Transcript The Forearm, Wrist, Hand, and Fingers

The Forearm, Wrist, Hand,
and Fingers
Chapter 24
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, radial
styloid process, ulnar head, ulnar styloid
 Musculature: flexors& pronators (lie anteriorly.
ulnar side), extensors & supinators (lie
posteriorly, medial side)
 Nerve/Blood Supply: median and radial nerve
and brachial, radial, and ulnar artery


Forearm Assessment
History
Observation
Visually inspect, including wrsit and elbow
If no deformity present, observe while they
supinate and pronate
Palpation
Special Tests
Management of Forearm
Injuries
Contusion
Etiology:direct blow
Why more common to ulna?
Signs and Symptoms
Management
 Forearm Splints
Etiology: repeated severe static contraction
Signs and Symptoms:dull ache between extensors,
interosseous membrane
Management: early season vs late in season?
Note: Acute / Chronic exertional compartment
syndrome: deep compartment most common and
associated with avulsions, distal radius fracture, or
crushing injuries; management same as in lower leg
Colles’ fracture
Etiology: FOA, forces radius and ulna back and up =
hyperextension
Signs and Symptoms (posterior displacement)
Management
Reverse Colles’ = fall on back of hand
 Forearm Fractures
Etiology
Signs and Symptoms: more common for radius and ulna
to fracture simultaneously
Management
Wrist, Hand, and Finger
Anatomy
Bones: carpals and metacarpals
Joints: radiocarpal, carpal, metacarpal, and
phalangeal joints
Ligaments: “many at each joint in the hand”
TFCC (triangular fibrocartilage complex); b/t head of
ulna and triquetrial bone
Musculature: “many intrinsic and extrinsic
muscles”
Blood and Nerve Supply: ulnar, median, radial
nerve and radial and ulnar superficial and deep
palmar arch arteries.
Assessment of Wrist,
Hand, and Finger Injuries
History
Observation
Palpation
Special Tests: Finklestein’s test, Tinel’s
Sign, Phalen’s test, valgus and varus
stress test,
Circulatory and Neurological Evaluation
Allen test
Functional Evaluation
Special Tests
 Finklesteins’ Test
De Quervains (tenosynovitis)
Thumb tucked inside fist with ulnar deviation
 Tinel’s Sign
 Tap over transverse carpal ligament
 Pain numbness and tingling indicates median nerve disruption and
presence of carpal tunnel
 Phalen’s Test
 Carpal tunnel
 Bilateral wrist flexion and press them together; pain is positive sign
 Valgus/varus at wrist, MCP, and IP joints
 Circulatory / neurological evaluations
 Allen's test: test function of radial and ulnar arteries
 Athlete makes fist 4-5 times; while holding final fist, evaluator pinches
off both arteries; hand should be blanched
 Release arties individually
Recognition and Management
of Wrist, Hand, and Finger
Injuries
 Wrist Sprain
Etiology
Signs and Symptoms
Management
 Triangular Fibrocartilage Complex Injury
Etiology:forced hyperextension or
compression of radioulnar joint and proximal
row of carpals
Signs and Symptoms
Management
 Tenosynovitis
Etiology: repeated wrist acceleration and
deceleration
Signs and Symptoms: pain w/ passive stretching
Management: may need splinting and
strengthening
 Tendinitis
Etiology: repetitive pulling motions and pressure
on palm of hand
Signs and Symptoms:pain with AROM and passive
stretching
Management
 Nerve Compression, Entrapment, Palsy
Etiology: median (carpal tunnel) and ulnar
(pisiform and hamate)
Signs and Symptoms:deformities(bishop’s, claw
and drop wrist)
Management: if chronic, may require surgical
 Carpal Tunnel Syndrome
Tunnel = pink
Bones = white
Ligament = blue
 Carpal tunnel syndrome
Etiology: repeated
flexion
Signs and Symptoms:
sensory and motor
impairment
Management
Recognition and Management
of Wrist, Hand, and Finger
Injuries
 Dislocation of the Lunate
Bone
Etiology:forced
hyperextension of wrist
Signs and
Symptoms:difficulty
with wrist and finger
flexion; may have
impaired nerves
Management: referral
for reduction
 Hamate Fracture
Etiology: contact while
holding
something(racket)
Signs and Symptoms
Management
 Wrist Ganglion(synovial
cyst)
Etiology:herniation of
joint capsule or tendon
Signs and Symptoms
Management
 De Quervain’s Disease
Etiology:
tenosynovitis of
thumb
Signs and
Symptoms
Management
Scaphoid Fracture
Etiology: compression of scaphoid
b/t radius and ulna
Concerns: portion of scaphoid has
decreased vascular supply; improper
healing can occur and result in aseptic
necrosis of the scaphoid bone
Signs and Symptoms
Anatomical snuffbox pain
Management
Finger anatomy
Bones
Ligaments
PIP and DIP have the same
design
Collateral ligaments,
palmar fibrocartilage, and
loose posterior capsule or
synovial membrane
(protected by extensor
expansion)
Finger anatomy
Musculature
PIP: Flex. Digitorium Superficialis
DIP: Flex. Digitorium Profundus
PIP & DIP: Exten. Digitorium Longus (becomes
extensor expansion after MCP)
Intrinsics:
Dorsal and palmar interosseei:
Lumbricals:volar surface; MCP flex., IP exten.
