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Hand and Wrist Lecture

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Title: Hand and Wrist Lecture


1
Hand and Wrist Lecture
  • Brian Hardy, ATC

2
Forearm Anatomy
  • Bony
  • Radius
  • Ulna

3
Forearm Anatomy
  • Extensor Group
  • Extensor Digitorum Communis
  • Extensor Digiti Quinti Propruis
  • Extensor Carpi radialis L/B
  • Extensor Carpi Ulnaris
  • Brachioradialis

4
Forearm Anatomy
  • Extensor Group Contd
  • Adductor Pollicus Longus
  • Extensor Pollicus Longus and Brevis
  • Extensor indicis Proprius
  • Supinator
  • All Extensors in Forearm innervated by Radial
    Nerve

5
Forearm Anatomy
  • Flexor Group
  • Flexor Carpi Radialis
  • Pronator Teres
  • Palmaris Longus
  • Flexor Carpi Ulnaris
  • Flexor Digitorum Superficialis

6
Forearm Anatomy
  • Flexor Group Contd
  • Flexor Digitorum Profundus
  • Flexor policis Longus
  • Pronator Quadratus

7
Hand Anatomy
  • Bony Anatomy
  • Carpels
  • Scaphoid
  • Lunate
  • Triquetral
  • Trapezium
  • Trapezoid
  • Hamate
  • Pisiform

8
Wrist Anatomy
  • Bony Anatomy
  • Interactive look at carpel bone interactions

9
Wrist Anatomy
  • Muscular Anatomy

10
Hand Anatomy
  • Intrinsics Lumbricales
  • R N. on palmar side
  • Left 2 Median N.
  • Medial 2, Ulnar N.
  • Interossei - Ulnar N.
  • Dorsal 4 ABD
  • Palmar (3) ADD

11
Hand Anatomy
  • Muscular Anatomy
  • Thenar Group (thumb)
  • Flexor Pollicis Brevis
  • Adductor Pollicis
  • Palmaris Brevis
  • Flexor Pollicis Brevis
  • Opponens Pollicis
  • Median Nerve Intervation

12
Hand Anatomy
  • Muscluar Anatomy
  • Opponens Digiti Minimi
  • Flexor Digiti Minimi
  • Abductor Digiti Minimi

13
Wrist Anatomy
  • Tendon Sheaths
  • Dorsal Aspect

14
Hand Anatomy
  • Tendon Sheaths
  • Palmer Aspect

15
Hand Anatomy
  • Ligamentous Anatomy
  • Palmer Aspect

16
Hand Anatomy
  • Ligamentous Anatomy
  • Dorsal Aspect

17
Hand Anatomy
  • B. Nerves
  • Radial - extensors of the wrist, sensation of the
    dorsal web space
  • Median - wrist flexion on the radial side, finger
    add
  • Ulnar - wrist flexion on the ulnar side, hand
    squeeze
  • Sensory Nerves

18
Hand / Forearm Blood Supply
  • Cubital Fossa - split
  • Radial Artery
  • Superficial Lateral
  • Lies in Anatomical Snuff Box
  • Supplies Dorsal Arch in Hand
  • Ulnar Artery
  • Deep and Medial Blood Supply
  • Main blood supply runs palmar superficial Arch

19
Wrist Kinematics
  • Scaphoid, lunate, triquetrum
  • greater carpal bone motion in proximal row
  • Total flexion and extension are divided equally
    between radiocarpal and midcarpal joints

20
Kinematics of the Wrist
  • Scaphoid normally flex under compressive load
    (similar to lunate)
  • Triquetrum extends with compressive load move
    the lunate into extension

21
Wrist Kinematics
  • Lunate is in a state of dynamic balance between
    two antagonist
  • when balance is interrupted the lunate will tend
    to flex w/loss of ulnar support from the
    triquetrum or extend is loss of radial stability.

22
Ulnar Deviation Kinematics
  • During radial to ulnar deviation distal row
    translates dorsally rotates radial to ulnar
  • During radial dev. and ulnar dev. Proximal row
    moves from Flx to Ext.

