AUF LAS BSPT 2022

WRIST COMPLEX - part of Distalradioulnar jt

- Most complex jt, Biaxial 2 DOF (Fx & - Connected by Dorsal and Volar RU lig

Ex, UD & RD)

TFCC
- primary support of RU, RU DISC + Fibrous
2 JOINTS attachment
• RADIOCARPAL
- Distal Radius & Metacarpals
MENISCUS HOMOLOG (Lower lamina)
• MIDCARPAL - Group of lig & bones

- Carpals of proximal & distal row - Region of irregular connective tissue

- Ligaments that connects the ulna to the

- Any loss of function in the upper limb carpal bones

regardless of the segments translates into - Below the Radioulnardisc/upper lamina

diminished function of its most distal joints

- ECU tendon, Triquetrium, Hamate, 5th MC
- Upper limb 40%, Hand 60% (Thumb (ulnar collateral ligaments)

40-60%)
DISTAL RADIUS
FUNCTION OF WRIST
- Proximal row of carpals/Schaphoid, lunate,
- Control length tension of hand muscles triquetrium

resting & weak activities

- Connected by Schapholunate inter

- Reverse length tension relationship (the ligament & Lunotriquetrial inter ligament

shorter the lower the tension) better when - Pisiform increases MA of FCU since it is
near axis
the insertion of FCU

- Reverse because it is for resting and - The Pisiform does not participate in
weak activities
articulation

TENDONESIS EFFECT Fx & EX > UD & RD

- Shortening of muscles - No pronation/supination because distal
radioulnar is above wrist and it only
RADIOCARPAL/WRIST JT STRUCTURE follows the forearm

- Formed by radius & radioulnardisk

Normal Axial Loading:

- TFCC (PROXIMAL) (R+RUD=TFCC) - 60% Schaphoid: most fractured, 2nd
- TFCC (Triangular Fibrocartilage most dislocated
Complex) - 40% Lunate: 2nd most fractured, most
- Wrist jt: radoiocarpal/wrist + carpal dislocated
- 80% Schaphoid & Lunate

- Distal: scaphoid, lunate, triquetrium; no - 20% TFCC: more damaged (since it is a

pisiform (above triquetrium)
ligament)

Wrist is more located medially & anteriorly Ulnar Negative Variance

- Oblique(23˚ inclination), angulated volarly & - Degeneration (osteoarthritis)

ulnarly
- Bone to bone, Radius is lower → smaller
- Floor of radius(distal) and ulna (proximal) space in radius

are not same

- Greater space the greater the load

• (Ulna = elbow & Radius ≠ elbow)

- Due to axial loading ex: to much load on
• (Ulna ≠ wrist & Radius = wrist)
upper ex

- Abnormal force distribution

RADIOULNARDISC (Upper Lamina), (part

of TFCC)
- Connects ulna to the wrist (since ulna is
not really attached)

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Radiocarpal capsule & Ligaments
- Ligaments cross the RC jt & contribute to
stability at MC jt
Carpal
- Radiocarpal is a passageway of ligaments
and tendons
Carpal
MIDCARPAL STRUCTURE
- 2 DOF (Fx & Ex, UD & RD)
- PROX: Schaphoid, lunate, triquetrium
- (distal to prox row to RC jt)
- DISTAL: Trapezium,Trapezoid,Capitate,
Hamate
Movements of RC & MC jt
- Functional rather than anatomical
(similar to ST), they act as one joint
- separate anatomically from RC
• Carpals are foundations of 2 Arcs/
Creases
- Distal & transverse arc (lines in your
palms)
- FX = MC<RC
- EX = MC>RC
- UD & RD = almost same
Ligamets of Wrist
- Extrinsic (out): Carpals → Radius/Ulna,
- Intrinsic (IN): Carpal → Carpal
Volar Extrinsic Ligaments
- From radius & ulna (RADIOCARPAL &
ULNOCARPAL LIG)
3 Radiocarpal Ligaments
- Radioscaphocapitate (radiocapitate):
most important stabilizer of scaphoid
- Radioulnotriquetrial
- Radioscapholunate
Ulnocarpal Ligaments
- TFCC
- Ulnolunate ligament
- Ulnacollateral ligament
Volar Intrinsic Ligaments (Carpal-Carpal)
- Scapholunate ligament
- Lunotriquetrial interrousous ligament
- → Stabilize Lunate & Triquetrium
Dorsal Carpal Ligament
- Dorsal Radiocarpal Ligament: Radius →
- Dorsal intercarpal Ligament: Carpal →
- (lunate->scaphoid->trapezium)
Functions of Wrist Complex
- UD/RD MC=RC, EX MC>RC, FX MC<RC
Muscles of the Wrist
- provide a stable base, controls & serve
length tension relationship
Volar Muscles (Anterior)
- Primary: PL, FCR, FCU
- Secondary: FDS,FDP,FPL (Fingers &
Carpals)
Flexor Retinaculum
- Tendon/sheet, covers ant border of wrist
- Prevent BOWSTRINGING → maintains
position (no overlaps)
- Not all tendons pass through it
10 STRUCTURES THAT PASS THROUGH
THE FLEXOR RETINACULUM
• 4 FDP tendons, 4 FDS tendons, FPL
tendon, 1 Median Nerve
- PL & FCU does not pass
FCR & FCU: RD & UD
- FCR not effective as extensor counterpart
• BECAUSE OF BICEPS
• PL (Palmaris Longus): Flexor, sacrificed
during reconstruction, 14% congenitally
absent
• FCU: Effective UD than RD, envelopes
pisiform increasing MA of FCU
• FPL: Flexor of thumb *FDS(+ wrist) & FDP
(+ fingers) = both finger flexors
• FDP: longer, deep, more joints cross it,
more likely to become actively insufficient

AUF LAS BSPT 2022

Dorsal Wrist Musculature/Dorsal Deep Transverse Metacarpal Ligaments

Compartment - Head of 2-5 metacarpals( volarly/
anteriorly)

Extensor Retinaculum - Prevents metacarpal from minimal

- Prevents friction on tendon & retinaculum
abduction @ CMCjt

- Each tendon encased within its own

tendon sheath
Proximal Transverse Carpal Arc
- Separated by tunnel/septa
- Bones: Distal Carpal Row (Trapezium,
Trapezoid, Capitate, Hamate)

6 Tunnels/Division - Ligaments: Transverse carpal and

- Each has tunnel diff muscles
Intercarpal lig

1)APL+EPB (ALEB) 4)EI+ED

2)ECRL+ECRB 5)EDM Transverse Carpal Ligament (Flexor
3)EP 6)ECU Retinaculum)
- b/w scaphoid & hamate

Septa of Retinaculum - TCL + Intercarpal ligament (maintains

- Prevent bowstringing of tendons
conativity & from carpal tunnel)

- Maintain stability of extensor tendons

- 9 tendons 1 Nerve

- Attached to dorsal carpal ligament

CMC/Carpometacarpal Jt
Anatomic Snuffbox (hole in wrist) - 2-4 plane synovial jt, provides arcs and
- Lateral: tunnel 1 (ALEB) creases

- Medial: EPL Floor: Scaphoid, Trapezium - (1) DOF (Fx&Ex), (2-3) 0DOF * Perceptible
Fx & Ex

De Quervain’s Disease (washer woman’s

Proximal transverse arch (carpal bones)
syndrome)
- Injury in anatomic snuffbox, inflammation - TCL + Intercarpal lig

of tunnel 1

- You can see the swelling in the scaphoid

Distal transverse arch
- mobile: 1,4,5 cmcjt

ECRL&ECRB: Wrist extensors, active in

- fixed: 2-3 cmcjt

grasp and release

ECU: Extends & UD

Longitudinal transverse arch
EDM: Pinky, EIP: Index, ED: middle & ring all
- From prox-distal/length of digits

still use/insert to ED

Deep Transverse Metacarpal ligament

3 Extrinsic Thumb Muscles (Snuffbox) - b/w mc bone and prox phalanx

- T1: ALEB, T2: EPL - give stability of the mobile arches during
grip functions

HANDCOMPLEX Palmar Arches (love line)

(4 Fingers & 1 Thumb) - hollowing flexion, flattening extension
- confirm to optimal shape of object
CMC (Carpometacarpal Jt) - enforce stability and sensory feedback
- b/w metacarpal & carpal

- Distal carpal row + (2-5 metacarpals = Opponens Digiti Minimi (ODM), Pinky
CMCjt) only 2nd-5th CMC
- Causes the crossing of pinky
- Thumb has its own CMC jt
- Acts exclusively on CMCJT
- Flex and rotate MCJT
- Have strong transverse and weak - Transverse carpal lig
longitudinal ligaments

AUF LAS BSPT 2022

MCPJT (Metacarpophalangeal Jt) FDP

- 2 DOF (Fx&Ex, Ab&Ad), Condyloid, - gentle grasp (Camper’s Chiasma),
knuckles

- Concave: base of phalanx

FDP+FDS
- Convex: metacarpal head
- FORCEFUL (Stonger & More Torque)
- connected by deep transverse lig →
connects all MCP
FDS: stronger
- Surrounded by capsule → allows rotation
of prox phalanx
FDS Tendon
- forceful pinch may create (PIP Ex & DIP
Volar Plates Fx)
- Stability of MCP, b/w MC & Phalanx
(circles @ hand)
Mechanism of Finger Flexors
- The fibrocartilage @ prox phalanx

- Prevent/limit hyperextension

Pulleys
- Good for gliding mechanism (prevents
Collateral Ligaments
- Ulnar collateral & Radial collateral ligament
friction)
- Sides of carpals
- Optimal tension of FDP & FDS depends
- Found @ MCP increases (Fx&Ex, UD&RD)
on stabilization of wrist and gliding
movements

IP JT (Interphalangeal Jt)
- Synovial/hinge jt, Fx&EX
• 4 FDS (crosses to enter hand) & 4 FDP
& 4 Fingers (Medial) → Ulnar bursae
- From head of prox phalanx - base of distal
phalanx
• FPL/Thumb → Radial bursae
- Volar + collateral lig

FDS/FDP - 5 Annular/Vaginal Pulleys

Wrist (vaginitis = inflammation), 3 Cruciate
- Opposite increases Pulleys
- Fx dorsal, Ex volar, UD Lat, RD med
Annular Pulleys (horizontal lines in
fingers)
• MCP: SAME
A1 - Metacarpal
• IP:SAME
A4 - mid shaft of distal
Extrinsic Finger Flexors A2 - Midshaft of prox (b/w A1&A3)
- Flexors/extensors “motor fingers of A5 - base of distal phalanx
thumb”
A3 - Base of prox phalanx
- From epicondyles to MC & IP

- Intrinsics: not extensor/flexor since they No man’s land: A1&A3

are within the hand

• LUMBRICALS: same origin and Cruciate (Oblique)

insertion
C1 = b/w A1 & A3
C2 = b/w A3 & A4
2 Muscles of finger flexors C3 = b/w A4 & A5
- FDS: MCP PIP(M)
- FDP (LONG): MCP PIP DIP(M) Pulleys : prevent pinching
- FPL: Distal thumb CMC Roof: prevent pinching of pulley
A2-A4: maintains FDS/FDP efficiency,
Wrist (PL,FCR,FCU), MCP (FDS&FDP), Thumb 2 AP, 1 OP
PIP (FDS), DIP (FDP)
AUF LAS BSPT 2022

Annular Pulley Lumbricals

- Keep flexor tendons close to the bone (be - only muscle that attaches to both tendons

positioned)
- relaxes the distal portion go FDP tendon
- Minimal bowstringing / overlapping
to allow DIP extension

Trigger Finger Swan Neck Deformity (ruptured lat band)

- usually 3rd/4th Annular Pulley Trauma
- MCP fx, PIP hyper ex, DIP fx
Vinicula Tendinum Boutonniere, button (ruptured central
- Vascularization of each tendon
band)
- Ulnar & radial arteries, synovial fluid
- MCP hyper ex, PIP fx, DIP hyper ex
- Digital arteries

Extrinsic Finger Extensors (6) (4 EDM, 1 Opening of hand:

EDI, 1 EDM - extensor retinaculum) - EDC, lumbricals, interosseous
- @MCP: EDC tendon of each finger merges - Unresisted: 2 muscles (lumbricals &
with a broad aponeurosis
interosseous)

- Will merge into one line & then split into - Resisted: 3 muscles (lumbricals,
3 bands (extensor hood) interosseous & EDC)

Extensor Hood/Extensor Expansion/ Closing of hand:

Dorsal Hood Mechanism (extends MCP)
- from 1-3 tendons, EDC - 1 central (mid
phalanx) -> 2 Lateral (distal phalanx)
- can’t be tightened by extrinsic alone
- requires assist of 2 intrinsic muscle
groups of hands
Intrinsic: Lumbricals (DIP EX) &
Interossoie (PIP EX) → Assistants
- Attach at both ends of other muscles
Intrinsic Plus (Ulnar, Passive):
- MCP = FX, IP = EX
- FDP, FDS interosseous
- light → FDP
- Heavy → FDP+FDS+ interossei
CMC THUMB (Carpometacarpal of
Thumb)
- 2 DOF (Fx & Ex, Ab *volar & Ad *dorsal)
• 9 Muscles in Thumb
• 4 Extrinsic: FPL, EPB, EPL, APL
• 5 Thenar Intrinsic: OP,APB,FPB,ADP
(ULNAR NERVE), 1st-6th interossei
• Grips: either medial/ulnar

Intrinsic Minus (Median, Active):

- MCP = EX, IP = FX • Power Grip: Fx & UD, EPB & API
damaged Ulnar nerve

PUMA = (Passive Ulnar Median Active)

- patient ex wrist and fx fingers = medial • Prehension Grip/Precision Grip: Median
active nerve (Finger-thumb) buttons

Interosseous • Hook Grip: No thumb, briefcase

- Assists central tendon of EDC in PIP

extension
• Cylinder Grasp/Palmar: Thumb& Entire
- Dorsal: Abduction Palmar/Volar: hand, phone

Adduction (PADAP)

• Spherical Grasp/Palmar Prehension:

Around sphere/ball
AUF LAS BSPT 2022

• 3 point chuck/digital prehension/ - attachment of FCR tendon, APB, OP

subterminal opposition: Ballpen

• Tip-tip prehension: ant finger rip of Lunate (Semilunar)

ballpen
- MC dislocated bone in the wrist

4 Stages of Gripping Pisiform

• Openning: EDC, lumbrical, interossei
- Smallest

• Closing: FDP, FDS - Pea-shaped and serves as attachment of

• Exerting force: Ulnar Deviation (UD)
FCU

• Releasing Objects: Radial Deviation (RD)

- Form medial border of the tunnel of
Gunyon
Radial Nerve Damage: releasing object, - No attachment

functional wrist position

- On top of Triquetrium

Median Nerve Damage: flexion of digits on Trapezoid (Lesser Multangular)**

radial side
Triquetrium(Triquetrium)**
Hamate (Unciform)**
Ulnar Nerve Damage: flexion on ulnar side; - 2ND bone to ossify

power grip
- forms lateral border of the tunnel go
Gunyon
DISTAL RADIOCARPAL JT
• Closed: Full Ex & RD/Full Fx * Difficult to palpate directly with
• Open: Neutral
palpation
Tunnel of Gunyon = where the ulnar nerve
MCP JT
passes
• Closed: Full Fx
• Open: 20˚ Fx APPLIED ANATOMY
Distal Radioulnar Joint
MCP JT 1 - Uniaxial Pivot Joint (1 DOF)

• Closed: Full Opposition - ULNA

• Open: 20˚ Fx
• Moves back and lateral during
pronation and forward and medially
IP JT during supination
• Closed: Full EX - Resting Position: 10˚ Supination

• Open: 20˚ Fx
- Closed Packed Position: 5˚ Supination

- Capsular Pattern: FULL ROM with pain at

FOREARM WRIST & HAND MAGEE extreme rotation

- most active and most least protected

Radiocarpal (Wrist Joint)

Capitate (Os Magnum) - Biaxial Ellipsoid Joint (2 DOF)

- Largest & most prominent

- 1st to ossify
• Radius articulated with scaphoid and
lunate
Scaphoid (Navicular) • the distal radius is not straight but is
- MC fractured of the carpal bones
angled toward the ulna (15-20˚)

- 2nd MC dislocated carpal bone

- The lunate and triquetrium - articulate with
- Represents the floor of the snuffbox
the Triangular Cartiliaginous Disc
Trapezium (Greater Multangular) (TFCC)
- With scaphoid: floor of the anatomical
snuffbox

AUF LAS BSPT 2022

- There is no Ulnocarpal, ulna is not direction convex other direction

articulated to any carpal & because concave)

- Lateral side
of the TFCC, serves as a blockage

• Scaphoid articulates with the trapezoid

- Distal End of Radius:CONCAVE
and trapezium forming a SELLAR JOINT

- Promximal Row of Carpal:CONVEX

- Closed Packed Position: Extension with
- Resting Position: Neutral with slight Ulnar Deviation

ULNAR DEV
- Resting Position: Neutral or slight flexion
- Closed Packed Position:Extension with with Ulnar Deviation

Radial Dev
- Capsular Pattern: Flexion = Extension

- Capsular pattern: flexion = extension

-
- Ligaments
Carpometacarpal Joint
• Schapholunate interroseous ligament
- At Thumb: Sellar joint: 3DOF

• palmar ligament
- 2nd - 5th CMC JT: Plane Joints

• dorsal ligaments
- Resting Position
• palmar extrinsic ligaments
• Thumb: midway b/w ABD-ADD &
• Radioschapholunate ligament (Most midway b/w flexion & extension

Important) • 2nd - 5th CMC: midway b/w flexion and

- Most commonly injured, FOOSH extension

INJURY - Closed Packed Position

• Radiolunate Ligament
• Thumb: ABD then extension

• Fingers: Equal Limitation

- On the ulnar side, the LIGAMENTS control - Dorsal and palmar ligaments, lateral
the triquetrium
ligament and interosseous ligament

• Palmar Radiolunotriquetrial

• Capitotriquetral
Intermetacarpal Joints
• Dorsal Intercarpal
- Plane Joints

• Fibrocartilaginous disc
- Small Gliding Movements

• TFCC
- Do not include the thumb articulation
- they are bound together

Intercarpal Joints • palmar

- Allows only small gliding movements • dorsal

- Proximal and distal row of carpal bones

• interosseous ligament

• (scaphoid, lunate, triquetrium)

• (trapezium, trapezoid, capitate, hamate)

Metacarpophalangeal Joints
- There are bound together by Intercarpal - Condyloid Joints

Ligaments
- Has Collateral Ligaments

• DORSAL
• tight on flexion, relaxed on extension:
• PALMAR
flexion more limited
• INTEROSSEOUS
- Ligaments

- Closed Packed Position: EXTENSION

- Capsular Pattern: NONE

• palmar ligaments

• deep transverse metacarpal ligaments

- Resting Position: Neutral or slight flexion

- 2 DOF except for the: 1ST MCP which
has 3DOF
Midcarpal Joints - Closed Packed Position
- Proximal and distal rows of carpal bones, • 1st MCP jt: MAX OPPOSITION

with the exception of the pisiform bone • 2nd - 5TH MCP jt: MAX FLEXION

- Medial side - Resting Position: Slight Flexion

• Scaphoid, Lunate, Triquetrium articulate - Capsular Pattern: FLEXION >

with the Capitate and Hamate forming a EXTENSION

SELLAR (SADLE SHAPED JOINT) (One

Interphalangeal Joints
AUF LAS BSPT 2022

- Uniaxial Hinge joints: 1DOF

- Closed Packed Position: Proximal and Flexor Retinaculum Ligament

distal IP joints: FULL EXTENSION
- Fibrous band that spans the wrist on the
- Resting Position: Slight Flexion
ant surface of the wrist

- Capsular Pattern: flexion is more limited - its main function is to hold these tendons
than extension
close to the wrist
- Bound by: Palmar and collateral - it also prevents the two sides of the
Ligaments
carpal bones from spreading apart or
separating
Major Ligaments - Transverse and Palmar Carpal Ligament
Radial Collateral Ligament
- attaches to the styloid process of the Carpal Tunnel
radius and to the scaphoid and - 9 tendons: 4 FDP, 4 FDS & 1 FPL

trapezium bones
- Median Nerve

Ulnar Collateral Ligament Muscles of the forearm: Ant Compartment

- attaches to the styloid process of the ulna - these muscles are primarily flexors of the
and to the pisiform and triquetrium wrist and fingers

Dorsal Radiocarpal Ligament

- attaches from the post surface of the distal Muscles of the forearm: Post
radius to surface of the scaphoid lunate Compartment
and triquetrium
- primarily extensors of the wrist and fingers

- limits flexion
Intrinsic Muscles of the Hand
- Interossei: PADAB

Palmar Radiocarpal Ligament Muscles of the Thumb

- Anteriorly Extrinsic

- thick, tough ligament that limits wrist - FPL

extension
- EPL & EPB

- it is a broad band attaching from the ant - APL

surfaces of the distal radius and ulna to

the ant surface of the distal radius and Intrinsic
ulna to the ant surface of the proximal - Adductor Pollicis

carpal bones and to the capitate bone in - FPB

the distal row

- APB

- Opponens Pollicis

Palmar Fascia - Lat head of the 1st dorsal interossei

- relatively thick and triangular shaped

fascia
Length Tension Relationship: to shorten/to
- located superficially in the palm of the lengthen
hand
- Position of the wrist: controls the length
- also called palmar aponeurosis
of the extrinsic muscles of the digits

- covers the tendons of extrinsic muscles - As the fingers or thumb flex, wrist is
- provides some protection to the stabilized by wrist extensor muscles to
structures of the palm
prevent the FDP & FDS or the from
- serves as distal attachment of palmaris simultaneously flexing the wrist
longus, which blends into the fascia

- DUPUYTRENS: contracture of palmar - As the grip becomes stronger

fascia

AUF LAS BSPT 2022

• synchronous wrist extension concurrently as the intrinsic muscle

lengthens the extrinsic flexor tendons contract, or by stretch of the tendon which
across the wrist and maintains a more occurs with MCP FX

favorable overall length of the - Rupture of central slit in middle

musculocutendinous unit for a stronger phalanx: Bouttoneire

contraction
- Rupture of lateral slit in distal phalanx:
• greater tension in extension
Mallet Finger

- For stronger finger or thumb extension,

the wrist flexor muscles stabilize or flex Mechanism for finger extension
the wrist, so the EDM, EI, EPL muscles - We can Extend PIP &DIP jts without also
can function more efficiently
extending the MP

- In addition there is ULNAR DEV; the flexor - We can’t extend the PIP jt without
and extensor carpi ulnaris muscles are extending the DIP jt at the same time

both active as the hand open

- Flexing only the DIP jt without also flexing
- Extension: Wrist flexor Stabilization by the PIP jt is difficult

extensor muscles : towards wrist flexion

- Full (active or passive) flexion of the PIP jt
- Flexion: Wrist Extensor Stabilization by prevents active extension of the DIP jt

flexor muscles: towards wrist extension

CASCADE SIGN : convergence towards the

scaphoid during flexion
Muscles Acting on The Digits
- Extrinsic - Intrinsic
Patient History
• ED 4 Lumbricals -
Patient Age

• EIP 3 Palmar Interossei

- Occupation

• EDM 4 Dorsal Interossei

- MOI

• EPL Thenar Muscles

• Colles fracture, or scaphoid fracture, or
• EPB Hypothenar Muscles
extension of the fingers may cause
• APL Palmaris Brevis
dislocation the fingers.

• FDS
• A rotational force = Galeazzi
• FDP
fracture:fracture of radius & dislocation
• FPL
of distal end of ulna.

- Task Pt is unable or able to perform

Extensor Mechanism - When the injury or onset occur

- The extensor hood (extensor expansion) is - What is the dominant hand

primarily the ED tendon, its connective - Flexor tendons heal more slowly than
tissue expansion and fibers from the extensor tendons

tendons of the dorsal and volar

interossei and lumbricals Observation
- Each structure that is a part of the hood - Normal or Resting Position of the hand

has an effect on the extensor mechanism

- Bone and soft tissue contours

- An isolated contraction of ED produces - Posture of the hand at rest

clawing of the fingers (MCP HYPER EX - Muscle wasting

with IP FX from passive pull of the extrinsic - Localized swelling on the dorsal of the
flexor tendons called the hook position)
hand

- PIP and DIP extension occurs - Effusion and synovial thickening

concurrently and can be caused by the - Swelling

interrossei/lumbrical muscles through - Dominant hand tends to be larger than

their pull on the extensor hood
non-dominant

- There must be tension in the EDC tendon - Any vasomotor changes

for there to be interphalangeal extension

- Sudomotor changes (Sweat glands)

- this occurs either by active contraction of - Pilomotor changes (Erector Pili)

the muscle causing MCP extension - Trophic changes

- Loss of hair on the hand (Arterial)

AUF LAS BSPT 2022

- Brittle fingernails
- Caused by a combined median and ulnar
- Increase or decrease swearing of the palm
nerve palsy

- Shiny skin

- Hypetrophy of fingers
Trigger Finger
- Ulcerations
- AKA digital tenovaginitis stenosis

- Change in color of the limb

- thickening of the flexor tendon sheath,
- Rotational or angulated deformities (recent which causes sticking of the tendon when
fractures)
the patient attempts to flex the finger

- Wounds or scars (hypertrophic:within - when the patient attempts to flex the

boundaries, keloids: beyond the finger, the tendon ticks, and the finger ‘lets
boundaries, scar color)
go’ often with a snap

- Observe Fingernails
- as the condition worsens, eventually the
finger will flex but not let go and will
Heberden’s Node: DIP Bouchard’s Node:
have to be passively extended
PIP

Club Finger: decreased oxygenation

Ape Hand Deformity

Spoon Shaped Nails: IRON deficiency
Anemia
Common Hand and Finger Deformities
Swan-Neck Deformity
- wasting of the thenar eminence of the
hand occurs as a result of median nerve
palsy
- patient also is unable to oppose or flex the
thumb

- Flexion:MCP & DIP Extension: PIP

- Contracture of the intrinsic muscle or Bishop’s hand or Benediction Hand

tearing of the Volar plate (volar ligament)

Deformity
Boutonniere Deformity
- Wasting of the hypothenar muscles of the
- Extension: MCP & DIP Flexion: PIP hand, interossei muscle & two medial
(primary deformity)
lumbrical muscles
- Rupture of the central tendinous slip of - Due to ulnar nerve palsy

extensor hood

Drop Wrist Deformity

Ulnar Drift - The extensor muscle of the wrist are
- Rheumatoid Arthritis
paralyzed as a result of radial nerve palsy
- due to weakening of the - wrist and fingers can’t be actively
capsuloligamentous structures of the MCP extended by the patient
jt

“Z” deformity of the thumb

Extensor Plus Deformity - the thumb is flexed at the MCP jt and
- Adhesions/shortening of the extensor hyperextended at the IP jt
communis tendon proximal to the MCP jt

- Inability of the patient to simultaneously Myelopathy Hand

flex MCP and PIP, although they may be - this deformity is a dysfunction of the hand
flexed individually
due to cervical spinal cord pathology in
conjunction with cervical spondylosis
Claw Fingers - the patient shows and inability to extend
- Loss of intrinsic muscles action and and adduct the sign and little finger and
over the action of the extrinsic (long) sometimes the middle finger
extensor muscles on the proximal
phalanx of the fingers
Dupuytren’s Contracture
- MCP: hyperextended, PIP & DIP: flexed
- contracture of the palmar fascia
- If intrinsic functions ls lost = intrinsic - flexion deformity of the MCP and proximal
minus
IP joints (similar to benedict)

AUF LAS BSPT 2022

- seen in the ring or little finger and the skin

is often adherent to the fascia
Precision or Prehension Grip
- PINCH Grip

Mallet Finger • three point chuck, three fingered or

- rupture or avulsion of the distal extensor digital prehension

tendon
• lateral key, pulp to side pinch, lateral
- the distal phalanx rests in a flexed position
prehension or subterimnolateral
- DIP of only problems
opposition

• tip pinch, tip to tip prehension or

terminal opposition

PALPATION (DORSAL SURFACE)

- Anatomic Snuffbox
STAGES OF GRIP
- 6 tendon tunnels
1. Opening of hand, action of the intrinsic
• Tunnel 1: APL & EPB
muscle of the hand and the long extensor
• Tunnel 2: ECRL & ECRB
muscles

• Tunnel 3: EPL
2. Closing of the fingers and thumb to
• Tunnel 4: EDM & EI
grasp the object and adapt to the
• Tunnel 5: EDM
object’s shape, which involves intrinsic
• Tunnel 6: ECU
and extrinsic flexor and opposition
muscles

- Carpal Bones
3. Extensor force, which varies depending
- Metacarpal Bones and Phalanges
on the weight, surface characteristics,
fragility and use of the object, again
PALPATION (ANTERIOR SURFACE) involving the extrinsic and intrinsic flexor
- Pulses
and opposition muscles

- Tendons
4. Release in which the hand opens to let
- Palmar Fascia and Intrinsic Muscles
go of the object, involving the same
- Skin Flexion Creases
objects as for opening the hand

- Arches

• Carpal Transverse Arch

• Metacarpal Transverse Arch

Testing Grip and Pinch Strength
• Longitudinal Arch
Dynamometer: GRIP STRENGTH

Pinch meter: PINCH STRENGTH

EXAMINATION - Jebson-Taylor Hand Function Test

- Stable Segment
- Minnesota Rate of Manipulation Test

- Mobile Segment
- Purdue Pegboard Test

- Functional Position
- Crawford Small Parts Dexterity TEST

- Position of rest
- Stimulated Activities of Daily Living
- Wrist of immobilization
Examination

- AROM
- Moberg’s Pickup Test

- PROM
- Box and Block Test

- RESISTED ISOMETRIC MOVEMENT

- Nine- Hole Peg Test

- FUNCTIONAL ASSESMENT

Special Tests
- Test for Ligament, Capsule and Jt
FUNCTIONAL ASSESMENT (GRIP) Instability

- Tests for tendon and muscles

Power Grip (STRONG GRIPS)

- Test for Neurological Dysfunction

- Hook Grasp
- Test for circulation and swelling

- Cylindrical Grasp = type of palmar

prehension

- Fist Grasp = or digital palmar prehension

- Spherical Grasp

AUF LAS BSPT 2022

FOREARM AND WRIST REGION FCR TENDINITIS

- FCR passes through a tunnel formed by
FCU TENDONITIS Transverse Carpal lig, Trapezial Ridge and
- Since FCU tendon inserts in the Pisiform, a Scaphoid Tuberosity before inserting on
Pisotriquetral Compression Syndrome the 2nd MC base

which eventual Pisotriquetreal OA can be - Uncommon condition

associated with this condition

ETIOLOGY
• remember pisiform increases - Activities that require repetitive gripping
mechcanical advantage of FCU
with wrist flexion and RD predispose this
condition

ETIOLOGY
- Results from Repetitive micro-trauma
CLINICAL MANIFESTATIONS
- Symptoms usually develop slowly and
• Activities w/Wrist Flexion and UD; include radial wrist pain with gripping
racquet sports & golf
and forceful wrist flexion and RD

CLINICAL MANIFESTATIONS DIAGNOSIS

- Typically report, insidious onset of volar - Physical examination

ulnar wrist pain. • tenderness over distal FCR tendon and

pain w/passive wrist extension or with
- Activities requiring wrist flexion and UD resisted wrist flexion combined with RD

aggravate the condition

- Crepitus in the region of the TREATMENT

Pisotriquetral joint during wrist - If splinting is required, a wrist hand
orthosis with 25˚ of wrist flexion is
movements may also be felt
appropriate

- tendinitis = inflammation = rest, if

DIAGNOSIS inflammation is gone = strengthen

- Physical examination:

• localized edema and tenderness to DE QUERVAIN’S SYNDROME

palpation over the distal FCU tendon
- MC tendonitis of the wrist
• Compression of the pisiform against the - First dorsal compartment: APL & EPB

triquetrum can cause pain if • Runs beneath a sheath over the dorsal
osteoarthritis is present .
aspect of radial styloid process along
- Diagnostic procedures the inferior portion of anatomic snuffbox

• RADIOGRAPHS: Lateral wrist

radiographs with slight supination & ETIOLOGY
extension can also demonstrate - Shear and repetitive micro-trauma can
pisotriquetral jt osteoarthritis
result in stenosing tenosynovitis

- Seen in patients who perform forceful

TREATMENT gripping with UD or repetitive thumb
- Splinting
use
• Wrist hand orthoses w/wrist @ 25˚
flexion can assist in symptom control
CLINICAL MANIFESTATIONS
- If non-operative treatment fail
- Insidious onset of pain over the dorsal
• Surgical resection of pisiform bone with aspect of the wrist aggravated by racquet
or without Z-plasty lengthening of the sports, golf or fly fishing

FCU tendon
- Wrist crepitus

AUF LAS BSPT 2022

DIAGNOSIS - Non-dominant hand in two handed tennis

- Finklestein test (+) back hand

- Physical examination - Rupture or attenuation of the overlying

• mild edema localized to dorsal radial tendon sheath can result in subluxation of
wrist and tenderness to palpation over the ECU

1st dorsal compartment

CLINICAL MANIFESTATIONS
TREATMENT - ECU tendon usually presents dorsoulnar
- Rest, modalities, analgesics, thumb spica wrist pain that occurs during forceful or
splint.
repetitive wrist extension & UD
- 1st dorsal compartment peritendinous - Patients with tendon subluxation report a
corticosteroid injection reduces “POP” after a forceful volar wrist flexion
symptoms in 62-100% of cases
and UD with subsequent pain

INTERSECTION SYNDROME DIAGNOSIS

- APL & EPB cross the ECRL & ECRB - Physical examination: tenderness to
tendons 4-6cm to Lister’s tubercle
palpation over the ECU tendon and pain
- Inflammatory condition developing at the with resisted wrist extension & UD.

crossing
- Subluxation can be induced by having the
patient perform active UD while fully
supinated

ETIOLOGY - ECU tendon might palpably and or visually

- Result from friction from tendons subluxation ulnarly over the ulnar styloid
rubbing against each other.
process

- Most seen in oarsmen, weight lifters and

racquet sports athletes
TREATMENT
- Neutral wrist-hand orthosis is commonly
CLINICAL MANIFESTATIONS used.

- Dorso radial forearm pain aggravated by - If pt does not respond to conservative tx a

repetitive wrist extension
search for other diagnoses that mimic
ECU tendonitis (i.e TFCC injury) should be
DIAGNOSIS undertaken

- Physical examination: mild edema and • Have similar pain & similar location

acute tenderness 4-6 cm proximal to

Lister’s tubercle, frequently associated - Acute ECU subluxation can be treated
with crepitation during wrist flexion and with cast immobilization of the wrist in a
extension
pronated and dorsiflexed position for 6
weeks. Early surgical repair for acute
TREATMENT injuries, however has also been advocated
- Neutral wrist-hand orthosis commonly to improve predictability of outcome

used in treatment

- Corticosteriord injection into the point of - Chronic ECU recurrent subluxation,

surgical reconstruction of the subsheaths
max tenderness is used if pt does not
should be performed

respond to initial treatment

- Rarely requires surgical intervention

Schapholunate Instability
• eventually the muscle recovers
- MC wrist ligament injury
ECU TENDONITIS AND SUBLUXATION
- 2nd most frequent tendonitis of the wrist
ETIOLOGY
- Can occur on Pronated FOOSH with
ETIOLOGY wrist Extension and UD
- Repetitive wrist extension with UD

AUF LAS BSPT 2022

- Dorsal Intercalated Segmental • The scaphoid is positioned distal to the

Instability or DISI pattern radius and is part of the proximal row of
• After scapholunate lig disruption, carpals.

Scaphoid moves into Flexed position, • The scaphoid is the primary restraint to
whereas Lunate & Triquetrium become excessive wrist extension and is
Extended. therefore prone to injury.

• If not diagnosed early and treated
properly, joint stress will ultimately lead
to progressive wrist orthosis and
scapholunate advanced collapse
CLINICAL MANIFESTATIONS
• The scaphoid receives its blood supply
from a branch of radial artery that enters
the scaphoid through its distal pole.
Consequently, proximal or middle third
fractures of the scaphoid are prone to
avascular necrosis and nonunion as a
result of a disruption in the blood supply

- Wrist edema, ecchymosis & restricted - Scaphoid fractures in the middle third
ROM
80% of the time, the proximal third 15% &
distal third 4% of the time.

DIAGNOSIS • Only 1% of scaphoid fx occur on the

- Physical Examination: tenderness over distal tubercle

scapholunate jt, particularly on the dorsal

of the wrist
ETIOLOGY
- (+) Watson test - Patient falls on extended wrist

- Radiographic evaluation: Anteroposterior

with clenched fist, lateral & oblique CLINICAL MANIFESTATIONS
radiographs
- Experience dorsal radial wrist pain, mild
• Lateral radiograph = presence DISI anatomic snuffbox edema and
pattern of injury
ecchymosis.

• Characterized by scapholunate angle

more than 60˚. DIAGNOSIS
• A gap of more than 3mm b/w scaphoid - Physical examination: Snuff box is
and lunate on anteroposterior tender to palpation

radiographs also diagnostic for - Directly above: Scaphoid Fracture, Pain

scapholunate instability
above snuffbox: DQT

- Radiography then MRI: Scaphoid fx can

- MRI & Arthrography could be used if be very subtle in radiographs

radiographs are not diagnostic

- Neurovascular function should be
- Wrist arthoscopy = Gold standard for assessed

diagnosing this entity

TREATMENT
TREATMENT - Early cast mobilization is used (minimal
- Acute scapholunate injuries should be edema only)

treated surgically
- Non-displaced middle or proximal third fx
- Chronic: more difficult to treat and also = first 6 weeks of mobilization with used of
require surgery/
long-arm thumb spica cast with elbow in
• Partial wrist arthrodesis (becomes fixed)
90˚ flexion and wrist in neutral flexion
• Proximal row carpectomy used to treat extension and neutral deviation
advanced scapholunate collapse
incorporating 1st metacarphalangeal jt
with thumb in slight extension and abd

Scaphoid Fracture - Non-displaced w/middle or proximal third

- 6% of all fractures involve carpal bones
fx can be switch from long-arm to short
• 70% of those carpal fractures involve arm spica after 6wks (total duration being
the scaphoid
12-20wks)

AUF LAS BSPT 2022

- If the fracture occurs in the distal third of - Minimally displaced Type 1 & 2 fx can be
the scaphoid or is a high index suspician managed with closed reduction &
short-arm thumb spica is used
immobilization with double sugar-tong
- During cast immobilization, pt should be splint with the wrist in slight flexion and
encouraged to perform ROM and UD (forearm in neutral, elbow flexed 90˚)

strengthening exercises of the - Satisfactory reduction requires that there is

nonimmobilized upper limb regions.
less than 5 mm of radial shortening, no
- After immobilization, pt should begin an dorsal tilt of the distal radius and less than
exercise program to restore full pain-free 2mm of displacement of fracture
ROM of the immobilized joints and fragments.

strengthening the immobilized - Pt should be evaluated again in 3 days for

musculature.
repeat radiographs

- Displaced fractures, with sustained - Pt with minimally displaced fractures

scapholunate dissociation or those that
develop avascular necrosis or nonunion
should be referred to an orthopedist
and then every 2 weeks until healing is
status postreduction should receive repeat
radiographs weekly for the first 3 weeks
complete

DISTAL RADIAL FRACTURE - Pt should be instructed ROM exercises for

- Postmenopausal woman & children are the joints that are not immobilized, and
most susceptible
after discontinuation of the cast, a rehab
- 3 articulations of distal radius:radiolunate, program should be instituted to ensure
radioscaphoid and distal radioulnar jt.
restoration of full joint ROM and upper
- Distal radius is one of the most fractured limb strength

areas
- Pt with Frykman type 3 fractures or higher,
- Distal radius normally has a volar tilt of comminuted fractures, or fractures with
approx 11˚, a radial inclination along the significant displacement or that are
articular surface as viewed on unstable should be referred to an
anteroposterior radiograph that is 23˚ and orthopedist for management.

a 12mm distance b/w tip of radial styloid

process to a line drawn perpendicular to DIAGNOSIS
the distal ulnar articular surface (this can - FOOSH

be measured on a standard - Physical examination: edema, ecchymosis,

anteroposterior radiographic)
deformity at fracture site.

- Majority of pt who sustain distal radius fx • fracture site tender to palpation

report falling on an extended wrist

• important to document normal
neuromuscular function during
examination

Frykman classification • Radiograph

- Type 1 & 2: Extraarticular fractures

- X-ray

- Type 3 & 4: Intraarticular fractures

involving radoiocarpal jt
KIENBOCK’S DISEASE
- Type 5 & 6: Intraarticular fratures involving
radioulnar jt
ETIOLOGY
- Type 7 & 8: intraarticular fractures both - Progressive collapse of lunate resulting
radioulnar and radoiocarpal its
from repetitive compressive forces to the
- Even numbered fx indicated presence of wrist causing micro-fractures in the lunate
an associated ulnar styloid fx leading to vascular compromise, avascular
- MC fx is Type 1 = COLLES FRACTURE
necrosis and eventual collapse of the
• Fx line 2cm prom to the distal radius lunate

with dorsal angulation of the distal - Occurs more often in pt with ulnar minus
fragment and radial shortening
variant wrists

TREATMENT CLINICAL MANIFESTATIONS

AUF LAS BSPT 2022

- Presents pain and stiffness in the wrist

- Positive ulnar variance results in an
DIAGNOSIS
- Physical examination: limited wrist ROM
and tenderness to palpation over the
increase in the load-bearing function of the
TFCC which results in a higher incidence
of TFCC injuries (too much space since
ulnar positive)

lunate on the dorsum of the wrist

• Usually reveal ulnar minus variant

DIAGNOSIS
• Ulnar negative variance (too - Physical Examination: tenderness to
compressed)
palpation in the hollow n/w the FCU
- Radiographic: demonstrated increased tendon and ECU tendon, distal to ulnar
uptake, even when MRI if radiographs are styloid

negative
- Radiographic evaluation: reveal ulnar
plus variant in anteroposterior view)

TREATMENT - Tricompartment wrist arthrogram, MRI and

- In early stages, wrist should be also MRI arthrogram can provide more specific
immobilized in an attempt to allow info regarding TFCC pathology

revascularization

- If patient has ulnar minus wrist variant

TREATMENT
• to relive lunate trauma, ulnar - Surgical debridement: tx of choice

lengthening procedure or radial

shortening procedure can be performed

HAND AND FINGER CONDITIONS

- For more advanced cases, partial wrist
arthrodesis or lunate excision with soft
tissue or silicone replacement might be EXTENSOR TENDON CENTRAL SLIP
required
DISRUPTION/“BOUTONNIERE
INJURY”
TFCC INJURIES - Rupture of Central Slip of the
- The TFCC is composed of an avascular Extensor Tendon at the base of the
central articular disc and vascular dorsal middle phalanx results in a
and palmar radioulnar ligaments
boutonniere injury
- Pt might report either an insidious onset or
a single traumatic event.
MANIFESTATIONS
- Traumatic tears occur more frequently in - Inability to actively extend the PIP
young athletes, whereas degenerative joint, Flexed:PIP Extended:DIP

tears are more common in older patients.

- Full PIP jt extension can be maintained
- Pt with acute injuries often report an axial if passively placed in this position

load to the wrist associated with

rotational stress
- Pt may report wrist catching & locking
ETIOLOGY
- The TFCC is the primary stabilizer of the
distal radioulnar jt and can be injured in
ETIOLOGY
- Due to migration of lateral bands of
the extensor mechanism volarly below
the axis of rotation in the PIP joint
resulting in a flexion force at the jt →
remains flexed

acute traumatic event

- The lateral bands continue to exert
• FOOSH
an extension force on DIP joints

• Repetitive microtrauma: gymnastics

- This injury can result from a rupture of
- Axial loading the wrist results in 18% of the central slip tendon itself or an
the load being born through the TFCC and
avulsion fracture at the central slip’s
the remaining 82% through the
radoiocarpal jt
insertion

- MOI: Crush injury, forced flexion of the

interphalangeal jts, or lateral volar PIP jt

AUF LAS BSPT 2022

• Flexion can prevent adequate

DIAGNOSIS healing and predispose to a
- Physical Examination: will reveal the permanent extension lag
deformity, tenderness over dorsum of - 1 - 2 months healing & 6 - 8 weeks
PIP jt
splinting

TREATMENT FLEXOR DIGITORUM PROFUNDUS

- Dorsal extension splint of the PIP jt
RUPTURE/“JERSEY FINGER”
• 5-6wks
- Distal FDP tendon disruptions

- If unsplinted, DIP flexion exercises can

be initiated early in tx

ETIOLOGY
- If chronic an aggressive rehab program - Can occur with vigorous gripping
involving serial casting to restore
passive jt ROM must be implemented
activities, such as when a football
- If larger avulsion fx: early surgical tx
player is making a tackle by gripping
the opponent’s jersey.

- Studies reveal that the ring finger has

TERMINAL EXTENSOR TENDON a lower breaking strength than other
DISRUPTION/ “MALLET FINGER” FDP tendons

- Disruption of the Distal Extensor • Increased incidence of disruption in

the tendon to this digit compared
Tendon at its insertion on the dorsal
with other digits

proximal aspect of the distal phalanx

results to mallet finger
DIAGNOSTICS
- MC in index finger - Radiographic evaluation of DIP jt, to
- Pt reprts rule out associated avulsion fx of the
proximal volar aspect of the distal
ETIOLOGY phalanx

- Tendon Rupture or Avulsion Fx of the

dorsal proximal distal phalanx
TREATMENT
- Usually occurs as a result of a hyper- - Primary treatment is surgical repair.

flexion force to an extended DIP jt.

- If Tendon has retracted to the palm,

• A zone of hypo-vascularity within • Repair should be performed within

the distal extensor tendon 7-10 days of injury to prevent
predisposes to this injury
adhesion formation.

- does not immediately heal/has a • Associated fx should be addressed

less chance of healing
at time of injury

- If Tendon does no retract below PIP jt

MANIFESTATION • delayed repair can be performed

- DIP jt pain & inability to extend it
- DIP is in flexed position
- Tenderness to palpation
TREATMENT
within 6-8 weeks of the injury
LATERAL SLIP/SWAN NECK
DEFORMITY
- Flexed DIP & Hyperextend PIP

- Usually nonoperative, unless large - Reverse of boutonniere

avulsion fx is present then surgery is

required
PIP JOINT DISLOCATION
- Splinting the DIP JT in extension, 24 - The PIP joint is the most frequently
hrs/day for 6-8 weeks
dislocated in the hand.

- DIP flexion during this period is not - Dislocations can occur in any
allowed directions, with dorsal dislocations
being the most common
AUF LAS BSPT 2022

• Avulsion fx common in dorsal dislo

- UCL injuries to the 1st MCP jt can be
categorized into three-grade severity
ETIOLOGY scale of ligament sprains

- Dorsal dislocations result from an

axial load to the joint combined with
hyperextension.
GRADE 1:Tenderness to palpation
- Dorsal dislocations result in various without joint laxity

levels of injuries to the volar plate of

the PIP joint and radial and UCLs and GRADE 2:Tenderness to palpation with
can also be accompanied by a fracture.
joint laxity but a good endpoint

- Volar dislocations are usually d/t

varus or valgus force across the joint GRADE 3:Tenderness to palpation with
combined with a volar force to the significant joint laxity and no endpoint

middle phalanx

MANIFESTATIONS STENER LESION

- Dislocations usually present with - Interposition of the Adductor Pollicis
deformity, pain, ecchymosis, and Aponeurosis between the base of the
edema.
1st proximal phalanx and the ruptured
- Pt can report falling on the affected jt
end of the UCL, can prevent adequate
- Tenderness to palpation
healing of this injury, leading to chronic
joint pain and instability.

TREATMENT - Occurs when a Grade 3 UCL sprain of

- 45˚ extension block splint of the PIP jt the 1st MCP JT results from an
to allow for healing of the volar plate avulsion of the distal end of the
injury and associated collateral ligament
ligament injuries

- The extension block splint angle can MANIFESTATIONS

be reduced by 10˚ each week, with a - “POP” and feeling of instability in the
return to full extension in the fifth joint.

week.
- Tenderness to palpation over the UCL

- When splinting is stopped, Buddy - If a Stener lesion is present, a

taping the injured finger to the palpable mass on the ulnar side of
adjacent finger for a few weeks can the 1st MCP jt might be present,
provide some stability for the joint as representing the avulsed UCL.

tissue healing continues and ROM

exercises are instituted

- Surgical indications: Radiologic or DIAGNOSTICS

gross instability after reduction, - UCL stress examination must be
fractures involving >50% of the performed after local anesthesia via
articular surface, inability to reduce the wrist block

dislocation, pilon fx
- Must be performed with join in both full
extension & 30˚ flexion

1ST MCP JT ULNAR COLLATERAL

LIGAMENT SPRAIN/“GAMEKEEPER’S
THUMB”
- Radially directed forces across the
1st MCP jt can result in an UCL injury.
immobilization in a thumb spica cast
- Frequently seen in skiers & athletes
who participate in sports such as
basketball and football.
weeks and a hand-based thumb spica
TREATMENT
Partial tears
- Modalities, analgesics and
for 10 to days, followed by a wrist-
hand-thumb spica orthosis for 2
orthosis for 2-4 more weeks
AUF LAS BSPT 2022

- Patients who participate in contact - Cervical root compression and thoracic

sports should continue to wear a outlet abnormalities can also be
thumb spica splint during competition associated with CTS

for the remainder of the season.

- No hand preference, dominant or
- Local taping for stability during activity nondominant, has been identified, and
can be used after the period of 60% of patients have (B) symptoms

splinting is completed.

- Gentle progressive ROM exercise ETIOLOGY

should begin after cast immobilization - Many factors contribute to CTS
by removing the splint twice daily, and development:

activity should be progressed as • Vibration, local pressure over the carpal

tolerated
tunnel, awkward wrist positions, and
forceful hand positions

Complete Tears/Stener Lesion - It is still debated whether CTS is a result of

- Early surgical repair, particularly if a repetitive stress without other factors
Stener lesion is present
being present

- Indicated for individuals with an - Food processing, construction, and

avulsion fracture of the base of the manufacturing are occupations that have a
proximal phalanx with angulation and higher incidence of CTS

displacement greater than 3 mm or - Debate remains of association of CTS and

with chronic recurrent instability
computer keyboard work

- It has even been hypothesized that

keyboard work may be associated with
DELISA less CTS

CTS is thought to be the result of

increased pressure within the
fibroosseous tunnel.
- Normal pressure: 7 to 8 mm Hg with the
wrist in neutral.
- Increased pressure of 30 mm Hg can
result in symptoms of CTS and 90 mm Hg
can be observed with wrist flexion and
extension

- Pressure increase causes relative ischemia

and impaired nerve conduction of the
median nerve

- If abnormally increased pressure

CTS continues, segmental demyelination
- Most common compressive neuropathy in occurs.

the UE
- The median nerve sensory fibers are the
- Typically causes paresthesias in the first to be affected owing to their extensive
median nerve distribution.
myelination and high metabolic demands.

- Prolonged pressure causes injury to the

EPIDEMIOLOGY motor fibers, and weakness ensues.

- 15% of the general population has

symptoms consistent with CTS.
RISK FACTORS
- The prevalence of EMG confirmed CTS is - Prevalence increases with pregnancy,
3% in women and 2% in men.
inflammatory arthritis, distal wrist fracture,
- Prevalence is greatest in women >55yrs
amyloidosis, hypothyroidism, diabetes,
- Frequently found in obese or smoker and acromegaly, and in individuals who use
people diabetes mellitus
corticosteroids and estrogens

AUF LAS BSPT 2022

- 1/3 of all cases are associated with these • Nocturnal symptoms are 51% to 77%
medical conditions; diabetes is the most sensitive and 27% to 68% specific for
common association CTS

- Gripping, driving, holding vibrating

DIAGNOSIS objects, or prolonged pinching, such as
- Diagnosis of CTS is first established on holding a book, may result in increased
history and clinical findings and then may paresthesias.

be confirmed by EMG evaluation. - Relief of their symptoms with shaking of

- Electromyogram (EMG) is often used for the hands
diagnostic confirmation of CTS.
- With progression, patients may describe
an awkward feeling or weakness of the
• It can measure the extent of damage hand and begin dropping objects.
and demyelination of the median nerve

• In mild cases, there may be an absence

of EMG and nerve conduction changes.
EXAMINATION
• Sensory distal latency is usually the first - Physical examination (Table 37-3)
abnormal EMG finding.
usually begins with the exclusion of any
- ULTRASOUND cervical, shoulder, or elbow pathology,
• Evaluation of the median nerve
which may produce similar symptoms.
• A change in the cross-sectional area of C6 radiculopathies are often confused
the median nerve when CTS is present
with CTS because the sensory
symptoms involve the radial aspect of
RELEVANT ANATOMY the hand.
Carpal tunnel - Strength testing:wrist flexion-extension,
- Located distal to the palmar wrist crease.
grip, and thumb opposition.

- It is surrounded on three sides by the

carpal bones, creating an arch.

- Radial wall: scaphoid and trapezium, - Specific CTS provocative tests include
- Dorsal: lunate and capitate, Phalen’s test, in which the wrist is held
- Ulnar wall: hamate.
in full passive wrist flexion. This
position increases pres- sure within the
Flexor Retinaculum/Transverse carpal lig
carpal tunnel and may reproduce
- Is a fibrocartilaginous band that covers the paresthesias in individuals with CTS.
arch
This test has a wide reported range of
- Nine tendons that pass through sensitivity and specificity (40% to 80%)
• 4 (FDS) (28,30,31). The time to the development
• 4 (FDP) of paresthesias should be noted
• 1 (FPL) because it can be used to monitor
- Median nerve: traverses with these change with treatment.
tendons through the tunnel on its way to - Tinel’s test involves tapping the median
provide innervation to the thenar muscles
and to pro- vide sensation to the radial nerve just proximal to the transverse
three and one half digits
carpal ligament (32). Reproduction of
the paresthesias into the hand by the
SYMPTOMS Tinel’s test is 20% to 60% sensitive and
- Typical symptoms: numbness, tingling, 67% to 87% specific for CTS (30,31).
pain, burning, or a combination of these
Carpal tunnel compression involves
• Symptoms occur in the radial three pressure placed with the examiner’s
and one half digits: the thumb, index, thumb or index and long fingers over
middle, and half of the ring finger.
the carpal tunnel. This pressure is
- CTS often causes nocturnal awakening maintained for 30 seconds to 1 minute
2˚ to hand paresthesias.
and if positive will reproduce paresthe-
AUF LAS BSPT 2022

sias. Durkan (33) believes that this test
is more sensitive and specific for CTS
than Tinel’s or Phalen’s test.
Treatment
- Modification of repetitive or awkward
activities that precipitate paresthesias.
ULNAR NEUROPATHY
- Splinting the wrist in a neutral position at
night has been demonstrated to reduce
symptoms in 80% of patients
- Nonsteroidal anti-inflammatory drugs
(NSAIDs), diuretics, vitamin B6, and oral
steroids have been tested
Arcade of Struthers, Cubital tunnel, and
- Therapeutic interventions: ultrasound,
iontophoresis, gentle stretching and
strengthening exercises, ice, and carpal
- Postoperative rehabilitation versus home
exercises seem to have the same
outcomes, except that it has been shown
that rehabilitation hastens the time to
return to work
- There are four areas of common
compression around the elbow and one
area at the wrist at Guyon’s canal.
- The areas of compression
• Elbow: Medial intermuscular septum,
deep flexor aponeurosis
• Compression at Guyon’s canal

- 2˚ to thrombus at the ulnar artery

tunnel protection principles may be (hypothenar hammer syndrome) or
employed.
to ganglion cyst from the
- Protection principles stress avoidance of pisotriquetral joint or the triquetral
positions or activities that increase hamate joint.

pressure within the carpal tunnel.

- Nerve and tendon gliding exercises

- Acupuncture and yoga have

Manifestation
- Corticosteroid injections into the carpal - Weakness of the wrist ulnar deviators, the
tunnel
lumbricals of the ring and small fingers,
and all of the interosseus muscles.

• If splinting and other conservative - Sensory loss at the ulnar side of the hand
measures fail to reduce the symptoms.

• ↓ symptoms in 75% of patients and extending from the wrist crease to the tips
improve nerve conduction
of the small finger and ulnar half of the ring
finger both dorsally and in a palmar
• Injections are performed in a sterile direction.

fashion with needle placement ulnar to

the palmaris longus.
- Entrapment at Guyon’s canal: spares the
• Needle is directed dorsally, distally, and wrist muscles as well as the dorsal hand
radially at a 45˚ angle.
cutaneous sensation.

• With severe CTS, 80% have return of - Small sensory branch of the ulnar nerve,
symptoms in 1 yr despite appropriate the superficial cutaneous branch, is
care
also spared
- If symptoms of constant numbness, loss • Preserving a small area of sensory
of sensation, or thenar muscle atrophy innervation to the base of the
lasting longer than 1 year, serious hypothenar eminence.

consideration of surgery is recommended

- Complain of pain at medial elbow and
anywhere along the course of the ulnar
- CTS release, traditionally, an open incision nerve.
has been performed and the transverse - Numbness and paresthesias may also be
carpal ligament resected.
present. Weakness is usually a later sign.

- Atrophy of the interosseus and

- Endoscopic CTS release hypothenar muscles and show
• possible but may pose a slightly greater posturing of their hand.
risk for injury to the median nerve

• patients typically return to work quicker Claw “benediction sign”

with the endoscopic technique
- Since extrinsic finger extensors are
spared, a mismatch of strength is seen
AUF LAS BSPT 2022
between the extrinsic and intrinsic
finger muscles.
- Lumbricals of the index and long fingers
are median nerve innervated, these two
digits may show normal posturing.
- This “clawing” of the ring and small
fingers is called the “benediction sign”
TREATMENT
- Avoid leaning the elbow on tables,
counters, or arm rests may prevent
repetitive trauma to the nerve.
- Greater amounts of dissection around the
- Avoid prolonged elbow flexion or posturing
of the UE in any position that reproduces
their symptoms.
- Moreover, the amount of manipulation
- The patient may also wear various
forms of elbow pads or protective
elbow sleeves.
• Cushions the cubital tunnel area and
serves as a constant reminder to the
patient to avoid pressure on the elbow.
- Flexing the elbow may still stretch the
ulnar nerve.
• Possible since the ulnar nerve may
show as much as 21.9 mm of excursion
at the elbow and 23.2 mm at the wrist
with combined motion of the shoulder,
elbow, wrist, and fingers
THUMB CARPOMETACARPAL
• Excursion may be inhibited by fibrosis
or entrapment of the nerve at one or
more of the compression sites.
• The normal gliding of the ulnar nerve
may be limited and cause tension on the
nerve with movement either proximal or
distal to the elbow also with elbow
flexion and extension.
- Surgical decompression or
transposition of the ulnar nerve:
considered when the site of compression
is clear either by EMG findings or by
imaging and when the symptoms are
progressive or debilitating.
may also be a link between hand
- Many types of idiopathic ulnar
neuropathies may be unresponsive to
surgical treatment or may improve
spontaneously.
- Invasive treatment is considered,
• 3 major categories of surgical tx for
ulnar neuropathy at the elbow
1. Decompression of nerve
combined with Medial
Epicondylectomy.
2. submuscular transpositions
3. subcutaneous transpositions
elbow usually lead to greater chances of
postoperative elbow stiffness.
of the ulnar nerve is directly related to
the chances of damage or continued
neuropathy postoperatively.
- Therefore, the simpler procedures of
decompression tend to be the safest.
- Placing the ulnar nerve anterior to the
medial epicondyle protects it from direct
trauma and from stretching.
- In addition, the deeper the nerve is buried,
the less chance for further trauma to the
nerve.
OSTEOARTHRITIS
- Basilar thumb osteoarthritis is the most
common symptomatic arthropathy of the
hand.
- 30% of post-menopausal women >50 yrs
have radiographic evidence of OA of the
thumb CMC joint
ETIOLOGY
- multifactorial, including genetic,
environmental, and physiological
contributions
- Ligamentous laxity plus axial loading of
the joint are thought to be major
contributors to the development of OA at
the base of the thumb. However, there
osteoarthritis and obesity (55).

AUF LAS BSPT 2022

ANATOMY be helpful. In addition, one may use

pens, kitchen utensils, or gardening
The thumb CMC joint implements with built-up grips.

- Double-saddle configuration.

- This configuration allows for movement in - Splints are used to help stabilize the
multiple planes such as flexion-extension, thumb, reducing pain and enabling more
adduction-abduction, and pronation- symptom free function

supination.
- Short opponens splint which is hand-
- 16 ligaments have been described based and crosses the first metacarpopha
stabilizing the trapezium and the CMC langeal (MCP) joint;

joint
- Long opponens splint which is fore- arm-
• The most important lig: beak ligament based, supports the wrist, and crosses the
or deep anterior oblique ligament. interphalangeal joint.

- Patients typically best tolerate the long

DIAGNOSIS opponens, fore- arm-based splint at night
- Radiographic and is graded according to and prefer the less obstructive hand-
the change in the trapeziometacarpal based splint for daytime activities.

space, degree of synovitis, and - These splints usually put the thumb in
subluxation.
palmar abduction with the MCP in 30
degrees of flexion.

• Stage 1 is associated with a normal joint - Splints usually are not successful in
space,

symptom reduction when there is fixed

• Stages 2 to 4 have a decreased joint defor- mity of the joint.

space.

• Stage 3 has obligatory osteophyte - Pain-relieving modalities: contrast baths,

changes and sclerosis of the joint.

hot-water soaks, or paraffin baths. Anti-

• Stage 4 has all of the observations plus inflammatory medications are often used
involvement of the scaphotrapezial joint

for pain control.

• Symptoms vary with each stage.

- Cortisone injections into the CMC joint

TREATMENT
- If the patient has involvement of the
scapho-trapezio-trapezoidal (STT) joint,
- One tries to manage the symptoms.
this may be injected at the same time with
- No cure is known.
a single needle stick.

- We are not even sure that we can slow the

progression of the disease.

- Ideally, the patient acquires new prehen- - As a last resort, some patients may
sile patterns and adaptive equipment in consider surgical options for basilar thumb
order to minimize symptoms and maximize DJD.

function.
• ligamentous reconstruction of the joint,
- The CMC joint biomechanics is such that The trapezium is wholly or partially
any pinch force generated at the thumb excised.

and index finger is greatly magnified at the • Various techniques are used to weave
CMC joint interface.
the tendon between the bases of the
- The greater the distance between the first and second metacarpals with the
thumb and the fingertip, the less pressure distal scaphoid.

on the CMC joint; therefore, enlarging the • Ligamentous reconstruction tendon

grip of tools or objects that are being interposition (LRTI) or the “anchovy”
gripped decreases the pressure at the procedure: employ the remaining
base of the thumb. tendon slip as a cushion to fill in the gap
- Twisting activities also stress the CMC left by the trapezium.

joint by causing a torque or twisting force • The patients requiring a large amount of
on the joint.
grip strength and durability would be
better served by arthrodesis of the joint
• Therefore, various gadgets such as key
holders and electric can openers may
AUF LAS BSPT 2022

This allows for quicker recovery and compartment, causing impingement of the
preservation of grip strength
two tendons

de QUERVAIN’S TENOSYNOVITIS MANIFESTATIONS

- Characterized by pain on the radial aspect - The primary symptoms are pain and
of the wrist at the first dorsal swelling over the radial styloid process
compartment.
with progression up into the radial aspect
- This insidious condition most commonly of the forearm or distally into the thumb

affects women between the ages of 35 - Pain increases with grasping, adduction of
and 55 years
the thumb, or ulnar deviation of the wrist.

- Women are affected 10 times more - The symptom complex is usually gradual
frequently than men.
in onset, but traumatic etiologies have
- There does not appear to be a predilection been described
for dominant or nondominant hand nor for - Tenderness with palpation over the
race.
fibroosseous first dorsal compartment.
- Repetitive, prolonged unaccustomed Pain is commonly elicited with resisted
posturing of the thumb or nonneutral wrist thumb extension and abduction.

movements usually provoke symp- toms

- Waitresses, nurses, garment workers, DIAGNOSIS

maids, assembly line workers, and - A positive Finkelstein’s test

machine operators are at greater risk for • Increased pain in the region of the radial
development of this condition
styloid with this maneuver is considered
positive.

ANATOMY - de Quervain’s tenosynovitis is a clinical

- The extensor tendons to the fingers and diagnosis. X-rays have not been found to
wrist travel through six dorsal be beneficial. Other conditions with a
compartments of the wrist.
similar presentation include peripheral
- The first (most radial) dorsal compartment neuritis, collagen- vascular diseases,
contains the EPB and the adductor pollicis sprains of the CMC joint, arthritis of the
longus
CMC joint, fracture of the distal radius,
- These tendons course through an ganglions of the wrist, acute calcific
osteofibrous canal to their insertion on the tendinosis, and aberrant CTS

metacarpal and proximal phalanx of the

thumb.
TREATMENT

- A significant angulation is present as these - Activity modification is often the most

tendons traverse over the radial styloid, important consideration in conservative
placing the tendons at risk for repetitive treatment. Elimination of highly repetitive
injury
activities that include pinching or gripping
- The function of these muscles is to is beneficial

position the thumb in extension and - Immobilization of the thumb in a forearm-

abduction in preparation for gripping and based thumb spica splint offers protection
pinching. and rest.

- Heat modalities, stretch- ing of the first

- DQT is initially the result of inflammation dorsal compartment muscles, and ice may
within the first dorsal compartment. offer relief of symptoms.

Frequent reoccurrence of this condition - Individuals undergoing injections for this

results in a reactionary degenerative condition described symptom relief at 6
thickening of the extensor retinaculum and weeks.

synovial tendon sheath. In these chronic - If conservative treatment is not effective,

states, inflammation is absent
surgical release of the first dorsal
- The thickening results in a mechanical compartment can be performed

stenosis within the first dorsal

AUF LAS BSPT 2022

KISNER
Exercise Techniques to Increase Flexibility
and Range of Motion
Techniques for Musculotendinous Mobility

- Active muscle contraction and specific

motions of the digits and wrist are used to
maintain or develop mobility between the
multijoint musculotendinous units and
other connective tissue structures in the
wrist and hand.

- tendon-gliding exercises and tendon-

blocking exercises are used whenever
possible to develop or maintain mobility.

- Important when there has been

immobilization after trauma; surgery; or
fracture, and scar tissue adhesions have
developed.

- General stretching techniques also may be Exercises to Develop and Improve Muscle
necessary.
Performance, Neuromuscular Control, and
- The tendon-gliding and tendon-blocking Coordinated Movement
exercises described here also may be
used to develop neuromuscular control
and coordinated movement.

Scar Tissue Mobilization for Tendon

Adhesions

S

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