Wrist and Hand

The document discusses common conditions of the wrist and hand including: 1) De Quervain's tenosynovitis,
which involves inflammation of tendons on the thumb side of the wrist from repetiti… Full description

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Capsular pattern: FLEX and EXT equally tenosynovitis and inammation (rst
WRIST AND HAND limited compartment of the wrist)
Intercarpal Jts  Most common tendinitis of the wrist,
Range of Motion
Resting position: Neutral or slight exion most frequently seen in px who
Wrist
Close packed position: Extension perform activities requiring forceful
: 80°
Capsular pattern: None gripping with ulnar deviation or
Extension: 70°
Ulnar Deviation: 30° repetitive use of thumb
Midcarpal Jts  Racquet sports, golf, y shing
Radial Deviation: 20°
Resting position: Neutral or slight exion with  S/sx: pain and tenderness on dorsal
Hand
ulnar deviation radial side of wrist associated with
Flexion
Close packed position: Extension with ulnar movement, edema, and crepitus
 MCP: 90°
deviation  (+) Finkelstein’s Test
 PIP: 90°
Capsular pattern: Equal limitation of exion  Tx: rest, analgesics, thumb spica
 DIP: 90°
and extension splint (opponens orthosis),
 Thumb: MCP 50°, IP 90° CMC Jts
Extension peritendinous corticosteroid injection
Resting position: to rst dorsal compartment may
 MCP: 30°  Thumb: midway between abd and reduce symptoms
 PIP: 0° add, midway between ex and ext First Metacarpophalangeal Jt Ulnar Collateral
 DIP: 0°  Fingers: midway between ex and ext Ligament Sprain (Gamekeeper’s)
 Thumb: MCP 0°, IP 20° Close packed position:  Results from radially directed forces
Abduction  Thumb: full ext across the rst MCP
 Finger: 20°  Fingers: full ex  Grade 3 sprains could present with
 Thumb: 70° Capsular pattern Stener lesion , interposition of the
Adduction: 0°  Thumb: abd, ext Adductor Pollicis aponeurosis between
 Fingers: equal limitation in all base of the rst proximal phalanx and
Applied Anatomy directions ruptured UCL
Distal Radioulnar Jt MCP Jts Grade Signs
 Ulna moves back and laterally during Resting position: Slight ex 1 Tenderness without jt laxity
PRON, forward and medially during Close packed position:
SUP Tenderness with laxity but good
 Thumb: full opp 2
Resting position: 10° SUP end point
 Fingers: full ex
Close packed position: 5° SUP Tenderness with signicant jt
Capsular pattern: Flex, ext 3
Capsular pattern: Full ROM, pain at extremes laxity and no end point
IP Jts
of rotation S/sx: Pop, feeling of instability,
Resting position: Slight ex 

Radiocarpal Jt tenderness over UCL, palpable mass

Close packed position: Full ext
 Radius articulates with scaphoid and Capsular pattern: Flex, ext on ulnar side of rst MCP if Stener
lunate, lunate and triquetrum also lesion is present
articulate with triangular Conditions Tx: Partial tears use modalities, analgesics,
fbrocartilage complex, extends from De Quervain’s Tenosynovitis/Tenovaginitis and immobilization in a thumb spica cast for
ulnar side of radius to base of ulnar (Texter’s Thumb/Washerwoman’s Sprain) 10 to 14 days, followed by wrist-hand-thumb
styloid process spica orthosis for 2 weeks, and a hand-based
 Repetitive or direct trauma to the
Resting position: Neutral with slight ulnar thumb spica for 2 to 4 weeks. Gentle
sheath of
deviation progressive ROM after cast immobilization.
Abductor Pollicis Longus and Extensor
Close packed position: Extension with radial Early surgical repair for complete ruptures of
Pollicis Brevis tendons causing
deviation UCL and avulsion fractures of base of rst