23
Ulnar Deviation Kinematics
  • Hamate rotates into low position influencing
    triquetrum into dorsiflexion
  • Scaphoid becomes dorsiflexed (placing lunate into
    extension (20 deg maximally)

24
Radial Deviation Kinematics
  • During radial deviation, distal row translates
    plamarly to dorsally rotates radial to ulnar
  • During radial dev. and ulnar dev. Proximal row
    moves from Flx to Ext.
  • Flexion of scaphoid (15 deg.)
  • proximal row rotates into a physiologic palmar
    flexion

25
Finger Anatomy
Lateral Bands
Extensor Digitorum
Dig superficialis
Central Slips
Dig Profund
26
Flexor Expansion of the Hand
  • Lumbricales attach radial palmar side MC
  • FDS - attach base Int. Phalanx
  • FDP - attach base Distal Phalanx
  • Volar Plates- palmar MP, PIP, DIP joint

27
(No Transcript)
28
Balance of Finger Flexors
29
Normal Alignment
  • Lunate center finger
  • Sign Language A - all fingers point to lunate
  • On x-ray scaphoid angled 45 deg (30-60 deg
    considered normal)

30
Wrist Injury Basics
  • Most wrist injuries are tension injuries which
    occur with wrist hyperextension
  • Radiocarpal ligaments exceed their normal elastic
    limits with extreme hyperextension
  • Interosseous ligaments of distal row seldom fail
    clinically

31
Forearm splints
  • Mechanism overuse
  • Pathology Like shin splints
  • Treatment
  • Ice
  • Stretching and strengthening program
  • Modify activity as needed
  • Keep look out for stress fractures

32
Colles Fracture
  • Mechanism - Fall on outstretched arm with
    hyperextended wrist
  • Pathology - Fracture of the radius distally with
    volar dislocation.

33
Colles Fracture
  • Signs and symptoms
  • Silver fork Deformity
  • Check circulation and sensation
  • Treatment
  • Immobilization
  • Transportation to medical facility

34
Smith Fracture
  • Mechanism - Fall on outstretched arm with
    hyperflexed wrist
  • Pathology - Fracture of the radius distally with
    dorsal dislocation.

35
Smith Fracture
  • Signs and symptoms
  • Garden Spade fork Deformity
  • Check circulation and sensation
  • Treatment
  • Immobilization
  • Transportation to medical facility

36
Navicular (scaphoid) fracture
  • Mechanism - Fall on outstretched arm with
    hyperextended wrist (football block)
  • Pathology - Fracture of the Navicular (does not
    heal well to to lack of vascularity in the area)

37
Navicular Fracture
38
Navicular (scaphoid) fracture
  • Signs and symptoms
  • Pain in the anatomical snuff box
  • Swelling (only when acute)
  • Chronic pain
  • Treatment
  • Immobilization
  • Cast 6-10 weeks (past elbow)
  • Surgery if disunion occurs (avascular necrosis
    may occur)

39
Carpal Tunnel Syndrome
Carpal Tunnel Anatomy
40
Carpel tunnel syndrome
  • Signs and Symptoms
  • Pain in wrist
  • Numbness and tingling in the thumb and first two
    fingers
  • Positive Phalens test
  • Positive tap test
  • Treatment
  • Conservative Immobilization and ice
  • Radical Surgery to increase space in the tunnel

41
Carpel tunnel syndrome
  • A. Mechanism overuse, congenital, trauma
  • B. Pathology Compression of the median nerve in
    the tunnel

42
Ulnar Nerve Compression (Handle Bar Palsy)
  • Mechanism Compression at Pisaform Hamate
    (bikers)
  • Etiology Prolonged external pressure, blunt
    trauma to the heel of the hand, anatomical
    encroachment (fracture of pisaform or hamate)
  • Pathology Compression of the ulnar nerve in the
    canal of Guyon (this is not an overuse injury due
    to tenosynovitiy etc..)

