Transcript HuP 191B – Advanced Assessment of Upper Extremity Injuries

HuP 191B – Advanced
Assessment of Upper
Extremity Injuries
Wrist, Hand and Finger Evaluation
and Pathologies
History
History
 Location
of pain
 Mechanism of injury/etiology
 Unusual sounds/sensations
 Onset/duration and description of
symptoms
 Prior history/general health concerns
Location of Pain

Generally, local injury represented by local
symptoms – sometimes difficult to identify
specific structure/s

Must be aware of possible referred pain
from cervical, shoulder and/or elbow
pathologies
Mechanism of Injury

Direct trauma

Hyperextension/hyperflexion injuries of wrist
and/or fingers

Insiduous onset increases likelihood of chronic
conditions

Identify factors which increase or decrease
symptoms
Unusual Sounds or Sensations

Numbness/tingling indicative of neurological
pathology – must establish if local or referred

Fractures, dislocations and tendon ruptures often
accompanied by “popping” sensation

Some overuse conditions (tendonitis) may present
with “snapping” sensation
Onset/Duration and Description
of Symptoms

Type of pain (ache, throb, etc.)

Intensity of pain (objectify)

Immediate vs. gradual onset of symptoms

Changes in symptoms (better, worse)
Prior History and General
Health Concerns

Any previous injury, especially if neurological in
nature, may have lasting effect on function, etc.
 Hand is typically first part of body to be affected
by:
– Arthritis
– Peripheral vascular disease (PVD)

Insufficient vascular structures to provide adequate circulation
– Raynaud’s phenomenon

Reaction to cold temps – alternating bouts of pallor and
cyanosis (vascular responses)
Inspection/Observation
Inspection/Observation

General inspection

Inspection of wrist and hand

Inspection of thumb and fingers
General Inspection

Hand posture
– Relaxed normal hand is slightly flexed with subtle
palmar arch

Gross deformity
– Associated with fractures and/or dislocations

Palmar creases
– May not be visible if severe swelling

Cuts, scars, lacerations
– Superficial nature of neurovascular structures makes
them susceptible to injury even with superficial wounds
Inspection of Wrist and Hand

Distal radioulnar continuity
 Carpal and metacarpal continuity/contour
 MP joint alignment
– Depressed knuckle = Boxer’s fracture

Wrist and hand posturing
– Neurovascular conditions may prompt
abnormalities (drop wrist, Volkmann’s ischemic
contracture)
Inspection of Wrist and Hand

Ganglion cyst
– Defined as benign
collection of thick fluid
within a tendinous
sheath or joint capsule
– Most commonly found
in wrist and hand
– Painful with motions
that impinge upon
when symptomatic
Inspection of Thumb and Fingers

Skin and fingernails
– Subungual hematoma
– Paronychia – infection at nail periphery
– Felon – infection/abscess at or distal to DIP

Finger alignment and deformity
– If finger out of alignment, may be spiral fracture of
phalanx/metacarpal
– Secondary to fracture, dislocation or tendon injury
Skin and Fingernail Conditions
Palpation
Palpation

Wrist and finger flexors

Wrist and finger extensors

Bony anatomy
– Non-carpal bones
– Carpal bones

Ligamentous and intrinsic muscular structures
Wrist and Finger Flexors

Flexor carpi ulnaris tendon

Flexor carpi radialis tendon

Tendons of finger flexors
– Superficialis vs. profundus

Palmaris longus tendon
Wrist and Finger Extensors

Extensor digitorum tendons

Anatomical snuffbox
– Extensor pollicis longus – medial (ulnar) border
– Abductor pollicis longus and extensor pollicis
brevis – lateral (radial) border
– Scaphoid - floor
Anatomic Snuffbox
Non-Carpal Bony Anatomy

Distal radius/radial styloid process

Lister’s tubercle (dorsal and distal radius)

Ulnar head/ulnar styloid process

Metacarpals

Phalanges
Carpal Bony Anatomy

Scaphoid
– Floor of snuffbox, easier with ulnar deviation

Lunate
– Typically aligned with 3rd metacarpal, distal to Lister’s
tubercle and flex wrist

Triquetrum
– Just distal to ulnar styloid process

Pisiform
– Small, rounded prominence at proximal aspect of
hypothenar eminence in palm
Carpal Bony Anatomy

