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The Forearm Wrist Handand Fingers
Chapter 24
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Forearm Anatomy
Radius and Ulna: Elbow
Joints: radioulnar joint (superior, middle,and distal)
Bone: proximal radial head, olecranon process,radial shaft, ulnar shaft, distal radius, radialstyloid process, ulnar head, ulnar styloid
Musculature: flexors& pronators (lie anteriorly.ulnar side), extensors & supinators (lieposteriorly, medial side)
Nerve/Blood Supply: median and radial nerveand brachial, radial, and ulnar artery
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Forearm Assessment
History
Observation
Visually inspect, including wrsit and elbow
If no deformity present, observe while theysupinate and pronate
PalpationSpecial Tests
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Management of Forearm
Injuries
ContusionEtiology:direct blowWhy more common to ulna?
Signs and SymptomsManagement
Forearm SplintsEtiology: repeated severe static contraction
Signs and Symptoms:dull ache between extensors,
interosseous membraneManagement: early season vs late in season?
Note: Acute / Chronic exertional compartmentsyndrome: deep compartment most common andassociated with avulsions, distal radius fracture, or
crushing injuries; management same as in lower leg
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Colles fractureEtiology: FOA, forces radius and ulna back and up =
hyperextension
Signs and Symptoms (posterior displacement)Management
Reverse Colles = fall on back of hand
Forearm Fractures
EtiologySigns and Symptoms: more common for radius and ulna
to fracture simultaneously
Management
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Wrist, Hand, and Finger
Anatomy
Bones: carpals and metacarpals
Joints: radiocarpal, carpal, metacarpal, andphalangeal joints
Ligaments: many at each joint in the handTFCC (triangular fibrocartilage complex); b/t head of
ulna and triquetrial bone
Musculature: many intrinsic and extrinsicmuscles
Blood and Nerve Supply: ulnar, median, radialnerve and radial and ulnar superficial and deep
palmar arch arteries.
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Assessment of Wrist,
Hand, and Finger Injuries
History
Observation
PalpationSpecial Tests: Finklesteins test, Tinels
Sign, Phalens test, valgus and varusstress test,
Circulatory and Neurological EvaluationAllen test
Functional Evaluation
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Special Tests
Finklesteins TestDe Quervains (tenosynovitis)
Thumb tucked inside fist with ulnar deviation
Tinels Sign Tap over transverse carpal ligament
Pain numbness and tingling indicates median nerve disruption andpresence of carpal tunnel
Phalens Test Carpal tunnel
Bilateral wrist flexion and press them together; pain is positive sign
Valgus/varus at wrist, MCP, and IP joints Circulatory / neurological evaluationsAllen's test: test function of radial and ulnar arteries
Athlete makes fist 4-5 times; while holding final fist, evaluator pinchesoff both arteries; hand should be blanched
Release arties individually
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of Wrist, Hand, and Finger
Injuries
Wrist Sprain
Etiology
Signs and Symptoms
Management Triangular Fibrocartilage Complex Injury
Etiology:forced hyperextension orcompression of radioulnar joint and proximal
row of carpalsSigns and Symptoms
Management
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Tenosynovitis
Etiology: repeated wrist acceleration anddeceleration
Signs and Symptoms: pain w/ passive stretchingManagement: may need splinting and
strengthening
Tendinitis
Etiology: repetitive pulling motions and pressureon palm of hand
Signs and Symptoms:pain with AROM and passivestretching
Management
Nerve Compression, Entrapment, PalsyEtiology: median (carpal tunnel) and ulnar
(pisiform and hamate)
Signs and Symptoms:deformities(bishops, clawand drop wrist)
Management: if chronic, may require surgical
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Carpal Tunnel SyndromeTunnel = pink
Bones = white
Ligament = blue
Carpal tunnel syndrome
Etiology: repeatedflexion
Signs and Symptoms:sensory and motorimpairment
Management
Recognition and Management
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Recognition and Managementof Wrist, Hand, and Finger
Injuries
Dislocation of the LunateBone
Etiology:forcedhyperextension of wrist
Signs andSymptoms:difficultywith wrist and fingerflexion; may haveimpaired nerves
Management: referralfor reduction
Hamate Fracture
Etiology: contact whileholdingsomething(racket)
Signs and Symptoms
Management
Wrist Ganglion(synovialcyst)
Etiology:herniation ofjoint capsule or tendon
Signs and Symptoms
Management
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De Quervains Disease
Etiology:tenosynovitis of
thumbSigns and
Symptoms
Management
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Scaphoid FractureEtiology: compression of scaphoid
b/t radius and ulna
Concerns: portion of scaphoid hasdecreased vascular supply; improperhealing can occur and result in asepticnecrosis of the scaphoid bone
Signs and SymptomsAnatomical snuffbox pain
Management
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Finger anatomy
Bones
LigamentsPIP and DIP have the same
design
Collateral ligaments,palmar fibrocartilage, andloose posterior capsule orsynovial membrane(protected by extensorexpansion)
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Finger anatomy
MusculaturePIP: Flex. Digitorium Superficialis
DIP: Flex. Digitorium Profundus
PIP & DIP: Exten. Digitorium Longus (becomesextensor expansion after MCP)
Intrinsics:
Dorsal and palmar interosseei:
Lumbricals:volar surface; MCP flex., IP exten.
Thenar (4 that act on thumb) & hypothenar (4that act on 5th)
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Recognition and Management of
Wrist, Hand, and Finger Injuries Contusion to hand and fingers
Etiology
Signs and Symptoms: fingernail?
Management
Bowlers Thumb
Etiology: fibrosis of the ulnar digital nerveform pressure
Signs and Symptoms:pain, numbness, tingling
Management: pad area, decrease activity;
surgery PRN Jersey finger
Etiology:FDP rupture, grabbing jersey
Signs and Symptoms:DIP cannot flex
Management:SURGERY
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Trigger finger or thumb
Etiology: stenosing tendon by repeatedmovements
Signs and Symptoms: resistance to re-extension after thumb and finger flexed
Management:possible injections; splinting
Dupuytrens Contracture
Etiology: idiopathic development of nodules inpalmer aponeurosis
Signs and Symptoms:flexion deformity; cannotextend
Management: surgical removal
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Boutonniere deformity Etiology:rupture of
extensor tendondorsal to middlephalanx; trauma to tipof finger causes DIPextension and PIPflexion
Signs and Symptoms:
cannot extendManagement:splint
PIP in extension 5-8wks.
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Swan neck deformityAKA
Pseudoboutonniere
Etiology:severehyperextension;injury to volar plate
Signs andSymptoms:hyperextension of
PIPManagement:
splint 20-30degrees flexion 3wks
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Gamekeepers Thumb
Etiology:UCL ofthumb; forced
abductions, anhyperextension
Signs andSymptoms:inabilityto pinch; pain with
stressManagement:splint
3 weeks; protectwith activity
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Recognition and Management of
Wrist, Hand, and Finger Injuries
Sprains, Dislocations, andFractures
Etiology
Signs and SymptomsManagement
Sprains PIP and DIP joint
Etiology
Signs and Symptoms
Management
PIP Doral Dislocation
Etiology:twist whilesemiflexed
Signs and Symptoms
Management:splint inext
PIP Dorsal dislocation
Etiology:hyperext.
Signs and
symptoms:deformity;inability to move
Management:reduceand splint 20-30degrees flex
R iti d M t f W i t
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Recognition and Management of Wrist,
Hand, and Finger Injuries MCP dislocation
Etiology:twist an shear force
Signs and Symptoms:prox. Phalanx dorsal 60-90degrees
Management: reduce; splint; early ROM
Metacarpal fracture
Etiology:compressive axial forceSigns and Symptoms:appear angular or rotated
Management: reduce and splint
Bennetts Fracture
Etiology:thumb CMC; axial and ABD force to thumbSigns and Symptoms:base of thumb painful
Management:refer to surgeon due to unstablenature
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Distal/Middle/Proximal phalangeal fracture
Etiology:crushing force; direct trauma or twist
Signs and Symptoms: subungual hematoma subungualhematoma
Management:drain and splint / buddy tape; control pain Fingernail deformity
Occur for variety of reasons:Scaling or ridgingpsoriasis
Ridging or poor developmenthyperthyroidism
Clubbing and cyanosis-chronic respiratory disease or heart disorderSpooning or depression- chronic alcoholism and vitamin
deficiencies
R h bilit ti P i i l f
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Rehabilitation Principles for
the Forearm, Wrist, Hand, and
FingersGeneral Body Conditioning
Joint Mobilization:traction and mobilization helprestore ROM
Flexibility: full ROM is measure of good rehab
Strength:equal
Neuromuscular Control:great dexterity required
Return to Activity: Goals: full dexterity, fullROM, full strength