43
Ulnar Nerve Palsy
  • Treatment Conservative
  • Ice
  • pad area
  • 6-8 weeks with rest
  • Rarely surgical, but can be chronic leading to
    permanent damage

44
De Quervains disease
  • Mechanism overuse of the abductor pollicis
    longus
  • Pathology tenosynovitis of the abductor pollicis
    longus

45
De Quervains disease
  • Signs and Symptoms
  • Pain with thumb movement in abduction
  • Pain during eccentric wrist activities of the
    extensors of the thumb
  • Positive Finkelsteins test.
  • Treatment
  • Immobilization
  • Ice
  • Physician referral for meds if needed

46
Dislocation of Carpal Bones
  • Lunate Volar displacement of the lunate
  • Perilunate Dislocations Dorsal displacement of
    the carpal bones
  • Trans-scaphoid Perilunate Dislocations
  • Fracture of the scaphoid through its waist with
    dorsal displacement of the distal fragment and
    the carpal bones - continued attachment of the
    proximal fracture fragment to the radius and
    lunate

47
Dislocation of Carpal Bones
  • History Fall on outstretched arm
  • Inspection Deformity (Protrusion of lunate in
    volar direction mal-alignment, swelling)
  • Palpation Swelling, localized pain and
    tenderness, deformity

48
Dislocation of Carpal Bones
  • Functional Tests
  • restricted finger flexion (compression of finger
    flexors in carpal tunnel)
  • positive motor and sensory tests for median nerve
    involvement (compression of median nerve in
    carpal tunnel
  • restricted or painful movement
  • tap test most likely negative

49
Boxers Fracture
  • Mechanism impaction force exerted through the
    distal end of the metacarpal in closed fist
    potion
  • Pathology Fracture through the neck of the fifth
    metacarpal/volar displacement

50
Boxers Fracture
  • Clinical Eval
  • History direct trauma
  • Inspection dropped knuckle malalignment of
    fingers with MP and PIP joints flexed
  • Palpation False joint crepitus
  • Functional tests percussion

51
Dislocation of MP Joint in the Thumb
  • Mechanism Forced hyperextension of the MP
  • Pathology Rupture of the proximal membranous
    portion of the volar plate with dorsal
    dislocation of the proximal phalanx on the head
    of the MP (simple dislocation) possible
    entrapment volar plate in the MP joint (complex
    dislocation)
  • TX - immediate care, long term rehabilitation
    support

52
Gamekeepers Thumb (Skiers thumb)
  • Mechanism Forced abduction of the MP joint
  • Pathology Partial or complete rupture of the
    ulnar collateral lig. Of the MP joint(usually
    from its attachment to the proximal phalanx,
    possible interposition of adductor pollicis
    tendon)

53
Gamekeepers Thumb
  • Test positive pain or laxity during abduction
    stress test weakness of thumb index finger
    pinch.
  • Treatment Immediate RICE, Long term
    Rehabilitation exercises support up to 1 year.

54
Gamekeepers Thumb
55
Fractures of the Phalanx
  • Mechanism direct trauma (contact with external
    objects)
  • Complications
  • Fractures in joint line longitudinal diagonal
  • Tx surgical pin

56
Volar Plate Rupture
  • Volar plate injury most commonly results from
    landing on the hands, but with the wrist too
    straight. This puts the initial force on the
    fingers, bending them back too far. When the
    ligament on the proximal interphalangeal joint or
    PIPJ gets too tight, it may rupture, or may pull
    off a chunk of the bone.

57
Volar Plate Rupture
  • A volar plate injury may be a sprain (a
    stretching of ligaments -- the tissues that hold
    two bones together), or it may be much more
    serious. For example, a large avulsion fracture,
    where the ligament pulled off a piece of bone
    more than 1/3 of the joint surface, usually
    requires surgery. When only the ligament is
    injured, there are three degrees of seriousness
    1st degree stretching, 2nd degree partial
    tear, and 3rd degree complete rupture.
  • Hyperflexion injury with bruising under the PIPJ.
    When bruising is noted, it's either a tearing of
    the ligament or a fracture.