proximal phalanx with angulation or from its insertion and possibly  Galleazi fx – fx of distal radius with
displacement > 3 mm accompanied by bony fragment dorsal displacement & ulnar
Trigger Finger (Flexor  S/sx: Unable to ex DIP jt dislocation to volar side
Tenosynovitis/Stenosing Tenovaginitis)  Tx: referral
 Repetitive trauma causes Mallet Finger Observation
inammatory process to exor tendon  Sudden passive extension of DIP jt Take note of nodules in DIP
sheaths of digits, forms a nodule that when nger is extended, causing (Heberden’s), often associated with
catches on narrow annular sheath tendon rupture, avulsion fragment of OA, and PIP (Bouchard’s), commonly
resulting in nger locked in exed distal phalanx may occur associated with gastrectasis/OA
position  S/sx: Flexed DIP cannot be actively Systemic symptoms
 Commonly aects the middle and extended, DIP tenderness and edema o Spoon nails – infection,
index ngers  Tx: Splinting for 6-8 weeks, maintain anemia, iron deciency, long-
 Persons > 40 years old, associated nger at extension term diabetes, local injury,
with DM, RA, repetitive trauma developmental abnormality,
 S/sx: Catching or locking of nger Fracture of the First Metacarpal Base chemical irritants, psoriasis
during exion/extension, nodule may  Bennet’s fracture o Nail clubbing – hypertrophy of
be tender, thickening of exor tendon o Oblique fracture subluxation of underlying soft tissue, COPD,
sheath the base of thumb MC severe emphysema, congenital
 Tx: Immobility, NSAIDs, corticosteroid  Rolando’s fracture heart defects, cor pulmonale
injection o Fracture at base of thumb MC Common deformities:
 Management: that may be classied as a T, o Ape Hand – wasting of thenar
Invasive  Steroid injection → percutaneous Y, or comminuted conguration eminence, thumb falls back in
release → open surgery  S/sx: Tenderness and swelling at base line with the ngers, pt unable
Conservative  Splint & NSAIDs → Distal IP of digit, avulsed MC fragment in to ex or oppose thumb. D/t
splint/ MCP splint → Staxsplint/splint in 15° Bennet’s may subluxate secondary to median nerve palsy .
exion for 6 weeks pull abductor pollicis longus o Bishop’s Hand/Benediction
Dupuytren’s Contracture (Viking’s Disease)  Tx: Orthopedic referral Hand – wasting of hypothenar
 Thickening and contraction of palmar Boxer’s Fracture mm, interossei, two med.
fascia d/t brous proliferation  Fracture of the metacarpal neck/shaft lumbrical mm, exion of fourth
 Commonly seen in men > 40 years  Commonly seen in the fth digit after and fth ngers is most
old, associated with DM, ETOH, punching with poor technique obvious. D/t ulnar nerve palsy.
epileptics, pulmonary TB  S/sx: Tenderness and swelling in the o Boutonnière – Ext of MCP and
 S/sx: painless nodules in distal palmar area of hand DIP, ex of PIP. D/t rupture o
crease, exion of involved nger, central tendinous slip o ext
 Tx: Orthopedic referral
commonly at MCP of ring nger hood, m/c p trauma/RA.
Mechanisms o Injury:
 Tx: Ultrasound, splinting, massage, o Claw Fingers – Loss of
FOOSH
surgical if severe intrinsic mm action, overaction
 Colles fx (silver fork/dinner fork
Jersey Finger of extrinsic ext mm on prox
deformity)– fx of distal radius with
 Injury to exor tendon which may be phalanx of the ngers, MCP are
dorsal displacement
spontaneous as in RA or more hyperextended, PIP and DIP
 Smith’s fx – fx of distal radius with
commonly d/t traumatic nature are exed. If intrinsic function
volar displacement
 Commonly happens when a player’s is lost, hand is called intrinsic
 Scaphoid fx – best palpated at the
nger gets caught in the jersey of minus hand, normal cupping of
dorsal side
another, profundus tendon is avulsed hand is lost, longitudinal and
transverse arches disappear,

intrinsic mm wasting. D/t Thickening o exor tendon

combined median and ulnar sheath (Notta’s nodule).
nerve palsy. o Ulnar drift – commonly seen
o Drop-Wrist – extensors are with RA, results in ulnar
paralyzed, wrist and ngers deviation of the digits and
cannot be actively extended. bowstring eect of extensor
D/t radial nerve palsy. communis tendons. Weakening
o Dupuytren Contracture – o capsuloligamentous
Fixed exion of MCP and PIP structures.
jts, usually seen in ring or little o Zigzag Deformity of the
nger, skin is often adherent to Thumb – Thumb is exed at
fascia, men > women, 50-70 the CMC and hyperextended at
y/o. Genetic, progressive the MCP, associated with RA.
contracture o palmar ascia. D/t hypomobility.
o Extensor Plus – Inability of pt o Volkmann Ischemic
to simultaneously ex MCP and Contracture – exed wrist,
PIP jts, although they may be clawed ngers. Compartment
exed individually. Adhesions syndrome ater a dislocation or
or shortening o the EDC x o the elbow.
proximal to MCP.
o Mallet Finger –
Drop/Baseball/Cricket. Distal
phalanx rests in a exed
position. Rupture/avulsion o
extensor tendon where it
inserts into distal phalanx.
o Myelopathy Hand – Inability
to extend and adduct the ring
and little nger and sometime
the middle nger, especially
rapidly, exaggerated triceps
reex, (+) pathologic reex.
Cervical spinal cord pathology
with cervical spondylosis.
o Polydactyly and
triphalangism – presence of
more than the normal number
of ngers or toes, presence of
three phalanges in the thumb.
o Swan Neck – exion of MCP
and DIP, extension of PIP.
Contracture o intrinsic
mm/tearing o volar plate.
o Trigger Finger – digital
tenovaginitis stenosans.