tenderness over distal phalanx
– Management
• Must be surgically repaired
• Rehab requires 12 weeks and there is often poor
gliding of tendon, w/ possibility of re-rupture
• Dupuytren’s Contracture
– Etiology
• Nodules develop in palmer aponeurosis, limiting
finger extension - ultimately causing flexion
deformity
– Signs and Symptoms
• Often develops in 4th or 5th finger (flexion
deformity)
– Management
• Tissue nodules must be removed as they can
ultimately interfere w/ normal hand function
• Sprains, Dislocations and Fractures of
Phalanges
– Etiology
• Phalanges are prone to sprains caused by direct
blows or twisting
• MOI is also similar to that which causes fractures
and dislocations
– Signs and Symptoms
• Recognition primarily occurs through history
• Sprain symptoms - pain, severe swelling and
hematoma
• Gamekeeper’s Thumb
– Etiology
• Sprain of UCL of MCP joint of the thumb
• Mechanism is forceful abduction of proximal
phalanx occasionally combined w/ hyperextension
– Signs and Symptoms
• Pain over UCL in addition to weak and painful
pinch
– Management
• Immediate follow-up must occur
• If instability exists, athlete should be referred to
orthopedist
• If stable, X-ray should be performed to rule out
fracture
• Thumb splint should be applied for protection for
3 weeks or until pain free
• Splint should extend from wrist to end of thumb in
neutral position
• Thumb spica should be used following splinting for
support
• Sprains of Interphalangeal Joints of Fingers
– Etiology
• Can include collateral ligament, volar plate, extensor
slip tears
• Occurs w/ axial loading or valgus/varus stresses
– Signs and Symptoms
• Pain, swelling, point tenderness, instability
• Valgus and varus tests may be positive
– Management
• RICE, X-ray examination and possible splinting
• Splint at 30-40 degrees of flexion for 10 days
• If sprain is to the DIP, splinting for a few days in full
extension may assist healing process
• Taping can be used for support
• Swan Neck Deformity and
PsuedoBoutonniere Deformity
– Etiology
• Distal tear of volar plate may cause Swan Neck
deformity; proximal tear may cause
PsuedoBoutonniere deformity
– Signs and Symptoms
• Pain, swelling w/ varying degrees of hyperextension
• Tenderness over volar plate of PIP
• Indication of volar plate tear = passive
hyperextension
– Management
• RICE and analgesics
• Splint in 20-30 degrees of flexion for 3 weeks;
followed by buddy taping and then PRE
• PIP Dorsal Dislocation
– Etiology
• Hyperextension that disrupts volar plate at middle
phalanx
– Signs and Symptoms
• Pain and swelling over PIP
• Obvious deformity, disability and possible avulsion
– Management
• Treated w/ RICE, splinting and analgesics followed
by reduction
• After reduction, finger is splinted at 20-30 degrees
of flexion for 3 weeks -- followed by buddy taping
• PIP Palmar Dislocation
– Etiology
• Caused by twist while digit is semiflexed
– Signs and Symptoms
• Pain and swelling over PIP; point tenderness over
dorsal side
• Finger displays angular or rotational deformity
– Management
• Treat w/ RICE, splinting and analgesics followed by
reduction
• Splint in full extension for 4-5 weeks after which it
is protected for 6-8 weeks during activity
• MCP Dislocation
– Etiology
• Caused by twisting or shearing force
– Signs and Symptoms
• Pain, swelling and stiffness at MCP joint
• Proximal phalanx is angulated at 60-90 degrees
– Management
• RICE, splinting following reduction
• Buddy taping and given early ROM following
splinting
• Metacarpal Fracture
– Etiology
• Direct axial force or compressive force
• Fractures of the 5th metacarpal are associated w/
boxing or martial arts (boxer’s fracture)
– Signs and Symptoms
• Pain and swelling; possible angular or rotational
deformity
– Management
• RICE, analgesics are given followed by X-ray
examinations
• Deformity is reduced, followed by splinting 4 weeks of splinting after which ROM is carried out
• Bennett’s Fracture
– Etiology
• Occurs at carpometacarpal joint of the thumb as a
result of an axial and abduction force to the thumb
– Signs and Symptoms
• CMC may appeared to be deformed - X-ray will
indicate fracture
• Athlete will complain of pain and swelling over the
base of the thumb
– Management
• Structurally unstable and must be referred to an
orthopedic surgeon
• Distal Phalangeal Fracture
– Etiology
• Crushing force
– Signs and Symptoms
• Complaint of pain and swelling of distal phalanx
• Subungual hematoma is often seen in this condition
– Management
• RICE and analgesics are given
• Protective splint is applied as a means for pain relief
• Subungual hematoma is drained
• Middle Phalangeal Fracture
– Etiology
• Occurs from direct trauma or twist
– Signs and Symptoms
• Pain and swelling w/ tenderness over middle
phalanx
• Possible deformity; X-ray will show bone
displacement
– Management
• RICE and analgesics
• No deformity - buddy tape w/ thermoplastic splint
for activity
• Deformity - immobilization for 3-4 weeks and a
protective splint for an additional 9-10 weeks during
activity
• Proximal Phalangeal Fracture
– Etiology
• May be spiral or angular
– Signs and Symptoms
• Complaint of pain, swelling, deformity
• Inspection reveals varying degrees of deformity
– Management
• RICE and analgesics are given as needed
• Fracture stability is maintained by immobilization of
the wrist in slight extension, MCP in 70 degrees of
flexion and buddy taping
• PIP Fractures and Dislocation
– Etiology
• Combination of fracture and dislocation is the result
of an axial load on a partially flexed finger
– Signs and Symptoms
• Condition causes pain and swelling in the region of
the PIP joint
• Localized tenderness over the PIP
– Management
• RICE, analgesics, followed by reduction of the
fracture
• If there is a small fragment, buddy taping is used
• Large fragments - splint at 30-60 degrees of flexion
• Fingernail Deformities
– Changes in normal appearance of the fingernail
can be indicative of a number of different
diseases
• 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 deficiency
Rehabilitation of Injuries to the
Forearm, Wrist, Hand and
Fingers
• General Body Conditioning
– Must maintain pre-injury level of conditioning
– Cardiorespiratory, strength, flexibility and
neuromuscular control
– Many exercise options (particularly lower
extremity)
• Joint Mobilizations
– Wrist and hand respond to traction and
mobilization techniques
• Flexibility
– Full pain free ROM is a major goal of
rehabilitation
– The program should include active assisted and
active pain free stretching
• Strength
– Exercises should not aggravate condition or
disrupt healing process
– A variety of exercises are available for strength
(wrist and hand)
• Neuromuscular Control
– Hand and fingers require restoration of
dexterity
• Pinching, fine motor activities (buttoning buttons,
tying shoes, and picking up small objects)
– Customized bracing, splints and taping
techniques are available to protect the injured
wrist and hand
• Return to Activity
– Grip strength must be equal bilaterally, full
range of motion and dexterity
– Thumb has unique strength requirements
– Manual resistance can be instituted to
strengthen major motions; intrinsic muscles can
be strengthened w/ rubber band