Chapter 24: The Forearm, Wrist, Hand and Finger

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Chapter 24 The Forearm, Wrist, Hand and Finger
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Anatomy of the Forearm
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Blood and Nerve Supply

• Most of the flexors are supplied by the median
  nerve
• Most of the extensor are controlled by the radial
  nerve
• Blood is supplied by the radial and ulnar arteries

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Assessment of the Forearm

• History
• What was the cause?
• What were the symptoms at the time of injury, did
  they occur later, were they localized or diffuse?
• Was there swelling and discoloration?
• What treatment was given and how does it feel now?

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• Observation
• Visually inspect for deformities, swelling and
  skin defects
• Range of motion
• Pain w/ motion
• Palpation
• Palpated at distant sites and at point of injury
• Can reveal tenderness, edema, fracture,
  deformity, changes in skin temperature, a false
  joint, bone fragments or lack of bone continuity

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Palpation Bony and Soft Tissue

• Proximal head of radius
• Olecranon process
• Radial shaft
• Ulnar shaft
• Distal radius and ulna
• Radial styloid
• Ulnar head
• Ulnar styloid

• Distal radioulnar joint
• Radiocarpal joint
• Extensor retinaculum
• Flexor retinaculum
• Extensor carpi radialis longus and brevis
• Extensor carpi ulnaris
• Brachioradialis
• Extensor pollicis longus and brevis

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Palpation (continued)

• Abductor pollicis longus
• Extensor indicus supinator
• Flexor carpi radialis
• Palmaris longus
• Flexor digitorum superficialis
• Flexor digitorum profundus

• Flexor pollicis longus
• Pronator quadratus
• Pronator teres

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Recognition and Management of Injuries to the
Forearm

• Contusion
• Etiology
• Ulnar side receives majority of blows due to arm
  blocks
• Can be acute or chronic
• Result of direct contact or blow
• Signs and Symptoms
• Pain, swelling and hematoma
• If repeated blows occur, heavy fibrosis and
  possibly bony callus could form w/in hematoma

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• Contusion (continued)
• Management
• Proper care in acute stage involves RICE for at
  least one hour and followed up w/ additional
  cryotherapy
• Protection is critical - full-length sponge
  rubber pad can be used to provide protective
  covering

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• Forearm Splints
• Etiology
• Forearm strain - most come from severe static
  contraction
• Cause of splints - repeated static contractions
• Difficult to manage
• Signs and Symptoms
• Dull ache between extensors which cross posterior
  aspect of forearm
• Weakness and pain w/ contraction
• Point tenderness in interosseus membrane
• Management
• Treat symptomatically
• If occurs early in season, strengthen forearm
  when it occurs late in season treat w/
  cryotherapy, wraps, or heat
• Can develop compartment syndrome in forearm as
  well and should be treated like lower extremity

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• Forearm Fractures
• Etiology
• Common in youth due to falls and direct blows
• Ulna and radius generally fracture individually
• Fracture in upper third may result in abduction
  deformity due pull of pronator teres
• Fracture in lower portion will remain relatively
  neutral
• Older athlete may experience greater soft tissue
  damage and greater chance of paralysis due to
  Volkmans contracture
• Signs and Symptoms
• Audible pop or crack followed by moderate to
  severe pain, swelling, and disability
• Edema, ecchymosis w/ possible crepitus

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• Management
• Initially RICE followed by splinting until
  definitive care is available
• Long term casting followed by rehab plan

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• Colles Fracture
• Etiology
• Occurs in lower end of radius or ulna
• MOI is fall on outstretched hand, forcing radius
  and ulna into hyperextension
• Less common is the reverse Colles fracture

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• Signs and Symptoms
• Forward displacement of radius causing visible
  deformity (silver fork deformity)
• When no deformity is present, injury can be
  passed off as bad sprain
• Extensive bleeding and swelling
• Tendons may be torn/avulsed and there may be
  median nerve damage
• Management
• Cold compress, splint wrist and refer to
  physician
• X-ray and immobilization
• Severe sprains should be treated as fractures
• Without complications a Colles fracture will
  keep an athlete out for 1-2 months
• In children, injury may cause lower epiphyseal
  separation

