FRI, 06-10-2017

PT
STUDEN
T
 Principle of Treating
Exercise Wrist & Hand
 WRIST ANATOMY

• Bones
Apa saja tulang di wrist?
• Joints
Apa saja sendi di wrist?
 CARPAL BONES AND
ARTICULATIONS
• Bagian Proximal • Bagian Distal
• Apa saja yang dapat • Apa saja yang dapat
dipalpasi? dipalpasi?
• Scaphoid • Trapezium
• Lunate • Trapezoid
• Triquetrum • Capitate
• Pisiform • Hamate
• Radiocarpal joint • Intercarpal joints
• Ulnocarpal joint • Carpometacarpal joints
(related to hand)
• Intercarpal joints
 ARTICULATIONS AND ROM

• Distal Radioulnar joint

• Supination and Pronation – 80-90o
• Ulna moves posteriorly and laterally with pronation
• Radiocarpal joint (and Ulnocarpal joint)
• Flexion (80-90o) and Extension (75-85o)
• Radial (20o) and Ulnar (35o) Deviation
• Intercarpal joints
• Gliding
 SOFT TISSUE OF WRIST

• Ligaments
• Covered by a fibrous
capsule
• Radial and ulnar
collateral
• limit ulnar and radial
deviation; collectively
limits flexion and
extension
• Intercarpal and
Carpometacarpal
 SOFT TISSUE OF WRIST

Ligaments
• Dorsal – membatasi fleksi
• Dorsal Radiocarpal
• Palmar - membatasi extensi
• Transverse carpal ligament
• Palmar radiocarpal
• Palmar ulnocarpal ligament
 MUSCLE TISSUE OF WRIST

• Extensor muscles • Flexor Muscles

• Extensor • Flexor retinaculum
Retinaculum Terbagi menjadi 2
bagian
• Di Inervasi oleh
• Superficial
radial nerve • Deep
• Di inervasi median
and ulnar nerve
EXTENSORS FLEXORS
 WRIST AND HAND ANATOMY
• Nerves & Pembuluh darah
• Radial & ulnar arteri and vena
• Radial, ulnar, & median nerves
• Carpal Tunnel
• Flexor Tendons
• Median Nerve
 BLOOD AND NERVE SUPPLY

• Ada 3 Major Nerve

• Ulnar, median and radial
 WRIST INJURIES

• Strains
• Kondisi biasanya akut– FOOSH atau Overstretch
• Active ROM terbatas
• Wrist Ganglion
• Herniation dari kapsul sendi or selubung sinovial dari
tendon
 WRIST INJURIES

• deQuervain’s Disease - thumb/wrist

• tenosynovitis yang terjadi di extensor pollicis
brevis dan abductor pollicis longus.
• Tanda: crepitation, tenderness, strength loss.
• Special Test: = Finkelstein’s test
• Penanganan : RICE, NSAIDs
 WRIST INJURIES

• Sprains
• Onset is usually acute – FOOSH or overexertion
• Often diagnosed when other injuries are ruled out
• Both active and passive ROM are effected
• S/S: Laxity, pain, swelling, limited ROM
• Pain is usually with overstretching
• Special Tests: Varus/Valgus, Carpal Glide
• PRICE, Rehabilitation, Taping for prevention
 WRIST INJURIES

• Triangular Fibrocartilage Injuries - TFCC

• Onset is usually acute
• MOI: Forced hyperextension of wrist with loading
• S/S: Pain with pronation/extension and/or ulnar
deviation; Pain with loading; Point tenderness; Swelling;
Altered joint mechanics
• Special Test: Valgus test elicits pain but no laxity and
Varus test compresses and causes pain
• Immobilization and Surgery are often necessary
 NEURAL INJURIES
• Carpal Tunnel Syndrome
• Compression of median nerve
• Fibrosis of the synovium of flexor tendons secondary to tenosynovitis
• MOI: Insidious onset with repetitive wrist movement (and finger
movement); Acute onset with trauma; Progressive degeneration
• S/S: numbness palmar thumb, index,
middle fingers, dull ache, weak finger
flexion (grip). May worsen with sleep.
• Poor posture may predispose.
• Special Tests: Tinel’s sign
and Phalen’s
• Tx: Conservative (PRICE, NSAIDs) and Surgical
 NEURAL INJURIES
• Biker’s Palsy
• Ulnar nerve compression
• Ulnar nerve passes through tunnel of Guyon between pisiform and
hamate.
• MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar deviation
• Tx: Padding (Gloves), Ice, NSAIDs
• Drop Wrist Syndrome
• Radial nerve compression at elbow
• Inability to extend wrist and fingers
 WRIST INJURIES