Thenar (4 that act on thumb) & hypothenar (4
that act on 5th)
Recognition and Management of
Wrist, Hand, and Finger Injuries
 Contusion to hand and fingers
Etiology
Signs and Symptoms: fingernail?
Management
 Bowler’s Thumb
Etiology: fibrosis of the ulnar digital nerve
form 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
 Trigger finger or thumb
Etiology: stenosing tendon by repeated
movements
Signs and Symptoms: resistance to reextension after thumb and finger flexed
Management:possible injections; splinting
 Dupuytren’s Contracture
Etiology: idiopathic development of nodules in
palmer aponeurosis
Signs and Symptoms:flexion deformity; cannot
extend
Management: surgical removal
Boutonniere deformity
 Etiology:rupture of
extensor tendon
dorsal to middle
phalanx; trauma to tip
of finger causes DIP
extension and PIP
flexion
 Signs and Symptoms:
cannot extend
 Management:splint
PIP in extension 58wks.
 Swan neck deformity
 AKA
Pseudoboutonniere
Etiology:severe
hyperextension;
injury to volar plate
Signs and
Symptoms:
hyperextension of
PIP
Management:
splint 20-30
degrees flexion 3
wks
Mallet Finger
Etiology: strike to tip of
finger, jamming and
avulsing extensor
tendon
Signs and Symptoms:
unable to extend, may
palpate avulsed bone
Management:extension
splint 6-8 wks
 Gamekeepers Thumb
Etiology:UCL of
thumb; forced
abductions, an
hyperextension
Signs and
Symptoms:inability
to pinch; pain with
stress
Management:splint
3 weeks; protect
with activity
Recognition and Management of
Wrist, Hand, and Finger Injuries
 Sprains, Dislocations, and
Fractures
Etiology
Signs and Symptoms
Management
 Sprains PIP and DIP joint
Etiology
Signs and Symptoms
Management
 PIP Doral Dislocation
Etiology:twist while
semiflexed
Signs and Symptoms
Management:splint in
ext
 PIP Dorsal dislocation
Etiology:hyperext.
Signs and
symptoms:deformity;
inability to move
Management:reduce
and splint 20-30
degrees flex
Recognition and Management of Wrist,
Hand, and Finger Injuries
 MCP dislocation
Etiology:twist an shear force
Signs and Symptoms:prox. Phalanx dorsal 60-90
degrees
Management: reduce; splint; early ROM
 Metacarpal fracture
Etiology:compressive axial force
Signs and Symptoms:appear angular or rotated
Management: reduce and splint
 Bennett’s Fracture
Etiology:thumb CMC; axial and ABD force to thumb
Signs and Symptoms:base of thumb painful
Management:refer to surgeon due to unstable
nature
 Distal/Middle/Proximal phalangeal fracture
Etiology:crushing force; direct trauma or twist
Signs and Symptoms: subungual hematoma subungual
hematoma
Management:drain and splint / buddy tape; control pain
 Fingernail deformity
Occur for variety of reasons:
Scaling or ridging – psoriasis
Ridging or poor development – hyperthyroidism
Clubbing and cyanosis-chronic respiratory disease or heart disorder
Spooning or depression- chronic alcoholism and vitamin
deficiencies
Rehabilitation Principles for
the Forearm, Wrist, Hand, and
Fingers
General Body Conditioning
Joint Mobilization:traction and mobilization help
restore ROM
Flexibility: full ROM is measure of good rehab
Strength:equal
Neuromuscular Control:great dexterity required
Return to Activity: Goals: full dexterity, full
ROM, full strength