Chapter 24:

The Forearm, Wrist, Hand &

Fingers

Anatomy
ATHLTR 1811 BASIC ATHLETIC TRAINING
 The Wrist and Hand –
bony anatomy
DISTAL FOREARM
•Radius
• Styloid Process

•Ulna
• Styloid Process
 The Wrist and Hand –
bony anatomy
27 Bones
◦ Phalanges (14)
◦ Metacarpals (5)
◦ Carpals (8)
◦ + Sesamoids
◦ 2 at MCP joint of thumb
(not pictured)
 The Wrist and Hand –
bony anatomy
The carpal bones
◦ Proximal Row
◦ Scaphoid
◦ Lunate
◦ Triquetrum
◦ Pisiform
◦ Distal Row
◦ Trapezium
◦ Trapezoid
◦ Capitate
◦ Hamate
Anatomical Snuff box
Boundaries
Extensor Pollicis Longus

Extensor Pollicis Brevis &

Abductor Pollicis Longus

Contents
Scaphoid
The Wrist and Hand –
joints
Wrist
◦ Radiocarpal
◦ Radius and radioulnar disc
◦ First row of carpal bones
◦ Midcarpal
◦ First row of carpal bones
◦ Second row of carpal bones
The Wrist and Hand –
joints
Hand
◦ Carpometacarpal (CMC)
◦ Metacarpophalangeal (MCP)
◦ Interphalangeal (IP)
◦ Proximal (PIP)
◦ Distal (DIP)
The Wrist and Hand –
ligaments and connective tissue

Dorsal – resists excessive flexion

Palmar (volar) – resists excessive extension
Radial collateral – resists excessive ulnar deviation
Ulnar collateral – resists excessive radial deviation
The Wrist –
ligaments and connective tissue

MCP
The Wrist/Hand -
musculature
Anterior
The Wrist/Hand - musculature
Posterior
Blood and Nerve Supply
Three major nerves
◦ Ulnar, median, and radial
◦ Most of the flexors are supplied by the median nerve
◦ Most of the extensor muscles are controlled by the radial nerve

Ulnar and radial arteries supply the hand

◦ Two arterial arches (superficial and deep palmar arches)
◦ Blood is supplied by the radial and ulnar arteries
Blood and
Nerve Supply
Wrist –
movements
WRIST - FLEXION/EXTENSION
WRIST – RADIAL/ULNAR DEVIATION
 Hand –
movements (fingers)
FINGER FLEXION EXTENSION ABDUCTION ADDUCTION
Hand –
movements (thumb)

**Note this looks different from text

Chapter 24:

The Forearm, Wrist, Hand &

Fingers

Injuries
ATHLTR 1811 BASIC ATHLETIC TRAINING
Anatomical Concepts
Review…..
Anatomical Snuff box
Boundaries
Extensor Pollicis Longus

Extensor Pollicis Brevis &

Abductor Pollicis Longus

Contents
Scaphoid
 The Wrist and Hand –
bony anatomy
The carpal bones
◦ Proximal Row
◦ Scaphoid
◦ Lunate
◦ Triquetrum
◦ Pisiform
◦ Distal Row
◦ Trapezium
◦ Trapezoid
◦ Capitate
◦ Hamate
 The Wrist and Hand –
bony anatomy
Pneumonic Devices
Sam Likes To Push The Toy
Car Hard.
She Looks Too Pretty Try
To Catch Her.
Sally Left The Party To Take
Cathy Home.
Assessment of the Forearm,
Wrist, Hand, and Fingers
History
◦ Past history
◦ MOI
◦ When does it hurt?
◦ Type of, quality of, and duration of pain?
◦ Sounds or feelings?
◦ How long were you disabled?
◦ Swelling?
◦ Previous treatments?
Assessment
Assessmentof
ofthe
theWrist,
Wrist,
Hand,
Hand,and
andFingers
Fingers(2)
Observation
◦ Postural deviations
◦ Is the part held still, stiff, or protected?
◦ Wrist or hand swollen or discolored?
◦ What movements can be performed fully?
◦ Thumb to finger touching
◦ Color of nailbeds
Palpation: Bony
Scaphoid Proximal, middle, and
Trapezoid distal phalanges of the
Trapezium
fingers
Lunate Proximal and distal
Capitate phalanges of the thumb
Triquetral
Pisiform
Hamate (hook)
Metacarpals 1–5
Palpation: Bony and Soft Tissue
Proximal head of radius Radiocarpal joint
Olecranon process
Extensor retinaculum
Radial shaft
Flexor retinaculum
Ulnar shaft
Distal radius and ulna Extensor carpi radialis
longus and brevis
Radial styloid process
Ulnar head Extensor carpi ulnaris
Ulnar styloid Brachioradialis
Distal radioulnar joint Extensor pollicis longus
and brevis
Palpation (continued)
Abductor pollicis longus Flexor pollicis longus
Extensor indicus supinator Pronator quadratus
Flexor carpi radialis Pronator teres
Palmaris longus
Flexor digitorum superficialis
Flexor digitorum profundus
Palpation (continued)
Triangular fibrocartilage Flexor digitorum superficialis
and profundus
Ligaments of the carpals
Palmar interossei
Carpometacarpal joints and ligaments
Metacarpophalangeal joints and Flexor pollicis longus and brevis
ligaments Abductor pollicis brevis
Proximal and distal interphalangeal Opponens pollicis
joints and ligaments
Flexor carpi radialis Opponens digiti minimi
Flexor carpi ulnaris
Lumbricale muscles
Palpation (continued)
Extensor carpi radialis longus and brevis
Extensor carpi ulnaris
Extensor digitorum
Extensor indicis
Extensor digiti minimi
Dorsal interossei
Extensor pollicis brevis and longus

