The Wrist, Hand, Fingers

1
Chapter 15

• The Wrist, Hand, Fingers

2
Carpals

• Distal Row (Fig 15-2, pg 519)
• Trapezium, Trapezoid, Capitate, Hamate
• Proximal Row
• Scaphoid( navicular), Lunate, Triquetrum,
  Pisiform
• Special Function
• Pisiform floats on triquetrum and acts as
  sesamoid for flexor carpi ulnaris
• Commonalities
• Scaphoid is most commonly fractured
• Lunate most commonly dislocated

3
Distal Radioulnar Articulation

• Allows for pronation and supination
• Requires both proximal and distal RU joints
  working in unison

4
Radiocarpal Joint

• Formed by distal radius, scaphoid and lunate
• Allows for flexion, extension, radial/ulnar
  deviation.
• Supported by radial collateral lig preventing
  ulnar deviation
• Also becomes taut in extreme flexion/extension

5
Palmar (volar) radiocarpal ligament

• Formed by radiocapitate lig, radiotriquetral lig,
  and radioscaphoid lig
• Fig 15-3, pg 521
• Limits wrist hyperextension

6
Dorsal Radiocarpal Ligament

• Attaches to lunate and triquetrum and limits
  hyperflexion

7
Ulnar-carpal joint

• No true joint due to lack of bony contact between
  ulna and carpal bones
• Fibrocartilaginous disk exists between the ulna
  and the associated carpal bones

8
Ulnar collateral ligament

• Runs from the ulna to the trequitrum (dorsally)
  and the pisiform (palmerly)
• Checks radial deviation
• Becomes taut during end ranges for flexion and
  extension

9
Carpometacarpal Joint

• Trapezoid MC I
• Trapezium MC II
• Capitate MC III
• Hamate MC IV and V
• CMC I saddle joint with flex/ext, abd/add,
  opposition/reposition
• CMC II IV flex/ext only
• CMC V flex/ext, abd/add

10
MCP Joint

• Palmar surface contains palmar ligament (volar
  plate)

11
Carpal Tunnel

• Floor formed by carpal bones
• Roof formed by transverse carpal ligament
• Flexor digitorum superficialis
• Flexor digitorum profundus
• Flexor pollicus longus
• Median nerve
• 2nd 4th fingers are affected with decreased
  grip strength and paresthesia being present

12
History

• Pain Fig 15-9, pg 528
• Duration
• Scaphoid fx
• General Medical
• Raynauds phenomenon

13
Inspection

• Posturing Box 15-1, pg 531
• Acute pathologies Box 15-2, pg 534
• Palmar creases
• May denote swelling
• Cuts or scars
• Russells sign callus formation from hitting
  teeth during purging
• Ganglion cyst Fig 15-11, pg 532
• Subungual hematoma
• Paronychia
• Felon
• Tinea unguium

14
Palpation

• Several figures in book are important
• Figure 15-17, pg 535
• Table 15-3, pg 537

15
Range of Motion

• Pg 537-545, 547

16
Ligamentous Testing

• Table 15-4, pg 545

17
Neurologic Testing

• Fig 15-24
• Upper Quarter Screening

18
Wrist Fractures

• Colles Fracture
• Dorsal displacement of radius approx 1.5 cm from
  radiocarpal joint
• Appearance of upside down fork
• Fig 15-26, pg 556
• Fig 15-33, pg 565 (Wrist dislocation, but common
  appearance of Colles Fracture)
• Mechanism Falling on outstretched hand
• Smiths Fracture or Reverse Colles Fracture
• Palmar displacement of radius approx 1.5 cm from
  radiocarpal joint

19
Scaphoid Fracture

• Mechanism falling on outstretched arm
• Early assessment important
• Not always visible on X-ray Bone scans, CT
  scans, and/or MRI scans may be needed
• Crepitation may be present
• Poor blood supply commonly leads to nonunion and
  malunion secondary to avascular necrosis
• Preisers disease
• Aching pain in anatomical snuff box that worsens
  upon palpation
• Pain with active and resisted wrist ext.

20
Lunate Dislocation

• Mechanism forced hyperextension of wrist and
  hand
• Complaint of pain along radial side of palmer or
  dorsal aspect of wrist that limits ROM
• Repeated trauma could compromise vascular supply
• Special tests Murphys sign
• Note alignment of 3rd MC with 2nd and 4th
• May result in Kienböcks disease

21
Metacarpal Fracture

• Mechanism often secondary to compressive force
  along shaft of bone
• Snap often heard
• Point tender over sight of fracture
• Boxers fracture fracture of 5th metacarpal
• -Characterized by depressed 5th MCP joint

22
Acute Finger Pathologies

• Jersey Finger
• Mallet Finger
• Boutonniere Deformity
• Box 15-2

23
Jersey Finger

• Avulsion of flexor digitorum profundus tendon
• Inability to actively flex the DIP joint

24
Mallet Finger

• Avulsion of the extensor digitorum longus tendon
• Inability to actively extend distal phalanx

25
Boutonniere Deformity

• Rupture of central extensor tendon
• Resulting position is extension of DIP and MCP
  joint, with flexion of PIP joint

26
DeQuervains Syndrome

• Tenosynovitis of extensor pollicis brevis and
  abductor pollicis longus tendons
• Mechanism Repetitive motions
• Pain with radial/ulnar deviation
• Special test Finkelsteins test

27
Thumb Sprains

• Skiers thumb/Gamekeepers thumb
• Sprain of UCL of thumbs MCP joint
• Mechanism Hyperabduction or hyperextension of
  the MCP joint
• Pain along ulnar aspect of MCP joint
• Valgus/Varus Ligamentous tests for instability at
  MCP joint

28
Bennetts Fracture

• Fracture of 1st MC
• Fig 15-32, pg 564

29
Interphalangeal Joint Dislocations

• Obvious deformity with IP joint
• Possibility of avulsion fracture
• X-rays to rule of fracture
• Can be reduced with traction under supervision of
  physician