Hand and Wrist Lecture

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Hand and Wrist Lecture

• Brian Hardy, ATC

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Forearm Anatomy

• Bony
• Radius
• Ulna

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Forearm Anatomy

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

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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

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Forearm Anatomy

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

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Forearm Anatomy

• Flexor Group Contd
• Flexor Digitorum Profundus
• Flexor policis Longus
• Pronator Quadratus

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Hand Anatomy

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

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Wrist Anatomy

• Bony Anatomy
• Interactive look at carpel bone interactions

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Wrist Anatomy

• Muscular Anatomy

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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

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Hand Anatomy

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

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Hand Anatomy

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

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Wrist Anatomy

• Tendon Sheaths
• Dorsal Aspect

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Hand Anatomy

• Tendon Sheaths
• Palmer Aspect

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Hand Anatomy

• Ligamentous Anatomy
• Palmer Aspect

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Hand Anatomy

• Ligamentous Anatomy
• Dorsal Aspect

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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

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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

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Wrist Kinematics

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

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Kinematics of the Wrist

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

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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.

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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.

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Ulnar Deviation Kinematics

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

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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

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Finger Anatomy
Lateral Bands
Extensor Digitorum
Dig superficialis
Central Slips
Dig Profund
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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

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Balance of Finger Flexors
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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)

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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

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Forearm splints

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

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Colles Fracture

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

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Colles Fracture

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

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Smith Fracture

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

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Smith Fracture

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

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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)

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Navicular Fracture
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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)

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Carpal Tunnel Syndrome
Carpal Tunnel Anatomy
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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

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Carpel tunnel syndrome

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

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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..)

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Ulnar Nerve Palsy

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

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De Quervains disease

• Mechanism overuse of the abductor pollicis
  longus
• Pathology tenosynovitis of the abductor pollicis
  longus

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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

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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

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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

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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

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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

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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

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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

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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)

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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.

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Gamekeepers Thumb
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Fractures of the Phalanx

• Mechanism direct trauma (contact with external
  objects)
• Complications
• Fractures in joint line longitudinal diagonal
• Tx surgical pin

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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.

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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.

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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

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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

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Boutonniere Deformity

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

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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

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Mallet Finger
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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.

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Swan Neck Deformity
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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.

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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

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FDP Repair
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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.

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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

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Wrist Ganglia
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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. 

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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.

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Hook of the Hamate Fractures
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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..

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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).
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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.

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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.

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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

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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

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Trigger Finger Injection
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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.

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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.

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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.

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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.

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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

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Hypothenar Hammer Sydrome

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

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Neurological Anatomy of the Hand

• Radial N. Supplies Dorsal Arch
• Supply for fingers
• Ulnar Nerve, Superficial arch
• supplies 1st dorsal interossei

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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.

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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)

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Radial Sided Ligaments

• Strong Prevent carpals from translating ulnarly
  on medially angulated slope of distal radius

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Radial Liagments

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

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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)

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Intrinsic Wrist Ligamentous Anatomy

• Originate and insert on carpals
• Capable of greater elongation than extrinsic
  before permanent deformation occurs

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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

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Triangular Fibrocartilage Rupture
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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

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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

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TFCC

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

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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)

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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)