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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Wrist and Hand ConditionsWrist and Hand Conditions
Chapter 16
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnatomyAnatomy
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Wrist ArticulationsWrist Articulations
• Radiocarpal joint
– Radius with scaphoid, lunate, and triquetrum
– Condyloid joint
– Sagittal plane motions (i.e., flexion, extension, and hyperextension)
– Frontal plane motions (i.e., radial deviation and ulnar deviation)
– Circumduction
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Wrist Articulations (cont.)Wrist Articulations (cont.)• Intercarpal joints
– Gliding joints
– Minimal contribution to wrist movement
• Distal radioulnar joint
– Immediately adjacent to radiocarpal joint
– TFCC – stabilizer
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Hand ArticulationsHand Articulations
• Carpometacarpal joints (CM)
– Thumb
• Saddle joint
– Fingers
• Gliding joints
• Intermetacarpal joints (IM)
• Metacarpophalangeal joints (MP)
– Condyloid joints
• Interphalangeal joints (IP)
– PIP and DIP hinge joints
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MusclesMuscles
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Muscles (cont.)Muscles (cont.)
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Muscles (cont.)Muscles (cont.)
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Muscles (cont.)Muscles (cont.)• Tendon sheaths
– Level of the metacarpal heads – point where flexor tendons enter a flexor tendon sheath
– Annular pulleys
• Keep flexor tendons and sheath closely applied to phalanges
– Cruciate pulleys
• Collapse to allow full digital flexion
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NervesNerves
• Median nerve
• Radial nerve
• Ulnar nerve
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Blood VesselsBlood Vessels
• Radial artery
• Ulnar artery
• Numerous divisions
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KinematicsKinematics• Wrist movements
– Flexion
– Extension/ hyperextension
– Radial deviation
– Ulnar deviation
– Circumduction
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Kinematics (cont.)Kinematics (cont.)
• CM
– Thumb – flexion, extension, abduction, adduction
• MP – fingers
– Fingers – minimal motion
– Flexion
– Extension
– Abduction
– Adduction
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Kinematics (cont.)Kinematics (cont.)
• MP – thumb– Flexion– Extension
• IP– Flexion– Extension
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Kinematics (Cont’d)Kinematics (Cont’d)
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KineticsKinetics• Wrist flexors of hand are 2× stronger than extensor muscles
• Grips
– Power
– Precision
– Lateral pinch; fencing
– Maximum grip strength – exerted with wrist in ulnar deviation and slight hyperextension
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Prevention of InjuriesPrevention of Injuries
• Protective equipment
– Pads and gloves
• Physical conditioning
– Strength and flexibility
– Exercises for wrist and elbow
• Proper skill technique
– Instruction on falling
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Contusions and Skin WoundsContusions and Skin Wounds
• Always important to consider an underlying fracture
• Contusion S&S: pain & discoloration
• Skin wounds – typically abrasions and lacerations
• Management
– Standard acute for closed wound & open wound
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SprainsSprains• Wrist
– Mechanism: axial loading on proximal palm during fall on outstretched hand
– S&S
• Standard – sprain
• Specific
Point tenderness on dorsum of radiocarpal joint
↑ Pain with active or passive extension
– Need to rule out fracture, especially scaphoid fx
– Management: standard acute; NSAIDs
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Sprains (cont.)Sprains (cont.)
• Gamekeeper’s thumb
– Tear of the UCL of the MP joint
– Mechanism: MP in extension and forceful abduction
– S&S
• Palmar aspect of joint – pain; swelling
• + abduction stress
– Management: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repair
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Sprains (cont.)Sprains (cont.)• IP sprains
– Excessive valgus and varus: collateral ligaments
– Hyperextension stress: volar plate
– S&S
• Rapid swelling; masks condition
– X-ray: rule out fracture and dislocation
– Management: standard acute; “buddy” taping
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DislocationsDislocations
• Distal radioulnar joint (DRUJ)
– Isolated or with radial fracture
– Mechanism: hyperextension
• With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation
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Dislocations (cont.)Dislocations (cont.)