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• Madelung Deformity
• Etiology
• Developmental deformity of the wrist
• Associated with changes in radius, ulna and
  carpal bone ? results in palmar and ulnar wrist
  subluxations
• Common in female athletes particularly gymnasts
• Carpals become wedged between radius and ulna
  following epiphyseal plate changes
• Signs and Symptoms
• Bowing of radius and ulna evident on X-ray
• Wrist pain and loss of forearm rotation
• Palmar subluxation with prominence of radius and
  ulnar styloid processes

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• Madelung Deformity (continued)
• Management
• Therapeutic modalities and NSAIDs for pain
• Wrist can be taped or braced to prevent wrist
  extension
• Typically corrected surgically in athletes with
  chronic pain and disability

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Anatomy of the Wrist, Hand and Fingers
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Blood and Nerve Supply

• Three major nerves
• Ulnar, median and radial
• Ulnar and radial arteries supply the hand
• Two arterial arches (superficial and deep palmar
  arches)

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Assessment of the Wrist, Hand and Fingers

• History
• Past history
• Mechanism of injury
• When does it hurt?
• Type of, quality of, duration of, pain?
• Sounds or feelings?
• How long were you disabled?
• Swelling?
• Previous treatments?

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• Observation
• Postural deviations
• Is the part held still, stiff or protected?
• Wrist or hand swollen or discolored?
• General attitude
• What movements can be performed fully and
  rhythmically?
• Thumb to finger touching
• Color of nailbeds

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Palpation Bony

• Scaphoid
• Trapezoid
• Trapezium
• Lunate
• Capitate
• Triquetral
• Pisiform
• Hamate (hook)
• Metacarpals 1-5

• Proximal, middle and distal phalanges of the
  fingers
• Proximal and distal phalanges of the thumb

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Palpation Soft Tissue

• Triangular fibrocartilage
• Ligaments of the carpals
• Carpometacarpal joints and ligaments
• Metacarpophylangeal joints and ligaments
• Proximal and distal interphylangeal joints and
  ligaments
• Flexor carpi radialis
• Flexor carpi ulnaris
• Lumbricale muscles

• Flexor digitorum superficialis and profundus
• Palmer interossi
• Flexor pollicis longus and brevis
• Abductor pollicis brevis
• Opponens pollicis
• Opponens digiti minimi

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Palpation Soft Tissue

• Extensor carpi radialis longus and brevis
• Extensor carpi ulnaris
• Extensor digitorum
• Extensor indicis
• Extensor digiti minimi
• Dorsal interossi
• Extensor pollicis brevis and longusAbductor
  pollicis longus

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• Special Tests
• Finklesteins Test
• Test for de Quervains syndrome
• Athlete makes a fist w/ thumb tucked inside
• Wrist is ulnarly deviated
• Positive sign is pain indicating stenosising
  tenosynovitis
• Pain over carpal tunnel could indicate carpal
  tunnel syndrome
• Tinels Sign
• Produced by tapping over transverse carpal
  ligament
• Tingling, paresthesia over sensory distribution
  of the median nerve indicates presence of carpal
  tunnel syndrome

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• Phalens Test
• Test for carpal tunnel syndrome
• Position is held for approximately one minute
• If test is positive, pain will be produced in
  region of carpal tunnel

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• Valgus/Varus and Glide Stress Tests
• Tests used to assess ligamentous integrity of
  joints in hands and fingers
• Valgus and varus tests are used to test
  collateral ligaments
• Anterior and posterior glides are used to assess
  the joint capsule

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• Lunotriquetral Ballotment Test
• Stabilize lunate while sliding the triquetral
  anteriorly and posteriorly
• Assessing laxity, pain and crepitus
• Positive test indicates instability that often
  results in dislocation of the lunate

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• Circulatory and Neurological Evaluation
• Hands should be felt for temperature
• Cold hands indicate decreased circulation
• Pinching fingernails can also help detect
  circulatory problems (capillary refill)
• Allens test can also be used
• Athlete instructed to clench fist 3-4 times,
  holding it on the final time
• Pressure applied to ulnar and radial arteries
• Athlete then opens hand (palm should be blanched)
• One artery is released and should fill
  immediately (both should be checked)
• Hands neurological functioning should also be
  tested (sensation and motor functioning)