58
Treatment Volar Plate Injury
  • Immediate care splint, ice rest
  • X-ray
  • Physician referral
  • Surgical only if splinting (3-6 weeks) does not
    prevent boutonnière deformity

59
Boutonniere Deformity
  • Caused by the rupture of the saggital bands and
    usually the triangular ligament. The lateral
    bands fall volarward, flexing the PIP joint and
    subsequent tightness will in time cause DIP joint
    hyperextension
  • Intrinsics become PIP flexion
  • Tightness of bands causes ext and DIP joint
  • Surgical finger
  • Pay attention on dislocations, finger jamming

60
Boutonniere Deformity
  • Rupture of the triangular ligament with extensor
    tendons shifting volarly. Surgical Finger

61
Mallet Finger Baseball Finger
  • Rupture of the instrinsics (ED) on the dorsum of
    the base of the distal phalanx. The athlete is
    unable to extend at the DIP
  • Cause caught in jersey, hit tip of finger
  • Immediately noticeable, unable to extend DIP
  • Immediate treatment (maintain in extension)
    potentially surgical

62
Mallet Finger
63
Swan Neck Deformity
  • Caused by a Volar plate rupture at the PUP and
    often accompanying triangular ligament rupture.
  • Lateral bands drift dorsally and exacerbate the
    hyperextension at the PIPI joint. They become
    ineffective in extension at the DIP joint and the
    unopposed action of the profundus causes flexion
    at the DIP joint.
  • Cause jamming dislocations
  • Immediately noticeable, if not immobilized will
    become surgical finger.
  • If not immediately noticed, finger will be
    bother to individual continually feel weak
    unable to complete without tape.

64
Swan Neck Deformity
65
Rupture of the Flexor Digitorum Profundus
  • Mechanism Forced extension of the DIP joint
    during active finger flexion(loss grasp of
    opponents jersey) usually ring finger due to
    limited independent extensibility.
  • Pathology Avulsion fracture of the flexor
    digitorum profundus tendon from its insertion
    into the volar lip of the distal phalanx tendon
    retraction to the 1) DIP, 2) hiatus of the FD
    sublimis, or 3) palm of the hand.

66
Rupture of the FDP
  • HistoryAbove
  • Inspection swelling on volar surface
  • Palpation point tenderness at distal tendon
    insertion tender mass on volar surface of the
    finger or palm of the hand at the point of
    retraction
  • Functional tests loss of active flexion of the
    DI joint with middle phalanx stabilized
  • TX surgical

67
FDP Repair
68
Wrist Ganglia
  • Most outpatient consultations for ganglia
    culminate in explanation and reassurance that
    ganglia are harmless and many resolve
    spontaneously. 40 disappear for at least twelve
    months after aspiration. Surgical scars on the
    dorsum of the wrist can be more painful than the
    ganglion. The recurrence rate after surgery is
    about 10 for dorsal wrist ganglia and 30 for
    ganglia adjacent to the radial artery.

69
Wrist Ganglia
  • Primary treatment
  • Reassurance as above.
  • Aspiration under local anaesthesia using a wide
    bore needle (16 gauge).
  • Apply a firm bandage for one week to prevent
    recurrence.
  • Refer when
  • The lesion cannot be emptied.
  • The lesion seems to be solid.
  • There is doubt about the diagnosis.
  • The ganglion recurs after aspiration and is
    symptomatic.
  • Surgery may be the best option

70
Wrist Ganglia
71
Hook Hamate Fractures
  • Hook of hamate fractures. This fracture may go
    undiagnosed until it results in attritional
    rupture of the long flexor tendon of the small
    finger. 

72
Hook of Hamate Fractures
  • Fractures of the hook of the hamate may be
    sustained in a fall, but more often occurs in
    sports such as tennis, baseball, and golf, in
    which a handle sharply impacts the proximal
    hypothenar palm. As with the scaphoid, these
    fractures are frequently missed initially, and
    may not be visible on standard x-rays.
  • Also similar to the scaphoid, they are prone to
    nonunion and may result in secondary
    complications. The hook of the hamate is the
    point of attachment for hypothenar muscles, and
    when fractured through the base, these muscles
    alternately stress the fracture in different
    directions, pre-disposing to nonunion.

