kin 188 wrist and hand evaluation and injuries

KIN 188 – Prevention and KIN 188 – Prevention and Care of Athletic InjuriesCare of Athletic Injuries

Wrist and Hand Evaluation Wrist and Hand Evaluation

and Injuriesand Injuries

AnatomyAnatomy

Bony AnatomyBony Anatomy Distal radius/ulnaDistal radius/ulna

Styloid processesStyloid processes

Carpal bonesCarpal bones 8 total (2 rows of 4, proximal/distal)8 total (2 rows of 4, proximal/distal)

MetacarpalsMetacarpals 1-5 (one = thumb, five = little finger)1-5 (one = thumb, five = little finger)

PhalangesPhalanges 14 total (proximal/middle/distal at each finger and proximal/distal at 14 total (proximal/middle/distal at each finger and proximal/distal at

thumb)thumb)

Carpal BonesCarpal Bones

Proximal row (lateral to Proximal row (lateral to medial)medial) ScaphoidScaphoid LunateLunate TriquetrumTriquetrum PisiformPisiform

““Some Lovers Try Some Lovers Try Positions”Positions”

Distal row (lateral to Distal row (lateral to medial)medial) TrapeziumTrapezium TrapezoidTrapezoid CapitateCapitate HamateHamate

hookhook

““That They Can’t That They Can’t Handle”Handle”

Bony AnatomyBony Anatomy

Bony AnatomyBony Anatomy

Joint AnatomyJoint Anatomy Distal radioulnar jointDistal radioulnar joint

Forearm pronation/supinationForearm pronation/supination Radiocarpal jointRadiocarpal joint

Allows wrist flexion/extension and radial/ulnar deviation ROMAllows wrist flexion/extension and radial/ulnar deviation ROM Intercarpal jointsIntercarpal joints

Subtle glide movements onlySubtle glide movements only Carpometacarpal jointsCarpometacarpal joints

Limited flexion/extension ROMLimited flexion/extension ROM Metacarpophalangeal (MP) joints – “knuckles”Metacarpophalangeal (MP) joints – “knuckles”

Flexion/extension and abduction/adduction ROMFlexion/extension and abduction/adduction ROM Proximal/distal (PIP/DIP/IP) interphalangeal jointsProximal/distal (PIP/DIP/IP) interphalangeal joints

Flexion/extension ROMFlexion/extension ROM

Joint AnatomyJoint Anatomy

Muscular AnatomyMuscular Anatomy

Extrinsic musclesExtrinsic muscles Flexor/pronator group from medial epicondyle of Flexor/pronator group from medial epicondyle of

humerushumerus Extensor/supinator group from lateral epicondyle Extensor/supinator group from lateral epicondyle

of humerusof humerus

Intrinsic musclesIntrinsic muscles Thenar eminence – thumbThenar eminence – thumb Hypothenar eminence – little fingerHypothenar eminence – little finger

Carpal TunnelCarpal Tunnel

Floor – proximal row of Floor – proximal row of carpal bonescarpal bones

Roof – transverse carpal Roof – transverse carpal ligamentligament

Contents (10 structures)Contents (10 structures) Median nerveMedian nerve Thumb flexor tendonThumb flexor tendon 8 finger flexor tendons8 finger flexor tendons

EvaluationEvaluation

HistoryHistory

Mechanism of injury/etiologyMechanism of injury/etiology Fall on outstretched handFall on outstretched hand

Scaphoid fracture, wrist dislocation, forearm fracture, wrist sprainScaphoid fracture, wrist dislocation, forearm fracture, wrist sprain Striking object with closed fistStriking object with closed fist

Metacarpal fractureMetacarpal fracture Forces applied to fingers/thumbForces applied to fingers/thumb

Bennet’s fracture, finger sprain/dislocation, mallet finger, Bennet’s fracture, finger sprain/dislocation, mallet finger, gamekeeper’s thumbgamekeeper’s thumb

