Wrist Anatomy

Bones
 Quiz - What
bones comprise
the wrist?
Joints
 Quiz - What joints
comprise the
wrist?
 Carpal Bones and
Articulations
Proximal Row Distal Row
 Where can you  Where can you
palpate these? palpate these?
 Scaphoid  Trapezium
 Lunate  Trapezoid
 Triquetrum  Capitate
 Pisiform  Hamate
Radiocarpal joint  Intercarpal joints
 Ulnocarpal joint  Carpometacarpal
joints (related to
Intercarpal joints hand)
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 – limits flexion
 Dorsal Radiocarpal
 Palmar - limit
extension
 Transverse carpal
ligament
 Palmar radiocarpal
 Multiple divisions
 Palmar ulnocarpal
ligament
 Multiple divisions
 Soft tissue of Wrist
Cartilage
 Triangular Fibrocartilage
Complex – TFCC
 “Meniscus” between
ulna and triquetrum
 Ulnar collateral ligament
and palmar ulnocarpal
ligaments have
attachments
 Compressed with
Pronation and
Extension
 Compressed with Ulnar
deviation
Muscle Tissue of Wrist
Extensor muscles
 Extensor
Retinaculum
 What’s its function?
 Muscles innervated
by radial nerve
 There are 8
 Name them…
Flexor Muscles
 Flexor retinaculum
(aka transverse
carpal ligament)
 Two compartments
 Superficial – 4
 Deep – 3
 Name them…
 Innervated by
median and ulnar
nerve
EXTENSORS FLEXORS
Wrist and Hand Anatomy
Nerves/Vessels
 Radial & ulnar artery and veins

 Radial, ulnar, & median nerves

Carpal Tunnel -
 Flexor Tendons - 9

 Median Nerve
 Wrist Injuries
Strains
 Onset usually acute – FOOSH or Overexertion
 S/S: Active ROM limited
Wrist Ganglion
 Herniation of the joint capsule or synovial sheath
of a tendon.

Tx: Bible Therapy

 Wrist Injuries
deQuervain’s Disease - thumb/wrist
 stenosing tenosynovitis of the extensor
pollicis
brevis and abductor pollicis longus.
 S/S: crepitation, tenderness, strength loss.

 Special Test: = Finkelstein’s test

 Tx: 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
 Joint pathology
Gamekeeper’s Thumb
 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 PIP Palmar Dislocation
 Etiology  Etiology
 Hyperextension that  Caused by twist while it is
disrupts volar plate at semiflexed
middle phalanx  Signs and Symptoms
 Signs and Symptoms  Pain and swelling over PIP;
 Pain and swelling over PIP point tenderness over
 Obvious deformity, dorsal side
disability and possible  Finger displays angular or
avulsion rotational deformity
 Management  Management
 Treated w/ RICE, splinting  Treat w/ RICE, splinting
and analgesics followed by and analgesics followed by
reduction reduction
 After reduction, finger is  Splint in full extension for
splinted at 20-30 degrees 4-5 weeks after which it is
of flexion for 3 weeks -- protected for 6-8 weeks
followed by buddy taping 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
 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
 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
 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
 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?