73
Hook of the Hamate Fractures
74
Hook of the Hamate Fractures
  • Confirmation of this diagnosis may require
    special x-ray views of the hamate, including
    carpal tunnel view and 20 degree supinated
    oblique views, bone scan or CT scan.
  • Standard treatment is excision of the hook
    fragment and smoothing the base to prevent future
    tendon chafing
  • The hook also functions as a trochlea for the
    flexor tendons of the small finger
  • Surface irregularities or chronic local
    inflammation can result in flexor tendon rupture,
    ulnar neuritis, and ulnar artery occlusion in
    Guyon's canal..

75
Dupuytren's contracture
Dupuytren's contracture is a disorder of the skin
and underlying tissue on the palm side of the
hand. Thick, scar-like tissue forms under the
skin of the palm and may extend into the fingers,
pulling them toward the palm and restricting
motion. The condition usually develops in
mid-life and has no known cause (though it has a
tendency to run in families).
76
Dupuytren's contracture surgery
  • Surgery is the only treatment for Dupuytren's
    contracture. The surgeon will cut and separate
    the bands of thickened tissue, freeing the
    tendons and allowing better finger movement. The
    operation must be done very precisely, since the
    nerves that supply the hand and fingers are often
    tightly bound up in the abnormal tissue.

77
Trigger Finger
  • The tendons that bend your fingers run through a
    tunnel or sheath. Trigger finger is caused by a
    thickening on the tendon catching as it runs in
    and out of the sheath.

78
Trigger Finger
  • The most common cause is tenosynovitis. Can be
    felt in the palm the finger moves. The system is
    very similar to bicycle brake cable. If the wire
    becomes bent or rusty, the brakes work badly

79
Trigger Finger Treatment
  • Two Ways to treat Inject Surgical
  • Injection A small amount of steroid is injected
    around the tendon. This flattens out the swelling
    on the tendon allowing it to glide freely in and
    out of the sheath once more. A single injection
    is all that is needed in 50 of cases. A further
    25 will respond to another injection (i.e.
    three-quarters of cases can be successfully
    treated in this way). The steroid injection does
    not work immediately. It causes no general
    side-effects but occasionally the skin around the
    injection-site can be made a little thinner.
    Therefore two injections are the maximum

80
Trigger Finger Injection
81
Trigger Finger Surgery
  • Surgery
  • This is needed if the steroid injections do not
    work. It involves a small procedure under local
    anaesthetic. A slit is made in the mouth of the
    sheath to prevent the tendon catching at this
    point.
  • The condition can occur in any finger and
    therefore the triggering may return in the
    affected or other fingers. This is, however, very
    unusual if you have had surgery.

82
Trigger Finger
  • 1 week post surgery daily activity can be resumes
    3-4 weeks athletic activities
  • Complications
  • Infection Any operation can be followed by
    infection and this would be treated with
    antibiotics.
  • Scar You will have a scar on the palm. This will
    be somewhat firm to touch and tender for 6-8
    weeks. This can be helped by massaging the area
    firmly with the moisturizing cream.
  • Stiffness About 5 (1 in 20) of people are
    sensitive to hand surgery and their hand may
    become swollen, painful and stiff after any
    operation (algodystrophy). This problem cannot be
    predicted but will be watched for afterwards and
    treated with physiotherapy.
  • Nerve The nerves running to the fingers can be
    damaged during the surgery and cause numbness in
    part of the finger. This complication is very
    rare and the nerve would be repaired immediately.

83
Dupuytren's contracture
  • The results of the surgery will depend on the
    severity of the condition. You can usually expect
    significant improvement in function, particularly
    after physical therapy (see Recovery and
    rehabilitation.), and a thin, fairly
    inconspicuous scar.
  • In some cases, skin grafts are also needed to
    replace tightened and puckered skin.

84
Hypothenar Hammer Syndrome
  • Occlusion of the palmar arch vessels is rare, but
    it can occur in athletes and workers who subject
    their hands to repeated blunt trauma or gripping
    activities
  • Occlusive symptoms include pain, cold
    intolerance, and numbness
  • The diagnosis rests on evaluating the patency of
    the palmar arches.