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• Functional Evaluation
• Range of motion in all movements of wrist and
  fingers should be assessed
• Active, resistive and passive motions should be
  assessed and compared bilaterally
• Wrist - flexion, extension, radial and ulnar
  deviation
• MCP joint - flexion and extension
• PIP and DIP joints - flexion and extension
• Fingers - abduction and adduction
• MCP, PIP and DIP of thumb - flexion and extension
• Thumb - abduction, adduction and opposition
• 5th finger - opposition

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Recognition and Management of Injuries to the
Wrist, Hand and Fingers

• Wrist Sprains
• Etiology
• Most common wrist injury
• Arises from any abnormal, forced movement
• Falling on hyperextended wrist, violent flexion
  or torsion
• Multiple incidents may disrupt blood supply
• Signs and Symptoms
• Pain, swelling and difficulty w/ movement

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• Management
• Refer to physician for X-ray if severe
• RICE, splint and analgesics
• Have athlete begin strengthening soon after
  injury
• Tape for support can benefit healing and prevent
  further injury

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• Triangular Fibrocartilage Complex (TFCC) Injury
• Etiology
• Occurs through forced hyperextension, falling on
  outstretched hand
• Violent twist or torque of the wrist
• Often associated w/ sprain of UCL
• Signs and Symptoms
• Pain along ulnar side of wrist, difficulty w/
  wrist extension, possible clicking
• Swelling is possible, not much initially
• Athlete may not report injury immediately

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• Management
• Referred to physician for treatment
• Treatment will require immobilization initially
  for 4 weeks
• Immobilization should be followed by period of
  strengthening and ROM activities
• Surgical intervention may be required if
  conservative treatments fail

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• Tenosynovitis
• Etiology
• Cause of repetitive wrist accelerations and
  decelerations
• Repetitive overuse of wrist tendons and sheaths
• Signs and Symptoms
• Pain w/ use or pain in passive stretching
• Tenderness and swelling over tendon
• Management
• Acute pain and inflammation treated w/ ice
  massage 4x daily for first 48-72 hours, NSAIDs
  and rest
• When swelling has subsided, ROM is promoted w/
  contrast bath
• Ultrasound and phonphoresis can be used
• PRE can be instituted once swelling and pain
  subsided

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• Tendinitis
• Etiology
• Repetitive pulling movements of (commonly) flexor
  carpi radialis and ulnaris repetitive pressure
  on palms (cycling) can cause irritation of flexor
  digitorum
• Primary cause is overuse of the wrist
• Signs and Symptoms
• Pain on active use or passive stretching
• Isometric resistance to involved tendon produces
  pain, weakness or both
• Management
• Acute pain and inflammation treated w/ ice
  massage 4x daily for first 48-72 hours, NSAIDs
  and rest
• When swelling has subsided, ROM is promoted w/
  contrast bath
• PRE can be instituted once swelling and pain
  subsided (high rep, low resistance)

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• Nerve Compression, Entrapment, Palsy
• Etiology
• Median and ulnar nerve compression
• Result of direct trauma to nerves
• Signs and Symptoms
• Sharp or burning pain associated w/ skin
  sensitivity or paresthesia
• May result in benediction/ bishops deformity
• (damage to the ulnar nerve) or claw hand
  deformity (damage to both nerves)
• Palsy of radial nerve produces drop wrist
  deformity caused by paralysis of extensor muscles
• Palsy of median nerve can cause ape hand (thumb
  pulled back in line w/ other fingers)
• Management
• Chronic entrapment may cause irreversible damage
• Surgical decompression may be necessary

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• Carpal Tunnel Syndrome
• Etiology
• Compression of median nerve due to inflammation
  of tendons and sheaths of carpal tunnel
• Result of repeated wrist flexion or direct trauma
  to anterior aspect of wrist
• Signs and Symptoms
• Sensory and motor deficits (tingling, numbness
  and paresthesia) weakness in thumb
• Management
• Conservative treatment - rest, immobilization,
  NSAIDs
• If symptoms persist, corticosteroid injection may
  be necessary or surgical decompression of
  transverse carpal ligament