– S&S• Pain; deformity; extensive swelling
• Dorsal dislocation – ulnar head prominent dorsally; volar dislocation – wrist appears narrow (result of overlap of the distal radius and ulna)
• elbow flexion and extension – normal unless fracture present; pronation and supination of forearm – limited
– Management: immobilization of limb in vacuum splint; immediate transportation to physician
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Dislocations (cont.)Dislocations (cont.)• Lunate
– Axial loading displaces in volar direction– S&S
• Point tenderness – dorsum of hand just distal to radius
• Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal)
• Passive and active motion may not be painful– Caution: bone into carpal tunnel – compression of
median nerve– Management: immobilization of limb in vacuum splint;
immediate transportation to physician
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dislocations (cont.)Dislocations (cont.)• Fingers
– Can involve collateral ligaments and volar plate– MCP
• Rare, but easily recognizable• Hyperextension or shear
– PIP • Hyperextension and axial loading (e.g., ball
striking extended finger)– DIP
• Usually occur dorsally • Individual often reduces injury on their own
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Dislocations (cont.)Dislocations (cont.)
– S&S: swollen, painful finger – Management: immobilization; ice; immediate
physician referral
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Dislocations (cont.)Dislocations (cont.)
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StrainsStrains
• Jersey finger
– Rupture of flexor digitorum profundus from distal phalanx
– Mechanism: rapid extension (from active flexion)
– S&S
• Unable to flex the DIP
• Palpate tendon in proximal aspect of finger
• Hematoma formation along the entire flexor tendon sheath
– Management: standard acute; physician referral
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Strains (cont.)Strains (cont.)• Mallet finger
– Rupture of extensor tendon from distal phalanx
– Mechanism: forceful flexion of PIP
– S&S
• Pain, swelling
• Lack of extension at DIP
– Management: standard acute; physician referral
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Strains (cont.)Strains (cont.)• Boutonnière deformity
– Rupture of central slip of extensor tendon at the middle phalanx
– Mechanism: rapid forceful flexion of PIP– Result: hyperextension at MCP, flexion of PIP,
hyperextension of DIP– S&S
• No active extension• Deformity usually not present immediately, but
develops over 2-3 weeks– Management: standard acute; injury that limits PIP
extension to <30º: immediate physician referral
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Strains (cont.)Strains (cont.)
• Tendinopathies
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Strains (cont.)Strains (cont.)• Tendinopathies
– Trigger finger• Finger flexors contract but are unable to re-extend • Due to a nodule within tendon sheath or sheath too
constricted to allow free motion • S&S
Locking usually occurs when wakening from sleep Painful popping sensation when PIP joint is
passively returned to extension• Management: NSAIDs, resting finger; splinting when
necessary; possible cortisone injections into the sheath
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Strains (cont.)Strains (cont.)– de Quervain's tenosynovitis
• Stenosing tenosynovitis of APL and EPB
• A forceful grasp, combined with repetitive use of thumb and ulnar deviation
• S&S
Pain over radial styloid process ↑ with thumb and wrist motion
Point tenderness over the tendons
Pain with RROM thumb abduction
+ Finkelstein’s test
• Management: standard acute; NSAIDS
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Strains (cont.)Strains (cont.)– de Quervain's
tenosynovitis
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Strains (cont.)Strains (cont.)• Intersection syndrome
– Tendinitis or friction tendinitis in 1st and 2nd dorsal compartments of wrist
– Overuse of radial extensors by excessive curling
– S&S
• Point tenderness on the dorsum of the forearm, 2-3 finger breadths proximal to the wrist joint
• Crepitus with AROM or PROM
– Management: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activities
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Strains (cont.)Strains (cont.)
• Dupuytren’s contracture
– Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformity
– S&S
• Fixed flexion deformity is visible
• Finger cannot be extended
– Management: surgical repair
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Strains (cont.)Strains (cont.)
• Gymnast’s wrist
– Stress fracture to distal radial epiphyseal plate
– Mechanism: compression (maximum dorsiflexion)
– S&S:
• Diffuse tenderness – dorsum of midcarpal area
• ↑ pain with extreme motion
– Management: splinting; NSAIDs; activity modification
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Strains (cont.)Strains (cont.)
• Ganglion cysts
– Benign tumor mass on dorsal aspect of wrist
– Associated with tissue sheath degeneration
– Treatment: symptomatic
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Finger Tip InjuriesFinger Tip Injuries
• Subungual hematoma
– Blood under fingernail
– Due to direct trauma
– Need to rule out fracture
– Management
• Soak in ice water for 10-15 minutes
• If pain does not diminish, may need to be drained under supervision of a physician
• Refer to Application Strategy 16.1
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Finger Tip Injuries (cont.)Finger Tip Injuries (cont.)