Direct traumaDirect trauma Contusions, fracturesContusions, fractures

Overuse/repetitive motion or activityOveruse/repetitive motion or activity Tendonitis, carpal tunnel syndromeTendonitis, carpal tunnel syndrome

HistoryHistory Unusual sounds/sensations at time of injuryUnusual sounds/sensations at time of injury History of previous injury/surgeryHistory of previous injury/surgery Change in activityChange in activity

Intensity, duration, frequency, biomechanics/technique, equipmentIntensity, duration, frequency, biomechanics/technique, equipment Acute/gradual onset of symptomsAcute/gradual onset of symptoms

Macrotraumatic vs. microtruamaticMacrotraumatic vs. microtruamatic Characterize painCharacterize pain

Location (point with 1 finger)Location (point with 1 finger) Dull, sharp, burning, throbbing, etc.Dull, sharp, burning, throbbing, etc. Rate on scale (1-10)Rate on scale (1-10) What increases or decreases?What increases or decreases?

Treatment, medication, evaluation to dateTreatment, medication, evaluation to date

Inspection/ObservationInspection/Observation ALWAYSALWAYS compare bilaterally compare bilaterally Obvious deformityObvious deformity

Swan neck deformity – flexor tendon from middle phalanxSwan neck deformity – flexor tendon from middle phalanx Boutonniere deformity – extensor tendon from middle Boutonniere deformity – extensor tendon from middle

phalanxphalanx Mallet finger – extensor tendon from distal phalanxMallet finger – extensor tendon from distal phalanx

BleedingBleeding Discoloration/ecchymosisDiscoloration/ecchymosis SwellingSwelling

Immediate vs. gradual, amountImmediate vs. gradual, amount ScarsScars

PalpationPalpation

Radial styloid processRadial styloid process Ulnar styloid processUlnar styloid process Carpal bonesCarpal bones ““Anatomic snuffbox”Anatomic snuffbox” MetacarpalsMetacarpals

Head/shaft/baseHead/shaft/base MP jointsMP joints PhalangesPhalanges

Proximal/middle/distalProximal/middle/distal

PIP jointsPIP joints DIP jointsDIP joints Flexor carpi ulnarisFlexor carpi ulnaris Flexor carpi radialisFlexor carpi radialis Palmaris longus tendonPalmaris longus tendon Thenar eminenceThenar eminence Hypothenar eminenceHypothenar eminence

Special TestsSpecial Tests

ROMROM Active – patient/athlete moves jointActive – patient/athlete moves joint Passive – clinician moves joint, evaluates end feelPassive – clinician moves joint, evaluates end feel Resistive – proximal stabilization and distal application of Resistive – proximal stabilization and distal application of

resistance (“break” test vs. resistance through ROM)resistance (“break” test vs. resistance through ROM)

NeurovascularNeurovascular

Special testsSpecial tests

Range of MotionRange of Motion Wrist flexion/extensionWrist flexion/extension

Flexion – 85-90 degrees, extension – 75-85 degreesFlexion – 85-90 degrees, extension – 75-85 degrees

Wrist radial/ulnar deviationWrist radial/ulnar deviation Radial – 20 degrees, ulnar – 35 degreesRadial – 20 degrees, ulnar – 35 degrees

Finger flexion/extensionFinger flexion/extension Flexion – MP 85-105 degrees, PIP 110-120 degrees, DIP 80-90 Flexion – MP 85-105 degrees, PIP 110-120 degrees, DIP 80-90

degreesdegrees Extension – MP 20-30 degrees, PIP/DIP 0 degreesExtension – MP 20-30 degrees, PIP/DIP 0 degrees

Finger abduction/adductionFinger abduction/adduction Midline is middle finger, motion at MP jointsMidline is middle finger, motion at MP joints 20-25 degrees each direction20-25 degrees each direction

Range of MotionRange of Motion

Range of MotionRange of Motion

Thumb flexion/extensionThumb flexion/extension Flexion – 60-70 degrees, extension – 0 degreesFlexion – 60-70 degrees, extension – 0 degrees

