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Chapter 24: The Forearm, Wrist, Hand and Finger


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 ... – PowerPoint PPT presentation

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Title: Chapter 24: The Forearm, Wrist, Hand and Finger

Chapter 24 The Forearm, Wrist, Hand and Finger
Anatomy of the Forearm
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Blood and Nerve Supply
  • Most of the flexors are supplied by the median
  • Most of the extensor are controlled by the radial
  • 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 an 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
  • Contusion
  • Etiology
  • Ulnar side receives majority of blows due to arm
  • 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
  • Protection is critical - full-length sponge
    rubber pad can be used to provide protective

  • Forearm Splints
  • Etiology
  • Forearm strain - most come from severe static
  • 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
  • Older athlete may experience greater soft tissue
    damage and greater chance of paralysis due to
    Volkmans 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
  • 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

Anatomy of the Wrist, Hand and Fingers
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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

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
  • 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
  • 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
  • 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
  • Finklesteins Test
  • Test for de Quervains syndrome
  • Athlete makes a fist w/ thumb tucked inside
  • Wrist is ulnar deviated
  • Positive sign is pain indicating stenosising
  • Pain over carpal tunnel could indicate carpal
    tunnel syndrome
  • Tinels Sign
  • Produced by tapping over transverse carpal
  • Tingling, paresthesia over sensory distribution
    of the median nerve indicates presence of carpal
    tunnel syndrome

  • Phalens Test
  • Test for carpal tunnel syndrome
  • Position is held for approximately one minute
  • If test is positive, pain will be produced I
    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)
  • Allens 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)
  • Hands 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
  • 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
  • Tape for support can benefit healing and prevent
    further injury

  • Triangular Fibrocartilage Complex (TFCC) Injury
  • Etiology
  • Occurs through forced hyperextension, falling on
    outstretched hand
  • Often associated w/ sprain of UCL
  • Signs and Symptoms
  • Pain along ulnar side of wrist, difficulty w/
    wrist extension
  • Swelling is possible, not much initially
  • Athlete may not report injury immediately
  • Management
  • Referred to physician for treatment

  • Tenosynovitis
  • Etiology
  • Cause of repetitive wrist accelerations and
  • 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, NSAIDs
    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

  • Tendinitis
  • Etiology
  • Repetitive pulling movements of (commonly) flexor
    carpi radialis and ulnaris repetitive pressure
    on palms (cycling) can cause irritation of flexor
  • 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, NSAIDs
    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 most common
  • Direct trauma to nerves
  • Signs and Symptoms
  • Sharp or burning pain associated w/ skin
    sensitivity or paresthesia
  • May result in benediction/ bishops 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,
  • If symptoms persist, corticosteroid injection may
    be necessary or surgical decompression of
    transverse carpal ligament

  • de Quervains Disease (Hoffmans disease)
  • Etiology
  • Stenosing tenosynovitis in thumb (extensor
    pollicis brevis and abductor pollicis longus
  • Constant wrist movement can be a source of
  • Signs and Symptoms
  • Aching pain, which may radiate into hand or
  • Positive Finklesteins test
  • Point tenderness and weakness during thumb
    extension and abduction painful catching and
  • Management
  • Immobilization, rest, cryotherapy and NSAIDs
  • Ultrasound and ice are also beneficial

  • Dislocation of Lunate Bone
  • Etiology
  • Forceful hyperextension or fall on outstretched
  • 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
  • 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
  • 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
  • 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
  • Signs and Symptoms
  • Wrist pain and weakness, along w/ point
  • 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 way

  • Contusion and Pressure Injuries of Hand and
  • 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

  • Bowlers 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 and, 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 Quervains disease -- if
    unsuccessful, injection and splinting are last

  • 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 rerupture

  • Dupuytrens Contracture
  • Etiology
  • Nodules develop in palmer aponeurosis, limiting
    finger extension - ultimately causing flexion
  • Signs and Symptoms
  • Often develops in 4th or 5th finger (flexion
  • 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, sever swelling and
  • Gamekeepers 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
  • 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
  • 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 possible
  • 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
  • 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
  • Tenderness over volar plate of PIP
  • Indication of volar plate tear passive
  • 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
  • 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 it 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

  • 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

  • Metacarpal Fracture
  • Etiology
  • Direct axial force or compressive force
  • Fractures of the 5th metacarpal are associated w/
    boxing or martial arts (boxers fracture)
  • Signs and Symptoms
  • Pain and swelling possible angular or rotational
  • Management
  • RICE, analgesics are given followed by X-ray
  • Deformity is reduced, followed by splinting - 4
    weeks of splinting after which ROM is carried out

  • Bennetts Fracture
  • Etiology
  • Occurs at carpometacarpal joint of the thumb as a
    result of an axial and abduction force to the
  • 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
  • Management
  • RICE and analgesics are given
  • Protective splint is applied as a means for pain
  • Subungual hematoma is drained

  • Middle Phalangeal Fracture
  • Etiology
  • Occurs from direct trauma or twist
  • Signs and Symptoms
  • Pain and swelling w/ tenderness over middle
  • Possible deformity X-ray will show bone
  • 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 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
  • If there is a small fragment, buddy taping is
  • Large fragments - splint at 30-60 degrees of

  • Fingernail Deformities
  • Changes in normal appearance of the fingernail
    can be indicative of a number of different
  • 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
  • Joint Mobilizations
  • Wrist and hand respond to traction and
    mobilization techniques

  • Flexibility
  • Full pain free ROM is a major goal of
  • 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
  • Customized bracing, splints and taping techniques
    are available to protect the injured wrist and
  • 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