85
Hypothenar Hammer Syndrome
  • Typical History
  • Acute or blunt trauma to the palmHand pain or
    soreness (may be nonspecific)Hand and/or finger
    numbnessCold intoleranceHand and digit
    coolness--not easily alleviatedGrip
    weaknessTenderness over the hypothenar
    eminenceNonhealing finger sores

86
Hypothenar Hammer Sydrome
  • Diagnositc tests
  • Angiography
  • perfusion bone scan
  • Treatment
  • Conservative Medications and blockade
  • Radical arterial reconstruction using a vein
    graft

87
Neurological Anatomy of the Hand
  • Radial N. Supplies Dorsal Arch
  • Supply for fingers
  • Ulnar Nerve, Superficial arch
  • supplies 1st dorsal interossei

88
Ligamentous Anatomy of the Hand
  • Ligaments of wrist most highly developed on
    palmar side of wrist
  • Palmar wrist lig. originate laterally from radial
    styloid directed in a distal ulnar direction.

89
Volar Capsule
  • Proximal Arcade Raiolunate lig. (lunate
    ,triquetrum)
  • Second Arcade
  • Arises on palmar facet radial styloid to capitate
  • Between these is the space of Poirier(place where
    lig. lax, perilunar dislocations)

90
Radial Sided Ligaments
  • Strong Prevent carpals from translating ulnarly
    on medially angulated slope of distal radius

91
Radial Liagments
  • Radial sided ligaments merge w/ligamentous fibers
    arising ulnarly from TFC and distal Ulna
  • radiolunotriquetral
  • radioscaphoid
  • radioscapholunate
  • radiocapitate

92
Extrinsic Wrist Ligamentous Anatomy
  • Between carpal bones radius or MC
  • Stronger/stiffer than intrinsic ligaments
  • Radiocapitate is the primary stabilizer of distal
    carpal row on proximal side
  • Palmar extrinsic bands 2 V shaped ligamentous
    bands
  • Ulnoluner (Medial) Key ligament with the TFC
  • Occasionally avulsed for insertion on Lunate
  • Ulnotriquetral (Medial)

93
Intrinsic Wrist Ligamentous Anatomy
  • Originate and insert on carpals
  • Capable of greater elongation than extrinsic
    before permanent deformation occurs

94
Extensor Expansion of the Hand
  • Interossei
  • Attach Dorsal MC ABD, Palmar MC ADD
  • Lumbricales attach radial palmar side MC
  • Extensor Digitorum
  • Attach base Distal Phalanx
  • Central Slip at base Int. Phalanx
  • Attached by Triangular Ligament

95
Triangular Fibrocartilage Rupture
96
Triangular Fibrocartilage Rupture
  • The ulnar continuant of distal radius presents
    concave surface for articulation w/lunate
  • Main stabilizer of distal radioulnar joint
  • TFCC normally not only stabilizes the ulnar head
    in sigmoid notch or radius but also acts as a
    buttress to support proximal carpal row

97
TFCC
  • During axial loading the radius carries the
    majority of load (82) and the ulna a smaller
    load (18)
  • W/TFCC avulsed the radial load increases to 94
  • Volar - TFCC prevents dorsal displacement of ulna
    in pronation
  • Dorsal - TFCC prevents volar displacement of ulna
    in supination

98
TFCC
  • Mechanism
  • Compressive load during ulnar deviation (batting
    baseball)
  • Usually unrecognized in radial fractures,
    dislocations

99
TFCC
  • Exam
  • pain centered about dorsal depression distal to
    ulnar head or on ulnar styloid
  • passive manipulation of carpus against head of
    ulnar causes pain
  • pain with forced forearm pronation and supination
  • TFSS symptomatic have clicking in wrist
    w/pronation/supination
  • clench fist pain w/pronation/supintaion
  • if pain unclenched fist positive SLD
    (ulnar/radial deviation)

100
TFCC
  • Exam
  • Piano Key sign laxity of the R-U joint
    w/controlled dorsal palmar shucking
  • Treatment - non-operative
  • Neutral cast above elbow 6-10 weeks
  • Treatment Surgical
  • Only if symptomatic
  • Sutured in place through drill hole (through
    palmar arthroscopy)
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