Abductor pollicis longus

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
◦ S&S
◦ Pain, swelling, and hematoma
◦ If repeated blows occur, heavy fibrosis and possibly bony callus could form
within hematoma
◦ Management
◦ Proper care in acute stage involves POLICE, followed by cryotherapy
◦ Protection is critical – pad area
 Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(4)
Forearm fractures
◦ Etiology
◦ Common in youth due to falls (FOOSH) and direct blows
◦ Common to see ulna and radius fractured simultaneously
◦ S&S
◦ Audible pop or crack followed by moderate to severe pain, swelling, and
disability
◦ Edema and ecchymosis with possible crepitus and deformity
Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(5)
Management
◦ Initially, splinting followed by POLICE until definitive care is available
◦ Long-term casting followed by rehabilitation plan
Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(6)
Colles’ fracture
◦ Etiology
◦ Occurs in lower end of radius
◦ MOI – FOOSH, forcing radius into hyperextension
◦ Less common is the reverse Colles’ fracture (Smith fracture)
◦ Anterior displacement of distal fragment
◦ Intraarticular fracture is referred to as a Barton fracture
Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(6)
Colles’ Fracture Smith Fracture
Recognition and Management
of Injuries to the Forearm
Fractures
◦ Colle’s Fracture
◦ Distal radius fracture
◦ FOOSH (extension)
◦ Non-articular
◦ Smith’s Fracture
◦ Distal radius fracture
◦ FOOSH (flexion)
◦ Non-articular
Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(7)
◦ S&S
◦ Forward displacement of radius causing visible deformity (dinner 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
◦ In children, injury may cause lower epiphyseal separation
Recognition
RecognitionandandManagement
Management
of
ofInjuries
Injuriesto
tothe
theForearm
Forearm(7)
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 or violent flexion or torsion
◦ S&S
◦ Pain, swelling, and difficulty with movement
◦ Management
◦ Refer to physician for X-ray if severe
◦ POLICE, splint, and analgesics
◦ Have patient begin strengthening soon after injury
◦ Tape for support can benefit healing and prevent further injury
 Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(13)

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

◦ VIDEO
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(14)

◦ S&S
◦ Sensory and motor deficits (tingling, numbness, and paresthesia);
weakness in thumb
◦ Tinel’s sign
Assessment of the Wrist,
Special Tests
Hand, and Fingers
(2)

Tinel’s sign
◦ Produced by tapping over transverse carpal ligament
◦ Tingling and paresthesia over sensory distribution of the median
nerve indicates presence of carpal tunnel syndrome
 Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(14)

◦ Management
◦ Conservative treatment - rest, immobilization, NSAIDs
◦ If symptoms persist, corticosteroid injection may be necessary or surgical
decompression of transverse carpal ligament
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(17)

Dislocation of lunate bone

◦ Etiology
◦ Forceful hyperextension or fall on
outstretched hand (FOOSH)
◦ MVA

◦ S&S
◦ Pain, swelling, and difficulty
executing wrist and finger flexion
◦ Numbness/paralysis of flexor
muscles due to pressure on median
nerve from the dislocated lunate
Recognition and Management
of Injuries to the Forearm
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(17)

◦ Management
◦ Treat as acute, and send to physician for reduction
◦ If not recognized, bone deterioration could occur, requiring surgical
removal
◦ Usual recovery is 1–2 months
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(19)

Scaphoid fracture
◦ Etiology
◦ FOOSH, compressing scaphoid
between radius and second row of
carpal bones
◦ Often fails to heal due to
poor blood supply
◦ S&S
◦ Swelling and severe pain in
anatomical snuff box
◦ Presents like wrist sprain
◦ Pain with radial flexion
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(19)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(20)