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• de Quervains Disease (Hoffmans disease)
• Etiology
• Stenosing tenosynovitis in thumb (extensor
  pollicis brevis and abductor pollicis longus
• Constant wrist movement can be a source of
  irritation
• Signs and Symptoms
• Aching pain, which may radiate into hand or
  forearm
• Positive Finklesteins test
• Point tenderness and weakness during thumb
  extension and abduction painful catching and
  snapping

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• de Quervains Disease (Hoffmans disease)
• Management
• Immobilization, rest, cryotherapy and NSAIDs
• Ultrasound and ice are also beneficial
• Joint mobilizations have been recommended to
  maintain ROM

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• Dislocation of Lunate Bone
• Etiology
• Forceful hyperextension or fall on outstretched
  hand
• Signs and Symptoms
• Pain, swelling, and difficulty executing wrist
  and finger flexion
• Numbness/paralysis of flexor muscles due to
  pressure on median nerve
• Management
• Treat as acute, and sent to physician for
  reduction
• If not recognized, bone deterioration could
  occur, requiring surgical removal
• Usual recovery is 1-2 months

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• Scaphoid Fracture
• Etiology
• Caused by force on outstretched hand, compressing
  scaphoid between radius and second row of carpal
  bones
• Often fails to heal due to poor blood supply
• Signs and Symptoms
• Swelling, severe pain in anatomical snuff box
• Presents like wrist sprain
• Pain w/ radial flexion
• Management
• Must be splinted and referred for X-ray prior to
  casting
• Immobilization lasts 6 weeks and is followed by
  strengthening and protective tape
• Wrist requires protection against impact loading
  for 3 additional months

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• Hamate Fracture
• Etiology
• Occurs as a result of a fall or more commonly
  from contact while athlete is holding an
  implement
• Signs and Symptoms
• Wrist pain and weakness, along w/ point
  tenderness
• Pull of muscular attachment can cause non-union
• Management
• Casting wrist and thumb is treatment of choice
• Hook of hamate can be protected w/ doughnut pad
  to take pressure off area

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• Wrist Ganglion
• Etiology
• Synovial cyst (herniation of joint capsule or
  synovial sheath of tendon)
• Generally appears following wrist strain
• Signs and Symptoms
• Appear on back of wrist generally
• Occasional pain w/ lump at site
• Pain increases w/ use
• May feel soft, rubbery or very hard
• Management
• Old method was to first break down the swelling
  through distal pressure and then apply pressure
  pad to encourage healing
• New approach includes aspiration, chemical
  cauterization w/ subsequent pressure from pad
• Ultrasound can be used to reduce size
• Surgical removal is most effective treatment
  method

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• Contusion and Pressure Injuries of Hand and
  Fingers
• Etiology
• Result of blow or compression of bones w/in hand
  and fingers
• Signs and Symptoms
• Pain and swelling of soft tissue
• Management
• Cold compression until hemorrhaging has ceased
• Follow w/ gradual warming - soreness may still be
  present -- padding may also be necessary
• Bruising of distal phalanx can result in
  subungual hematoma - extremely painful due to
  build-up of pressure under nail
• Pressure must be released once hemorrhaging has
  ceased

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• Bowlers Thumb
• Etiology
• Perineural fibrosis of subcutaneous ulnar digital
  nerve of thumb
• Pressure from bowling ball on thumb
• Signs and Symptoms
• Pain, tingling during pressure on irritated area
  and numbness
• Management
• Padding, decrease amount of bowling
• If condition continues, surgery may be required

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• Trigger Finger or Thumb
• Etiology
• Repeated motion of fingers may cause irritation,
  producing tenosynovitis
• Inflammation of tendon sheath (extensor tendons
  of wrist, fingers and thumb, abductor pollicis)
• Thickening occurs w/in the sheath, forming a
  nodule that does not slide easily
• Signs and Symptoms
• Resistance to re-extension, produces snapping
  that is palpable, audible and painful
• Palpation produces pain and lump can be felt w/in
  tendon sheath
• Management
• Same treatment as de Quervains disease -- if
  unsuccessful, injection and splinting are last
  options

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• Mallet Finger (baseball or basketball finger)
• Etiology
• Caused by a blow that contacts tip of finger
  avulsing extensor tendon from insertion
• Signs and Symptoms
• Pain at DIP X-ray shows avulsed bone on dorsal
  proximal distal phalanx
• Unable to extend distal end of finger (carrying
  at 30 degree angle)
• Point tenderness at sight of injury
• Management
• RICE and splinting for 6-8 weeks

