Wrist and Hand E1

Which CMC joint is more prone to pathology compared to the others?

1st CMC (thumb)

How many compartments of the wrist are there?

8 *2 on volar and 6 on dorsal* *include nerves, arteries and tendons*

What is the combo of classical ROM to perform opposition of the CMC of the thumb?

ABD and Flexion

Trigger finger is most common in

Adults

Injury damages axons but not body of nerve Axons, myelin and internal structures are all disrupted Corresponds with 2nd, 3rd and 4th agree injury to a nerve Axons are disrupted and must regenerate while epineurium is intact Typically occurs with traction type injuries Regeneration occurs in intact neural tubes, but slowly (1mm/day) Sx: P! Evident mms atrophy Diminished motor, sensory and sympathetic function Recovery sensations return before motor function

Axonotmesis

Ask pt to make a fist and they are only able to flex 4th and 5th digits bc of loss of median nerve and therefore loss of flexion of 2nd and 3rd digits; active

Benediction Sign

Fx of base of first metacarpal Commonly associate with dislocation that involves CMC joint MOI: direct, axial force to thumb driving the metacarpal into the carpal bones resulting in fx of ulnar side of metacarpals base Thumb is usually in slight flexion Fx tends to be more anterior Small fx segment remains intact with trapezium secondary to this being location of attachment of strong ligament (volar oblique ligament) Metacarpal susceptible to dislocation in radial direction

Bennett's Fx

Pt holds their hand with 4th and 5th digits flexed d/t loss of ulnar nerve and medial two lumbricals that assist with PIP extension Pt unable to extend digits fully

Bishops' Deformity

Swelling or appearance of thickened bone at PIP Associated with OA and RA Hallmark findings: decreased joint space, sclerosis of subchondral bone, osteophytes at articular margins, and joint deformities

Bouchard's nodes

D/t displacement of lateral bands at PIP joints in the volar direction Results in PIP joint being pulled into flexion while MCP and DIP are in extension Consequence of: RA, inflammatory arthritis, traumatic tendon avulsions, contractures, and nerve injuries

Boutonniere deformity

D/t someone punching that is not trained AKA street fighters fx Fx of neck of 5th metacarpal resulting in unskillful blow with clenched fist Impact made with ulnar side of clenched fist where metacarpal 4/5 are mobile (if on radial side the metacarpals are more rigid and less mobile)

Boxer's Fx

This joint is saddled-shaped which is why it is not in reference to the anatomical position and the actual position of the joint itself (angle position)

CMC of the thumb

Osteopenia, Hyperalgesia, edema, atrophy and glassy skin are all characteristic features of?

CRPS

These associated S&S are for: Atrophy of hair, nails, and other soft tissue Alterations of hair growth Loss of joint mobility Impaired motor function (weakness, tremor) Sympathetically maintained p! (may be present) P! described as burning, throbbing, shooting or aching Hyperalgesia Allodynia (perception of p! with normally innocuous stimuli - sympathetic mediated p!) Abnormal sweating or anhydrosis Redness or bluish discoloration Heat or cold sensitivity

CRPS

What comprises the medial distal row?

Capitate and Hamate

This tunnel has these characteristics: Contains: all 4 FDP tendons, all FDS tendons, FPL tendon, and median nerve Most common pathology: median nerve entrapment (most common overuse injury of the wrist)

Carpal tunnel

What are the 2 volar compartments of the wrist?

Carpal tunnel Guyon's canal

Transverse fx through distal radius MOI: FOOSH with wrist in extension but with force traveling dorsally through distal radius; forearm tends to be in supination to brace themselves Distal segment of radius will have dorsal angulation that may be seen with visual inspection (dinner fork deformity) Most common fx in adults over 50 y/o and occurs in women more than men; higher prevalence of osteoporosis in women Can result in: Radioulnar or radiocarpal instability Median and ulnar nerve injury Post traumatic arthritis Soft tissue adhesions RSD Shortening or lengthening of radius

Colles Fx

Form of hypersensitivity typically in UE characterized by p! and hypersensitivity that is not proportional to inciting event AKA RSD, Sudeks atrophy and shoulder hand syndrome

Complex Regional Pain Syndrome (CRPS)

Primarily complaint is p! and intolerable hypersensitivity that is not proportional to any specific event Can be d/t direct trauma to sympathetic/peripheral nerves, immobilization/in presence of edema, and psychological predisposition S&Sx most commonly associated with ANS AKA Reflex Sympathetic Dystrophy (RSD) Associated S&Sx: Atrophy of hair, nails and other soft tissue Alterations of hair growth Loss of joint mobility Impaired motor function (weakness/tremor) Sympathetically maintained pain (may be present) P! described as burning, throbbing, shooting or aching Hyperalgesia Allodynia Abnormal sweating or anhydrosis Redness or bluish discoloration Heat or cold sensitivity

Complex Regional Pain Syndrome (CRPS)

The four bones of the distal row will function as a ____ on the proximal row

Concavity

Radiocarpal joint is a ___ surface moving on a ___ radius

Convex; concave *Therefore roll and glide of entire proximal carpal row will be in opposite directions*

The four bones the proximal row will function as a _____ on the distal radius/ulna

Convexity

Thickening of tendon sheaths around APL and EPB d/t edema, inflammation, or actual thickening secondary to degenerative changes Finkelstein's special test = 81% Sensitivity and 50% Specificity *Must r/o superficial radial nerve entrapment, 1st CMC arthritis/hypomobility, scaphoid fx*

DeQuervain's Tenosynovitis

What are the 5 possible causes of CRPS?