Thumb abduction/adductionThumb abduction/adduction Abduction – 70-80 degrees, adduction – 0 degreesAbduction – 70-80 degrees, adduction – 0 degrees

Thumb oppositionThumb opposition Touch thumb to little fingerTouch thumb to little finger

NeurovascularNeurovascular

Neurological evalationNeurological evalation Nerve root level and peripheral nerve sensory and Nerve root level and peripheral nerve sensory and

motor distributions from cervical spine/brachial motor distributions from cervical spine/brachial plexusplexus

Vascular evaluationVascular evaluation Skin temperature/colorSkin temperature/color Capillary refillCapillary refill Radial pulseRadial pulse

Special TestsSpecial Tests Varus/valgus stress tests to MP/IP/PIP/DIP joints – Varus/valgus stress tests to MP/IP/PIP/DIP joints –

medial/lateral collateral ligament injuriesmedial/lateral collateral ligament injuries

Metacarpal longitudinal stress – fractures (“false joint”)Metacarpal longitudinal stress – fractures (“false joint”)

Phalen’s test – carpal tunnel syndromePhalen’s test – carpal tunnel syndrome

Tinel sign – carpal tunnel syndromeTinel sign – carpal tunnel syndrome

Intercarpal glides – wrist sprainIntercarpal glides – wrist sprain

InjuriesInjuries

Wrist InjuriesWrist Injuries Wrist sprainsWrist sprains

Hyperextension or hyperflexion mechnismsHyperextension or hyperflexion mechnisms

Carpal tunnel syndromeCarpal tunnel syndrome Compression of median nerve in tunnelCompression of median nerve in tunnel

Evaluate with Phalen’s test/tinel signEvaluate with Phalen’s test/tinel sign

Distal radius/ulna fractureDistal radius/ulna fracture Usually from fall on outstretched arm Usually from fall on outstretched arm Colles fracture – dorsal displacement of fracture fragmentsColles fracture – dorsal displacement of fracture fragments

Scaphoid fractureScaphoid fracture Most commonly fractured carpal bone, usually from hyperextension Most commonly fractured carpal bone, usually from hyperextension

mechanismmechanism Poor blood supply often results in non-union and subsequent surgeryPoor blood supply often results in non-union and subsequent surgery

Wrist InjuriesWrist Injuries

Hand and Finger InjuriesHand and Finger Injuries Metacarpal fractureMetacarpal fracture

44thth and 5 and 5thth metacarpals most commonly injured (Boxer’s fracture) metacarpals most commonly injured (Boxer’s fracture)

Deformities/tendon injuriesDeformities/tendon injuries ““Swan neck” deformity (flexor tendon from middle phalanx), Swan neck” deformity (flexor tendon from middle phalanx),

“boutonniere” deformity (extensor tendon from middle phalanx)“boutonniere” deformity (extensor tendon from middle phalanx)

Finger fracturesFinger fractures Distal phalanx most commonly fractured, avulsion fractures from Distal phalanx most commonly fractured, avulsion fractures from

flexor (mallet finger) and extensor (jersey finger) tendon attachmentsflexor (mallet finger) and extensor (jersey finger) tendon attachments

DislocationsDislocations Obvious deformity present, refer for x-ray prior to reductionObvious deformity present, refer for x-ray prior to reduction

Metacarpal FracturesMetacarpal Fractures

DeformitiesDeformities

Finger FracturesFinger Fractures

Finger DislocationsFinger Dislocations

Thumb InjuriesThumb Injuries

SprainsSprains Medial collateral ligament of thumb (1Medial collateral ligament of thumb (1stst MP joint) is most MP joint) is most

common areacommon area Called “gamekeeper’s thumb” – hyperextension and Called “gamekeeper’s thumb” – hyperextension and

hyperabductionhyperabduction

FracturesFractures If fracture extends into joint surface (carpometacarpal If fracture extends into joint surface (carpometacarpal

joint), referred to as Bennet’s fracturejoint), referred to as Bennet’s fracture

Thumb InjuriesThumb Injuries