Scaphoid fracture (continued)

◦ Management
◦ Must be splinted and referred for X-ray prior to casting
◦ Immobilization lasts 6 weeks
◦ Wrist requires protection against impact loading for 3 additional
months
◦ Unstable fractures extending through the scaphoid will likely need a
screw inserted to enhance healing
◦ Without stabilization, the fracture may become a nonunion fracture,
extending the time for healing
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(20)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(21)

Hamate fracture
◦ Etiology
◦ Occurs as a result of a fall or more commonly from contact while
athlete is holding an implement
◦ S&S
◦ Wrist pain and weakness and point tenderness
◦ Pull of muscular attachment can cause nonunion
◦ Management
◦ Casting wrist and thumb is treatment of choice
◦ Hook of hamate can be protected with doughnut pad to take pressure
off area
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(22)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(22)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(23)

Wrist ganglion
◦ Etiology
◦ Synovial cyst (herniation of joint
capsule or synovial sheath of tendon)
◦ Generally appears following wrist
strain
◦ S&S
◦ Generally appears on the back of the
wrist
◦ Occasional pain with lump at site
◦ Pain increases with use
◦ May feel soft, rubbery, or very hard
Recognition and Management of
Special
Injuries toTests
the Wrist,
(24) Hand, and Fingers
◦ 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 and chemical cauterization with
subsequent pressure from pad
◦ Ultrasound can be used to reduce size
◦ Surgical removal is most effective treatment method
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(27)

Extensor tendon avulsion (Mallet finger)

◦ Etiology
◦ Caused by a blow to tip of finger avulsing extensor tendon from insertion
◦ Also referred to as baseball or basketball finger
◦ S&S
◦ Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx
◦ Unable to extend distal end of finger
◦ Point tenderness at sight of injury
◦ Management
◦ POLICE and splinting for 6–8 weeks
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(27)
 Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(28)

Boutonniere deformity
◦ Etiology
◦ Rupture of extensor expansion dorsal
to the middle phalanx
◦ Tendon slides below axis of PIP joint;
forces DIP joint into extension and PIP
into flexion
◦ S&S
◦ Severe pain, obvious deformity, and
inability to extend IP joint
◦ Swelling and point tenderness
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(29)

◦ Management
◦ Cold application, followed by splinting
◦ Splinting must be continued for 5–8 weeks
◦ Athlete is encouraged to flex distal phalanx
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(30)

Flexor digitorum profundus rupture (Jersey finger)

◦ Etiology
◦ Rupture of flexor digitorum profundus tendon from insertion on distal
phalanx
◦ Often occurs with ring finger when athlete tries to grab a jersey
◦ S&S
◦ DIP cannot be flexed, finger remains extended
◦ Pain and point tenderness over distal phalanx
◦ Management
◦ Must be surgically repaired
◦ Rehabilitation requires 12 weeks, and there is often poor gliding of
tendon, with possibility of rerupture
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(30)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(32)

Gamekeeper’s thumb
◦ Etiology
◦ Sprain of ulnar collateral ligament
(UCL) of MCP joint of the thumb
◦ Mechanism is a forceful abduction of
proximal phalanx, occasionally
combined with hyperextension
◦ S&S
◦ Pain over UCL in addition to weak and
painful pinch
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(32)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(33)

◦ 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 three 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
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(34)

Sprains of interphalangeal joints

◦ Etiology
◦ Can include collateral ligament, volar plate, and extensor expansion tears
◦ Occurs with axial loading or valgus/varus stresses
◦ S&S
◦ Pain, swelling, point tenderness, and instability
◦ Valgus and varus tests may be positive
◦ Management
◦ POLICE, X-ray examination, and 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
Special Tests (36)
PIP & DIP dislocation
◦ Etiology
◦ Hyperextension that disrupts volar plate at middle phalanx
◦ S&S
◦ Pain and swelling over PIP or DIP
◦ Obvious deformity, disability, and possible avulsion
◦ Management
◦ Treated with POLICE, splinting, and analgesics followed by
reduction
◦ After reduction, finger is splinted at 20–30 degrees of flexion for
three weeks, followed by buddy taping
Special Tests (36)
Recognition and Management of
Special Tests
Injuries to the Wrist, Hand, and Fingers
(39)

Metacarpal fracture
◦ Etiology
◦ Direct axial force or compressive force
◦ Fractures of the fifth metacarpal are associated with boxing or
martial arts (boxer’s fracture)
◦ S&S
◦ Pain and swelling; possible angular or rotational deformity
◦ Management
◦ POLICE, analgesics are given followed by X-ray examinations
◦ Deformity is reduced, followed by splinting - 4 weeks of splinting
after which ROM is carried out
Recognition and Management of
Injuries to the Wrist, Hand, and Fingers