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• Boutonniere Deformity
• Etiology
• Rupture of extensor tendon dorsal to the middle
  phalanxForces DIP joint into extension and PIP
  into flexion
• Signs and Symptoms
• Severe pain, obvious deformity and inability to
  extend DIP joint
• Swelling, point tenderness
• Management
• Cold application, followed by splinting
• Splinting must be continued for 5-8 weeks
• Athlete is encouraged to flex distal phalanx

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• Jersey Finger
• Etiology
• Rupture of flexor digitorum profundus tendon from
  insertion on distal phalanx
• Often occurs w/ ring finger when athlete tries to
  grab a jersey
• Signs and Symptoms
• DIP can not be flexed, finger remains extended
• Pain and point tenderness over distal phalanx
• Management
• Must be surgically repaired
• Rehab requires 12 weeks and there is often poor
  gliding of tendon, w/ possibility of re-rupture

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• Dupuytrens Contracture
• Etiology
• Nodules develop in palmer aponeurosis, limiting
  finger extension - ultimately causing flexion
  deformity
• Signs and Symptoms
• Often develops in 4th or 5th finger (flexion
  deformity)
• Management
• Tissue nodules must be removed as they can
  ultimately interfere w/ normal hand function

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• Sprains, Dislocations and Fractures of Phalanges
• Etiology
• Phalanges are prone to sprains caused by direct
  blows or twisting
• MOI is also similar to that which causes
  fractures and dislocations
• Signs and Symptoms
• Recognition primarily occurs through history
• Sprain symptoms - pain, severe swelling and
  hematoma
• Gamekeepers Thumb
• Etiology
• Sprain of UCL of MCP joint of the thumb
• Mechanism is forceful abduction of proximal
  phalanx occasionally combined w/ hyperextension

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• Signs and Symptoms
• Pain over UCL in addition to weak and painful
  pinch
• Management
• Immediate follow-up must occur
• If instability exists, athlete should be referred
  to orthopedist
• If stable, X-ray should be performed to rule out
  fracture
• Thumb splint should be applied for protection for
  3 weeks or until pain free
• Splint should extend from wrist to end of thumb
  in neutral position
• Thumb spica should be used following splinting
  for support

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• Sprains of Interphalangeal Joints of Fingers
• Etiology
• Can include collateral ligament, volar plate,
  extensor slip tears
• Occurs w/ axial loading or valgus/varus stresses
• Signs and Symptoms
• Pain, swelling, point tenderness, instability
• Valgus and varus tests may be positive
• Management
• RICE, X-ray examination and possible splinting
• Splint at 30-40 degrees of flexion for 10 days
• If sprain is to the DIP, splinting for a few days
  in full extension may assist healing process
• Taping can be used for support

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• Swan Neck Deformity and PsuedoBoutonniere
  Deformity
• Etiology
• Distal tear of volar plate may cause Swan Neck
  deformity proximal tear may cause
  PsuedoBoutonniere deformity
• Signs and Symptoms
• Pain, swelling w/ varying degrees of
  hyperextension
• Tenderness over volar plate of PIP
• Indication of volar plate tear passive
  hyperextension
• Management
• RICE and analgesics
• Splint in 20-30 degrees of flexion for 3 weeks
  followed by buddy taping and then PRE

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• PIP Dorsal Dislocation
• Etiology
• Hyperextension that disrupts volar plate at
  middle phalanx
• Signs and Symptoms
• Pain and swelling over PIP
• Obvious deformity, disability and possible
  avulsion
• Management
• Treated w/ RICE, splinting and analgesics
  followed by reduction
• After reduction, finger is splinted at 20-30
  degrees of flexion for 3 weeks -- followed by
  buddy taping

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• PIP Palmar Dislocation
• Etiology
• Caused by twist while digit is semiflexed
• Signs and Symptoms
• Pain and swelling over PIP point tenderness over
  dorsal side
• Finger displays angular or rotational deformity
• Management
• Treat w/ RICE, splinting and analgesics followed
  by reduction
• Splint in full extension for 4-5 weeks after
  which it is protected for 6-8 weeks during
  activity