• Paronychia
– Infection along nail fold– Fold is red, swollen, and painful; can produce
purulent drainage – Management
• Warm water soaks and germicide.• More severe cases, physician referral
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Nerve Entrapment SyndromesNerve Entrapment Syndromes
• Median nerve
– Anterior interosseous nerve syndrome
• Following set of strenuous or repetitive elbow motion exercises
• Affects motor but not sensation
• S&S
• Acute – sudden loss of use of flexor pollicis longus index finger profundus tendons
• Gradual – weakness becomes apparent during heavy activity
• + pinch grip test
• Management: splint extremity; avoid heavy activity
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)– Carpal tunnel syndrome
• Median nerve, finger flexors, and flexor pollicis longus
• Due to direct trauma, repetitive overuse, or anatomic anomalies
• S&S
Awakening pain in middle of night; often relieved by “shaking out their hands”
Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger
+ Phalen’s maneuver; + Tinel’s sign
Weak thumb abduction
• Management: physician referral
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)• Carpal tunnel
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)• Ulnar nerve entrapment
– Ulnar tunnel syndrome
• Due to repetitive compressive trauma to the palmar aspect of the hand
• S&S
Numbness in the ulnar nerve distribution (especially little finger)
+ Froment’s sign
Slight weakness in grip strength
+ Tinel’s sign
• Management: splinting, NSAIDs; activity modification
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)
• Ulnar nerve entrapment
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)
– Cyclist's palsy
• Due to leaning on handlebar for extended period; leads to swelling in hypothenar area
• Symptoms mimic ulnar nerve entrapment syndrome, but disappear rapidly after end of ride
• Key: proper padding; varying hand position
– Bowler’s thumb
• Compression of ulnar digital sensory nerve
• S&S
Numbness, tingling, or pain – medial aspect of thumb
• Management: standard acute; NSAIDs; immobilization
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)
• Radial nerve entrapment– Distal posterior interosseous nerve syndrome
• Due to compression associated with repetitive and forceful wrist dorsiflexion
• S&S• Deep, dull ache in wrist, reproduced with:
Forceful wrist extension Deep palpation of forearm with wrist in flexion
• Management: standard acute; activity modification
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Nerve Entrapment Syndromes (cont.)Nerve Entrapment Syndromes (cont.)
– Superficial radial nerve entrapment• Compressed at the wrist
Aggravated by repeated pronation and supination Tight wrist straps
• S&S Burning pain and sensory changes in dorsoradial
aspect of wrist, hand, dorsal thumb, and index finger + Tinel’s sign
• Management: standard acute; activity modification
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FracturesFractures• Distal radius/ulna fracture
– Mechanism: axial loading; fall on outstretched hand
– Monteggia’s
• Distal ulna with associated dislocation of radial head
– Galeazzi's
• Distal radius with associated dislocation or subluxation of distal radioulnar joint
– Colles’
• Distal metaphysis of radius, with displacement of distal fragment dorsally
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Fractures (cont.)Fractures (cont.)
• Distal radius/ulna fracture (cont.)
– Smith’s
• Distal radius, with displacement of distal fragment toward palmar aspect
– S&S: normal fracture
– Concerns:
• Circulatory impairment
• Nerve damage
– Management: immobilization in a vacuum splint; immediate physician referral
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Fractures (cont.)Fractures (cont.)• Forearm fractures
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Fractures (cont.)Fractures (cont.)
• Scaphoid fracture
– S&S
• History of falling on an outstretched hand
• Point tenderness in anatomic snuff box
• Pain with inward pressure along long axis
• ↑ pain with wrist extension and radial deviation
– Management: standard acute; splint; physician referral
– Concern: aseptic necrosis
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fractures (cont.)Fractures (cont.)
• Lunate fracture– Rare in sports– S&S: dorsal wrist pain, swelling, and weakness of wrist
associated with use– Concern: Kienböck’s disease – Management: standard acute; splint; physician referral
• Hamate fracture– Direct impact; when striking a stationary object with a
racquet or club in full swing
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Fractures (cont.)Fractures (cont.)
– S&S• Tenderness – hypothenar mass• Painful RROM abduction of the small finger • ↓ grip strength
– Management: standard acute; splint; physician referral
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Fractures (cont.)Fractures (cont.)
• Triquetrum fracture– Caused by impingement of ulnar styloid into dorsum of
triquetrum– S&S
• History of acute wrist dorsiflexion injury or direct trauma
• Pain – dorsal wrist over triquetrum– Management: standard acute; splint; physician referral
• Metacarpal fracture (typical)– Mechanism: axial compression
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Fractures (cont.)Fractures (cont.)