• Wrist Fractures
• Distal Radius/Ulna and Forearm Fractures
• Onset is acute
• MOI: Hyperextension or hyperflexion combined with
rotatory motion – FOOSH
• S/S: Deformity felt and observed; Crepitus
• Evaluated Neurovascular status
• Tx: Splint, Ice, Referral
 WRIST INJURIES
• Wrist Fractures
• Distal Radius/Ulna
• Colles’ Fracture
• MOI: hyperextension-fall on outstretched
• S/S: “silver fork deformity” - radius & ulna posteriorly
• Smith’s Fracture (Reverse Colles)
• MOI: hyperflexed
• S/S: “garden spade deformity” - radius
& ulna anteriorly
 WRIST INJURIES
• Wrist Fractures
• Scaphoid - most common carpal
• MOI: fall on outstretched hand
• S/S: wrist aches, pain in anatomical
snuff box,
painful handshake or with overpressure
• Tx: Splint, Referral, Ice
• Plain X-rays may not be enough
• Immobilization (long and/or short) – 12
weeks
• Risk: aseptic necrosis and non-union
fractures
• Preiser’s Disease
• Surgery may be necessary
 WRIST INJURIES
• Wrist Dislocations
• Radius or Ulna
• Lunate is very common
• MOI: force hyperextension
• Dorsal displacement = perilunate dislocation
• Palmar displacement (total rupture) = lunate dislocation
• S/S: Deformity, 3rd Knuckle is lower (Murphy’s sign),
Paresthesia of middle finger, weak finger flexion
• Risk: Untreated or repeated trauma
• Kienbock’s Disease
• Decreased grip, pain with ulnar deviation, weak
extension, pain with passive 3rd finger extension
• Immobilization – 6-8 weeks; Surgery may be necessary
 WRIST INJURY PREVENTION

• Good technique!
• But…these help
 Flexor
tendon
arrangement

Lumbricals

Dorsal
Interossei 4 3 1
Palmar 2
Interossei
 Extensor Hood, Long extensor
tendon, and lateral bands

Finger flexor
tendons

Unique finger
Look at pulley
system
 OBSERVATION
• Relaxed position of hand
• Fingers slightly flexed
• Relative shortness of finger flexors
• Skin and Nail health
• Discoloration, texture, hair patterns
• Finger alignment
• Tips of fingers should align with finger flexion
• Hand abnormalities
• Finger and metacarpal positioning
• Muscle atrophy
• Range of motion
 RANGE OF MOTION
• Carpometacarpal
• Flexion (70-80o)/Extension
• Abduction (70-80o)/Adduction
• Opposition
• Metacarpophalangeal
• Flexion (85-105o)/Extension (20-35o)
• Abduction/Adduction (20-25o)
• Interphangeal joints
• Thumb flexion (80-90o)
• PIP flexion (110-120o)
• DIP flexion (80-90o)
 PALPATION
• Metacarpals and joints
• Collateral ligaments of MCPs
• Phalanges and joints
• Collateral ligaments of PIPs and DIPs
• Thenar compartment
• muscles
• Thenar webspace
• muscles
• Central compartment
• Palmar fascia and muscles
• Hypothenar compartment
• muscles
 PATHOLOGY
• Tendon pathology
• Trigger Finger/Thumb
• Mallet Finger Dupuytren’s Contracture
• Boutonniere Deformity
• Jersey Finger
• Dupuytren’s Contracture
• Swan Neck Deformity
• Joint pathology
• Sprains Swan Neck Deformity
• Bony pathology
• Fractures
• Dislocations
 TENDON PATHOLOGY
• Trigger Finger or Thumb
• Etiology
• Repeated motion of fingers may cause irritation, producing tenosynovitis
• Inflammation of tendon sheath (flexor tendons of wrist, fingers and thumb,
abductor pollicis)
• Thickening 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
• Immobilization, rest, cryotherapy and NSAID’s
• Ultrasound and ice are also beneficial
• Injection
 TENDON PATHOLOGY
• Mallet Finger (baseball or basketball finger)
• Etiology
• Caused by a blow that contacts tip of finger avulsing
extensor tendon from insertion
• Avulses extensor digitorum at distal phalanx
• Signs and Symptoms
• Unable to extend distal end of finger (carrying at 30 degree
angle)
• Point tenderness at sight of injury
• X-ray shows avulsed bone on dorsal proximal distal phalanx
• Management
• RICE and splinting in hyperextension for 6-8 weeks
 TENDON PATHOLOGY
• Boutonniere Deformity
• Etiology
• Rupture of extensor tendon dorsal to the middle phalanx –
bone passes through central slip
• Forces 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 in PIP extension and
DIP flexion
• Splinting must be continued for 5-8 weeks
 TENDON PATHOLOGY
• 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
 TENDON PATHOLOGY
Dupuytren’s Contracture
• Dupuytren’s 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
 TENDON PATHOLOGY
• Swan Neck Deformity Etiology
• Distal tear of volar plate or finger trauma may cause
Swan Neck deformity
• Flexed MCP, extended PIP, and flexed DIP
• 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 PIP 20-30 degrees of flexion/DIP extension for 3
weeks; followed by buddy taping
 JOINT PATHOLOGY
• Sprains Phalanges
• Etiology
• Phalanges are prone to sprains caused by direct blows or twisting
• Signs and Symptoms
• Recognition primarily occurs through history
• Sprain symptoms - pain, severe swelling and hemorrhaging
• Gamekeeper’s Thumb
JOINT PATHOLOGY
• Etiology
• Sprain of UCL of MCP joint of the thumb
• Mechanism is forceful abduction of proximal phalanx occasionally combined
w/ hyperextension
• 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
 JOINT PATHOLOGY
• 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 possible
• 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
 JOINT PATHOLOGY
• 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
• PIP Palmar Dislocation
• Etiology
• Caused by twist while it 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
OPEN DISLOCATION
 JOINT PATHOLOGY
• 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, following reduction splinting in slight flexion (3 weeks)
• Buddy taping following splinting
• Therapy
 BONY PATHOLOGY
• Metacarpal Fracture
• Etiology
• Direct axial force or compressive force
• Fractures of the 5th metacarpal = Boxer’s 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 therapy starts
• Unstable fracture may need to be surgically pinned
 BONY PATHOLOGY
• Bennett’s 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
• Surgery and immobilization – season ending
 BONY PATHOLOGY
• 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
 BONY PATHOLOGY
• 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/ splint for activity
• Deformity - immobilization for 3-4 weeks and a protective
splint for an additional 9-10 weeks during activity
 BONY PATHOLOGY
• 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
 LACERATIONS
• Superficial location of tendons and nerves predisposes athletes to
damage form shallow lacerations.
• Any laceration to the fascia below the cutaneous layer should
receive a referral
• R/O trauma to tendons and nerves
• Prevent infection
• Suture to ensure minimal scarring
 FINGER NAIL
PATHOLOGY
• Subungual Hematoma
• MOI: finger caught between two surfaces
• Presents with bleeding under nail bed
• Draining – Drill or Cauterize
• Paronychia
• Infection around fingernail beds
• S/S: Redness, pain, drainage
• Warm soaks (Betadine), Antibiotic, Referral
• Changes in normal appearance - 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
 PREVENTION OF HAND
INJURIES
• Protection
• Gloves, Grips, Braces
• Proper Technique
• Sport and Ergonomics
• Physical Conditioning
• Reps and Sets for muscles of Hand
• Theraputty, Wrist curls/extensions, Fist pumps
PROBLEM SOLVING
Putting it together with
Case studies
 History
• What is the cause of pain?
• Mechanism of injury?
• Previous history?
• Location, duration and intensity of pain?
• Creptitus, numbness, distortion in temperature?
• Sounds or sensations?
• Technique changes?
• Weakness or fatigue?
• What provides relief?
 OBSERVATION
• Functional Evaluation
• Range of motion in all movements of wrist should be
assessed
• Active, resistive and passive motions should be assessed and
compared bilaterally
• Wrist - flexion, extension, radial and ulnar deviation
• Wrist “attitude”
• How do the carpals and metacarpals align with the distal radius
and ulna?
• Is there symmetry?
• How are those tendons looking?
• Is there a palmaris longus? - 10% of population it is absent
• Become a “palm reader”?
 PALPATION
• Bony and Soft Tissue Palpation
• Are they where they should be?
• Do they feel like they should feel?
• Circulatory and Neurological Evaluation
• Hands should be felt for temperature
• Cold hands indicate decreased circulation
• Take pulse – radial artery
• Pinching fingernails can also help detect circulatory problems (capillary
refill)
• Hand’s neurological functioning should also be tested (sensation and
motor functioning)
 IS IT NERVE?