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• MCP Dislocation
• Etiology
• Caused by twisting or shearing force
• Signs and Symptoms
• Pain, swelling and stiffness at MCP joint
• Proximal phalanx is angulated at 60-90 degrees
• Management
• RICE, splinting following reduction
• Buddy taping and given early ROM following
  splinting

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• Metacarpal Fracture
• Etiology
• Direct axial force or compressive force
• Fractures of the 5th metacarpal are associated w/
  boxing or martial arts (boxers fracture)
• Signs and Symptoms
• Pain and swelling possible angular or rotational
  deformity
• Management
• RICE, analgesics are given followed by X-ray
  examinations
• Deformity is reduced, followed by splinting -
  4 weeks of splinting after which ROM is
  carried out

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• Bennetts Fracture
• Etiology
• Occurs at carpometacarpal joint of the thumb as a
  result of an axial and abduction force to the
  thumb
• Signs and Symptoms
• CMC may appeared to be deformed - X-ray will
  indicate fracture
• Athlete will complain of pain and swelling over
  the base of the thumb
• Management
• Structurally unstable and must be referred to an
  orthopedic surgeon

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• Distal Phalangeal Fracture
• Etiology
• Crushing force
• Signs and Symptoms
• Complaint of pain and swelling of distal phalanx
• Subungual hematoma is often seen in this
  condition
• Management
• RICE and analgesics are given
• Protective splint is applied as a means for pain
  relief
• Subungual hematoma is drained

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• Middle Phalangeal Fracture
• Etiology
• Occurs from direct trauma or twist
• Signs and Symptoms
• Pain and swelling w/ tenderness over middle
  phalanx
• Possible deformity X-ray will show bone
  displacement
• Management
• RICE and analgesics
• No deformity - buddy tape w/ thermoplastic splint
  for activity
• Deformity - immobilization for 3-4 weeks and a
  protective splint for an additional 9-10 weeks
  during activity

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• Proximal Phalangeal Fracture
• Etiology
• May be spiral or angular
• Signs and Symptoms
• Complaint of pain, swelling, deformity
• Inspection reveals varying degrees of deformity
• Management
• RICE and analgesics are given as needed
• Fracture stability is maintained by
  immobilization of the wrist in slight extension,
  MCP in 70 degrees of flexion and buddy taping

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• PIP Fractures and Dislocation
• Etiology
• Combination of fracture and dislocation is the
  result of an axial load on a partially flexed
  finger
• Signs and Symptoms
• Condition causes pain and swelling in the region
  of the PIP joint
• Localized tenderness over the PIP
• Management
• RICE, analgesics, followed by reduction of the
  fracture
• If there is a small fragment, buddy taping is
  used
• Large fragments - splint at 30-60 degrees of
  flexion

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• Fingernail Deformities
• Changes in normal appearance of the fingernail
  can be indicative of a number of different
  diseases
• Scaling or ridging psoriasis
• Ridging and poor development hyperthyroidism
• Clubbing and cyanosis congenital heart
  disorders or chronic respiratory disease
• Spooning or depression chronic alcoholism or
  vitamin deficiency

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Rehabilitation of Injuries to the Forearm, Wrist,
Hand and Fingers

• General Body Conditioning
• Must maintain pre-injury level of conditioning
• Cardiorespiratory, strength, flexibility and
  neuromuscular control
• Many exercise options (particularly lower
  extremity)
• Joint Mobilizations
• Wrist and hand respond to traction and
  mobilization techniques

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• Flexibility
• Full pain free ROM is a major goal of
  rehabilitation
• The program should include active assisted and
  active pain free stretching
• Strength
• Exercises should not aggravate condition or
  disrupt healing process
• A variety of exercises are available for strength
  (wrist and hand)

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• Neuromuscular Control
• Hand and fingers require restoration of dexterity
• Pinching, fine motor activities (buttoning
  buttons, tying shoes, and picking up small
  objects)
• Customized bracing, splints and taping techniques
  are available to protect the injured wrist and
  hand
• Return to Activity
• Grip strength must be equal bilaterally, full
  range of motion and dexterity
• Thumb has unique strength requirements
• Manual resistance can be instituted to strengthen
  major motions intrinsic muscles can be
  strengthened w/ rubber band