Trapezium
– Between scaphoid and 1st metacarpal

Trapezoid
– Base of 2nd metacarpal

Capitate
– Move toward thumb from hamate, base of 3rd
metacarpal

Hamate
– “hook” of hamate is large prominence at distal
hypothenar eminence on palm
Ligamentous and Intrinsic
Muscular Anatomy

Radial collateral ligaments
– Radiocarpal joint, MP/IP/PIP/DIP joints

Ulnar collateral ligaments
– Ulnocarpal joint, MP/IP/PIP/DIP joints

Carpal tunnel (transverse carpal ligament)
 Thenar eminence
 Hypothenar eminence
Range of Motion
Range of Motion

Active/passive/resistive
– Wrist
 Flexion/extension, ulnar/radial deviation
– Thumb (carpometacarpal joint)\
 Flexion/extension, abduction/adduction, opposition
– Fingers
 MP joints: flexion/extension, abduction/adduction
 IP/PIP/DIP joints: flexion/extension
Wrist Ranges of Motion

Flexion – normally 80-90 degrees, firm end feel

Extension – normally 75-85 degrees, firm end feel

Radial deviation – normally 20 degrees, hard end
feel (scaphoid on radial styloid)

Ulnar deviation – normally 35 degrees, firm end
feel
Wrist Ranges of Motion
Thumb Ranges of Motion

Flexion – normally 60-70 degrees, soft end feel

Extension – 0 degrees, firm end feel

Abduction – 70-80 degrees, firm end feel

Adduction – 0 degrees, soft end feel

Opposition – flexion/adduction/rotation, touch thumb to
little finger, firm end feel
Thumb Motions
Finger Ranges of Motion

MP joints
– Flexion – 85-105 degrees, hard end feel (proximal
phalanges on distal metacarpal)
– Extension – 20-30 degrees, firm end feel
– Abduction/adduction – total of 20-25 degrees, firm end
feel

IP/PIP/DIP joints
– Flexion – IP: 80-90 degrees, PIP: 110-120 degrees,
DIP: 80-90 degrees, firm end feels except PIP is hard
end feel (middle phalanges on proximal phalanges)
– Extension – 0 degrees, firm end feels
Ligamentous/Capsular Testing
Ligamentous/Capsular Testing

Carpal glide tests
– Attempts to elicit abnormal glide of carpal bones

Varus/valgus stress tests (do at multiple joint
positions)
– Wrist
UCL limits radial deviation and flexion/extension
 RCL limits ulnar deviation and flexion/extension
 Can also assess with glide between radius/ulna and proximal
row of carpal bones
– MP/IP/PIP/DIP joints
 Thumb UCL is common injury site

Neurovascular Evaluation
Neurological Evaluation

Peripheral nerve distributions
– Median, ulnar and radial nerve sensory and
motor functions

Nerve root level distributions
– Dermatomes and myotomes
Vascular Evaluation

Radial artery

Capillary refill

Skin temperature and color

Allen test?
Pathologies
Pathologies

Wrist injuries

Hand injuries

Finger injuries

Thumb injuries
Wrist Injuries







Wrist sprains
Triangular fibrocartilage complex (TFCC) injury
Carpal tunnel syndrome
Wrist fractures
Scaphoid fractures
Lunate/perilunate dislocations
Neurological injuries
Wrist Sprains

Most common etiology is hyperflexion or
hyperextension (fall on outstretched arm)

Must rule out carpal fracture, neurological injury
and TFCC injury before assessing as wrist sprain

Most common presentation involves limited ROM
to all wrist movements due to pain, usually also
presents with weakness – assess with radiocarpal
and carpal glide tests - treated conservatively in
nearly all cases
TFCC Injury

Sprain to ligamentous structures on dorsal and
medial aspect of wrist – injury occurs acutely, but
often not reported until later
 Most common etiology is hyperextension with
ulnar deviation
 Presents with tenderness to dorsal medial wrist
distal to ulna, limited ROM (especially radial and
ulnar deviation), possibility of avulsion fracture
 Must be referred to MD – often surgically repaired
TFCC Injury
Carpal Tunnel Syndrome

Compression of median nerve in carpal tunnel –
must be able to differentiate from nerve root injury

Typically secondary to overuse conditions
(tendonitis, etc.) but may be due to acute trauma

Most common presentation is neurological
deficit/symptoms to median nerve distribution
(sensory and motor)
Carpal Tunnel Syndrome
Evaluate with Tinel’s sign to carpal tunnel –
positive if symptoms reproduced
 Evaluate with Phalen’s test – wrist flexion for ~1
minute – positive if symptoms reproduced
 Almost always treated conservatively initially
with rest, splinting (night), NSAIDs
 Failure of conservative measures can lead to
surgery – resection of transverse carpal ligament

Phalen’s Test
Wrist Fractures

Typically occur from fall on outstretched arm –
must consider neurovascular implications

Colles’ fracture
– Fracture of distal radius proximal to radiocarpal joint
with dorsal displacement of fracture

Smith’s fracture (reverse Colles’)
– Fracture of distal radius proximal to radiocarpal joint
with palmar/volar displacement of fracture
Colles’ Fracture
Smith’s Fracture
Scaphoid Fracture

Easily the most commonly fractured carpal bone

Most common etiology is hyperextension

Blood supply comes from distal aspect and
fracture in mid-substance often compromises
proximal blood supply – high incidence of nonunion/malunion fractures
Scaphoid Fracture
Scaphoid Fracture

Common presentation is pain/tenderness to
snuffbox, limited ROM due to pain (especially
extension/radial deviation), decreased grip
strength
 Conservative management involves
immobilization of wrist/thumb/forearm for 6-8
weeks, then progressive ROM/strengthening
exercises
 Surgical intervention occasionally done in acute
situation, but usually after failed conservative
approach
Perilunate and Lunate
Dislocations

Hyperextension is mechanism of injury – leads to
2 dislocation types (progressive severity of
injury): perilunate dislocation vs. lunate
dislocation

Common presentation is either palmar or dorsal
wrist pain/swelling, visible/palpable deformity, 3rd
knuckle level with others, neurological symptoms
(3rd finger)
Perilunate Dislocation

Palmar/volar displacement of proximal row of
carpal bones on lunate so that lunate is dorsal to
the other bones

Rupture of palmar/volar radiocarpal ligaments and
promimal row of carpals “stripped” away from
lunate

May spontaneously reduce, but usually remains
displaced
Perilunate Dislocation
Lunate Dislocation

Palmar/volar displacement of lunate relative to
carpals (really vice versa – carpals displaced
dorsally on lunate)

Further hyperextension forces ruptures dorsal
radiocarpal ligaments and the carpals are
subsequently displaced

May spontaneously reduce, but usually remains
displaced
Lunate Dislocation
Perilunate and Lunate
Dislocations

If closed reduction is stable, immobilized in
slight flexion for 6-8 weeks – regular reevaluation to maintain reduction stability

Requires surgical stabilization if closed
reduction not stable acutely or if
conservative attempts fail
Neurological Injuries

Median nerve – carpal tunnel syndrome

Ulnar nerve
– Passes in tunnel of Guyon between hook of hamate and
pisiform, can be compressed

Radial nerve
– Drop wrist syndrome from inability to extend
wrist/fingers if radial nerve injured
Hand and Finger Injuries

Metacarpal fractures

Collateral ligament injuries

Posturing and deformities

Finger fractures

Dislocations
Metacarpal Fractures

Etiology is direct trauma – injury to 4th and 5th are
most common
– Boxer’s fracture: 5th metacarpal fracture with
“depression or shortening” of knuckle

Often reports of hearing/feeling “pop or snap” at
time of injury

Common presentation is localized
tenderness/swelling/crepitus, possible
displacement, abnormal hand ROM, weakness to
affected area
Boxer’s Fracture
Metacarpal Fractures
Metacarpal Fractures

If no displacement, treat with cast
immobilization for 4-6 weeks followed by
progressive ROM/flexibility/strengthening

If displacement and/or fragmented, surgical
intervention necessary to re-establish
normal anatomical positioning – then
treated same as conservative approach
Collateral Ligament Injuries

Etiology is acute force application
 Present with localized pain/swelling, ROM
limited due to pain/swelling
 Varus and valgus stress tests often not
informative unless 3rd degree injury
 Generally conservatively managed with
splint and symptomatic treatment
Posturing and Deformities






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Ape hand
Bishop’s deformity
Claw hand
Dupuytern’s contracture
Swan neck deformity
Volkmann’s ischemic contracture
Boutonniere deformity
Trigger finger
Posturing and Deformities

Ape hand
– Median nerve inhibition resulting in thenar eminence
atrophy – inability to flex and oppose thumb

Bishop’s deformity
– Ulnar nerve inhibition resulting in hypothenar
eminence, interossei, and medial 2 lumbricale atrophy –
4th and 5th fingers assume flexed posture

Claw hand
– Ulnar and median nerve pathology resulting in flexion
of PIP and DIP joints with associated extension of MP
joints
Dupuytren’s Contracture

Flexion contracture of
MP and PIP joints
from
shortening/adhesions
in palmar aponeurosis
– most common at 4th
and 5th fingers
Swan-Neck Deformity

Flexion of MP and
DIP joints with
associated
hyperextension of PIP
joint – usually due to
volar plate injury, but
can have many causes
Volkmann’s Ischemic Contracture

Flexion contracture of wrist and fingers
from decreased blood supply to forearm
muscles secondary to fracture, dislocation
or compartment syndrome
Boutonniere Deformity

Extension of MP and DIP
joints with associated
flexion of PIP joint – due
to rupture of extensor
tendon from middle
phalanx causing it to slip
laterally at PIP joint
changing line of pull from
extension to flexion
Trigger Finger

“Locking” of ROM during finger flexion
from adhesions in flexor tendon sheaths

With flexion movements, adhesions require
additional effort to allow for flexion ROM

Tendon “release” often presents as an
audible “snap” as finger moves into flexion
Trigger Finger
Finger Fractures

Distal phalanx most commonly fractured
due to flexor/extensor tendon attachments
(avulsion) and crushing trauma
 Middle phalanx uncommonly injured
 Proximal phalanx injury usually not isolated
and has associated tendon and/or skin injury
 Presentation and treatment similar to
metacarpal fracture discussion
Finger Fracture
Finger Fractures

Avulsion fractures of the fingers
– Mallet finger
 Avulsion of extensor tendon from distal phalanx,
inability to actively extend DIP joint (passive OK),
commonly occurs if fingertip hits ball
– Jersey finger
 Avulsion of profundus tendon from distal phalanx,
inability to actively flex DIP joint if PIP joint
stabilized, commonly occurs when grabbing jersey
and joint forcefully extended against active motion
Mallet Finger
Jersey Finger
Finger Dislocations

Interphalangeal joint dislocations result in
obvious deformity

Must rule out associated fracture – refer to
MD for imaging prior to reduction

Generally, easy to reduce – must be splinted
after reduction
Finger Dislocations
Thumb Injuries

DeQuervain’s syndrome

Sprains

MP joint dislocations

Fractures
DeQuervain’s Syndrome

Tenosynovitis of extensor pollicis brevis and
abductor pollicis longus tendons from repetitive
stress (radial deviation)

Presents with pain/swelling to proximal
thumb/distal radius, pain with radial/ulnar wrist
deviation and thumb extension and abduction

Treated conservatively with rest (immobilization),
NSAIDs, modalities
DeQuervain’s Syndrome
Finkelstein’s Test

Evaluative for DeQuervain’s syndrome

Thumb flexed across palm and locked in by
finger flexion – wrist placed in ulnar
deviation – positive if pain reproduced or
increased

Can present with false-positive results
Finkelstein’s Test
Thumb Sprains

Medial (ulnar) collateral ligament of 1st MP
joint is easily most commonly injured –
must rule out avulsion fracture

May be due to repetitive stress, but typically
etiology is acute hyperextension and/or
hyperabduction (skiing, etc.) –
Gamekeeper’s thumb
Thumb Sprains

Commonly presents with localized
tenderness/swelling, may see ecchymosis in thenar
eminence, inability to pinch or grasp objects,
positive valgus stress test

If mild or moderate injury with good end point,
often treat conservatively with splint for 4-6
weeks

If rupture, early surgical intervention indicated to
provide acceptable joint stability
1st MP Joint UCL Sprain
1st MP Joint Dislocation

Etiology usually hyperextension and/or
hyperabduction – may have associated fracture

Rupture of volar (palmar) ligamentous structure

Presents with obvious deformity and inability to
perform ROM

Refer to MD for reduction
Thumb Dislocation
Thumb Fractures

1st metacarpal fractures due to acute trauma

If fracture extends into articular surface (joint
space), known as Bennett’s fracture

Bennett’s fracture often requires surgical
intervention to fixate fracture segment to allow for
normal bony alignment and stability
Bennett’s Fracture