What other test is

common for nerve
injury?

How else can you

detect a neural injury?
What test is this?
IS IT THE LIGAMENTS OR
JOINTS?

Which tests are these?

What are some distinguishing

characteristics of a ligament or joint
injury?
 IS IT MUSCLE OR
TENDON?
How do you assess the function
of a muscle?

What are some distinguishing

characteristics of a muscle
injury?

What test assesses

these structures?
 IS IT BONE?
What is are distinguishing signs of a potential fractures?
 CASE STUDY #1
• A 28 year old woman complains of pain in the right hand over the
last 3 months. She reports numerous FOOSH incidents and
currently works as a cashier at a grocery store. The pain awakens
her at night and is relieved only by vigorous rubbing of her hand
and motion of the fingers and wrist. There is some tingling in the
index and middle fingers. What is your assessment plan?
 CASE STUDY #2
• A 18 year old boy reports with wrist pain and
swelling on the dorsum of his wrist and hand. He
notes the pain is more near the base of the thumb.
He is an active weightlifter. He says he tripped and
experienced a FOOSH while playing recreational
football. He states that after the injury the wrist hurt,
he rested 2 days and iced, the pain decreased, but
then with weightlifting the swelling has developed
the last 5 days. Now it is very swollen and painful.
What is your assessment plan?
 CASE STUDY #3
• A 22 year old golfer comes to you with pain along
his right medial wrist. He reports that while on
spring break he went skiing and had a FOOSH. The
wrist was achy but didn’t bother after a few hours
especially since he put snow on it for 20 minutes.
Now that he has returned to school and golf practice
he is having trouble controlling his drives and long
iron shots because of pain in his wrist at the top of
the swing. What is your assessment plan?