– S&S: • ↑ pain and palpable – palm, directly over involved
metacarpal• ↑ pain with percussion and compression
– Management: immobilize in position of function; ice without compression; immediate physician referral
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Fractures (cont.)Fractures (cont.)• Bennett’s fracture
– Articular fracture – proximal end of first metacarpal
– Mechanism: axial compression
– Pull of APL tendon displaces shaft proximally; deep volar ligament holds small medial fragment in place → fracture-dislocation
– S&S
• Localized pain and swelling; ↑ pain with inward pressure long axis
– Management: standard acute; splint; immediate physician referral
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fractures (cont.)Fractures (cont.)
• Rolando fracture
– Similar to Bennett’s fracture
– Intra-articular fracture – proximal end of first metacarpal; tends to be more comminuted
– S&S: same as Bennett’s, but ↑ deformity
– Management: standard acute; splint; immediate physician referral
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Fractures (cont.)Fractures (cont.)• Boxer’s fracture
– Distal metaphysis or neck of fourth or fifth metacarpals
– Inherently unstable – S&S
• Sudden pain, inability to grip, rapid swelling, and deformity
• Point tenderness; crepitus • ↑ pain with axial compression and percussion
– Management: standard acute; splint; immediate physician referral
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fractures (cont.)Fractures (cont.)
• Phalangeal fracture
– Mechanism: compression; hyperextension
– S&S:
• ↑ pain with circulative compression of phalanx
• ↑ pain with percussion and compression (long axis)
– Management: standard acute; splint; immediate physician referral
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AssessmentAssessment
• History• Observation/inspection
– Expose entire arm• Palpation
– Pain, unable or unwilling to move wrist or hand; determine the possibility of a fracture or dislocation before moving the wrist or hand
– Proximal to distal• Physical examination tests
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Range of Motion (ROM)Range of Motion (ROM)• Active range of motion (AROM)
– Forearm pronation/supination
– Wrist
• Flexion/extension
• Radial deviation/ulnar deviation
– Fingers and thumb
• Flexion/extension
• Abduction/adduction
• Opposition of thumb and little finger
• Passive range of motion (PROM)
– Normal end feel – tissue stretch
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ROM (cont.)ROM (cont.)• Normal ranges
– Supination: 90°
– Pronation: 90°
– Wrist flexion: 80-90°
– Wrist extension: 70-90°
– Radial deviation: 15°
– Ulnar deviation: 30-45°
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ROM (cont.)ROM (cont.)• Resisted range of motion (RROM)
– Supination– Pronation– Wrist flexion– Wrist extension– Ulnar deviation– Radial deviation– Finger flexion/extension– Finger abduction/adduction– Thumb flexion/extension– Thumb abduction/adduction– Opposition
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ROM (cont.)ROM (cont.)
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ROM (cont.)ROM (cont.)
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Stress TestsStress Tests
• Wrist ligamentous instability tests
– Varus and valgus
• Finger ligamentous instability tests
– Varus and valgus
– Anterior/posterior glide
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Special TestsSpecial Tests
• Finkelstein’s test for de Quervain’s tenosynovitis
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Special Tests (cont.)Special Tests (cont.)
• Flexor digitorum superficialis (test for rupture of FDS)
• Flexor digitorum profundus
• Extensor tendon rupture
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Special Tests (cont.) Special Tests (cont.)
• Carpal tunnel compression test
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Special Tests (cont.)Special Tests (cont.)
• Phalen’s wrist flexion test
• Tinel’s sign
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Special Tests (cont.)Special Tests (cont.)
• Pinch-grip test for anterior interosseous nerve entrapment
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Special Tests (cont.)Special Tests (cont.)
• Froment’s sign for ulnar nerve paralysis
• Allen test for circulation
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Fracture AssessmentFracture Assessment
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Neurologic TestsNeurologic Tests• Myotomes
– Scapular elevation - C4– Shoulder abduction - C5– Elbow flexion and/or wrist extension - C6– Elbow extension and/or wrist flexion - C7– Thumb extension and/or ulnar deviation - C8– Abduction and/or adduction of fingers - T1
• Reflexes– Biceps - C5-C6– Brachioradialis - C6– Triceps – C7
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Neurologic Tests (cont.)Neurologic Tests (cont.)
• Dermatomes
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RehabilitationRehabilitation
• Restoration of motion
– Concern: joint contractures and stiffness – begin AROM ASAP
– Use of opposite hand to supply load
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness