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