Wrist and Hand

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Wrist and Hand
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Anatomy Review

• 29 bones
• 30 tendinous insertions
• Joint Motion
• Wrist
• Flexion / Extension
• Supination / Pronation
• Ulnar / Radial Deviation
• Phalanges
• Flexion / Extension
• Abduction / Adduction
• Opposition (thumb, 4th, 5th)

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Anatomy Review

• Muscles
• 20 extrinsic
• 19 intrinsic
• Fascia / Ligaments
• Transverse Carpal Ligament
• Extensor Retinaculum

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Tendon Zones

• Flexor
• Zone V Musculotendinous junction of extrinsic
  muscles to wrist surrounded by loose tendon
  sheaths (paratenons)
• Must prevent adhesions in this area after injury
• Zone IV wrist carpal tunnel
• Adhesions common following surgery or injury
• Zone III palm tendons leaving CT lumbricals
  attach to FDP
• Extrinsic tendons Often heal w/o difficulty
• Intrinsic muscles Adhesions / contractures from
  prolonged flexed positioning

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• Flexor
• Zone II distal palmar crease to middle phalanx
  No Mans Land
• Adhesions and loss of motion
• Zone I DIP joint Flexor Digitorum Profundus
• Tendon ruptures

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• Extensor
• Zone VII wrist wrist extensors and extrinsic
  finger extensors tendons in this area have
  synovial sheaths and are closely situated
• Common area of adhesions following immobilzation
  and injury
• Zones V and VI hand distally to MCP joints
  common area of edema formation in hand injuries ?
  increases risk for adhesions

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• Extensor
• Zones III IV proximal phalanx and PIP joints
• Area of boutonniere deformity
• Zones I II middle phalanx and DIP
• Area of mallet deformity ? swan-neck deformity

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Hand Use

• Power Grips
• Clenched fist
• Cylinder
• Spherical
• Hook
• Pinch
• Digital prehension
• Lateral prehension
• Tip-to-tip prehension

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ROM and Flexibility
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Tendon Glides

• See handout

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Strengthening
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• Isometrics

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• Isotonics
• Manual Resistive Exercises
• Rubber bands / tubing
• Free Weights
• Putty Exercises
• Isokinetics

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Special Considerations
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• Fractures
• Stable fracture
• Immobilized (splint / cast)
• Unstable Fracture
• ORIF (Open Reduction Internal Fixation)
• Distal forearm / wrist
• Colles Fracture distal radius fx / displaced
  dorsally
• Smiths Fracture distal radius fx / displaced
  palmarly
• Bartons Fracture radial articulation fx w/
  wrist subluxation

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• Fractures
• Carpal / Metacarpal
• Scaphoid most common
• 4-20 weeks of immobilization
• Hook of Hamate / Pisiform
• Boxers Fracture 4th or 5th metacarpal neck fx
• Bennetts Fracture 1st metacarpal

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Overuse Injuries

• Carpal Tunnel Syndrome
• Compression of the median nerve as it passes
  under transverse carpal ligament and through
  carpal tunnel
• Key Signs / Symptoms
• Night pain, loss of sensation of median nerve
  distribution in hand, weakness and pain
• Treatment options
• Night splints to keep wrist in neutral
• Modalities for pain relief
• Avoid aggravating activities / Technique
  evaluation
• Flexibility for wrist and long-finger flexors
• Strengthening protocol as tolerated
• If conservative treatment unsuccessful ? Surgical
  options

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• DeQuervains Disease
• Tendinitis of first dorsal compartment involving
  abductor pollicis longus and extensor pollicis
  brevis (As they pass radial styloid process)
• Treatment options
• Splint (15 Wrist Ext, Thumb Abd., MCP 10 Flex)
• Modalities
• Avoid aggravating activities
• Flexibility / ROM
• Gradual Strengthening Program
• If Conservative treatment unsuccessful ? Surgical
  options

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Reflex Sympathetic Dystrophy

• More common in upper extremity
• Key Signs / Symptoms
• Pain disproportionate to injury severity
• Exaggerated stiffness
• Hand edema Cyanotic discoloration
• Tight and shiny skin Excessive sweating
• Treatment options
• Referral to specialist