Direct trauma to sympathetic nerves Immobilization causing edema Direct trauma to peripheral nerve Immobilization Having psychological predisposition

Often overlooked just like the tib-fib syndesmosis at the ankle May be injured following fx to distal radius and/or ulna May be injured by itself following FOOSH (includes twisting motion (pronation and supination)) as hand is coming into contact with the ground

Distal Radio-Ulnar Joint Instability (DUJ)

What are the articulations that make up the wrist and hand complex?

Distal radio-ulnar joint Radio-carpal joint Inter-metacarpal joint Carpal-metacarpal joint Metacarpal-phalangeal joint Interphalangeal joint

Instability at this joint could have profound effects on wrist complex Primarily responsible for rolling over the distal ulna for the motion of supination and pronation

Distal radio-ulnar joitn

This arch of the hand is located at the level of the metacarpal shafts and metacarpal heads Allows for the hands ability to adapt to different shapes of objects

Distal transverse arch

For the capitate-hamate articulation, what glide would you perform to promote *wrist extension*?

Dorsal glide

For the scapho-lunate articulation, what glide would you perform to promote *wrist flexion*?

Dorsal glide

What is the correct glide of the distal carpal row to promote *wrist extension*?

Dorsal glide

What is the correct glide of the proximal carpal row to promote *wrist flexion*?

Dorsal glide

For the scapho-trapezium articulation, what glide would you do to promote *wrist flexion*?

Dorsal glide (scaphoid) and palmar glide (trapezium)

To promote ABduction of the thumb, what glide would you perform?

Dorsal glide of the metacarpal *Trapezium = convex* *Metacarpal = concave*

This is when both locations of the median nerve are compressed causing enough compression of the nerve causing motor and sensation loss

Double Crush Syndrome

Contracture of palmar fascia of the hand Pathology of unknown etiology Cellular process that begins with formation of nodules on palmar aspect of hand at location of palmar fascia eventually leading to thickening and shortening of the palmar fascia resulting in MCP and PIP joints being pulled into flexion Most commonly involved fingers are digits 4 and 5

Dupuytren's Contracture

This tunnel has these characteristics: Contains: ABD pollicis longus and extensor pollicis brevis Most common pathology: DeQuervain's tenosynovitis

Extensor Tunnel 1

This tunnel has these characteristics: Contains ECRL and ECRB Most common pathology: Intersection syndrome

Extensor Tunnel 2

This tunnel has these characteristics: Contains EPL Most common pathology: risk of rupture in Colle's fx and subject to attrition

Extensor Tunnel 3

This tunnel has these characteristics: Contains ED and EI Most common pathology: Frequent sites of ganglion cysts

Extensor Tunnel 4

This tunnel has these characteristics: Contains EDM Most common pathology: subject to attrition

Extensor Tunnel 5

This tunnel has these characteristics: Contains ECU Most common pathology: snapping syndrome over ulnar styloid process

Extensor Tunnel 6

What are the dorsal compartments of the wrist?

Extensor Tunnels 1-6 *Includes only tendons*

Extrinsic or Intrinsic mms? These mms are your primary movers

Extrinsic

These ligaments run from the radius to the carpals or the ulna to the carpals More susceptible for rupture More rope like, not wide and broad therefore they have small attachment

Extrinsic ligaments

T/F Tendinopathy will more likely involve an intrinsic mms than an extrinsic mms

FALSE *Extrinsic more than an intrinsic*

Fx of distal radius with dislocation of distal radio-ulnar joint Ulna is not fx and is left intact

Galeazzi fx

This tunnel has these characteristics: Contains: ulnar nerve and ulnar artery Most common pathology: Ulnar nerve entrapment

Guyon's Canal

This bone is AKA the "hog" of the hand d/t articulating with the 4th and 5th metacarpal

Hamate

Swelling or appearance of thickened bone at DIP joint Associated with OA Hallmark findings: decreased joint space, sclerosis of subchondral bone, osteophytes at articular margins, and joint deformities

Heberden's nodes

This is susceptible to fx d/t poor handling of large tools (e.g. axe) leading to poor performance leading to direct compression to it Injured when someone hits the table (firm surface) directly

Hook of Hamate

Trigger Thumb is more common in

Infants/toddlers

Specific location within hand that has great difficulty healing with no long term limitations Located from distal palmar crease to mid portion of middle phalanx Region is Flexor Zone 2 of the hand (tendons of FDP and FDS pass through) Surgery is required

Injury to No Man's Land

May be mis-dx as DeQuervain's tenosynovitis Friction (rubbing on) of tendons related to first extensor tunnel and tendons of second extensor tunnel (*The two groups cross over one another on the dorsal side of the wrist and prior to reaching the extensor retinaculum*) P! complaints primarily located proximal to radial styloid

Intersection syndrome

Extrinsic or Intrinsic mms? These mms contribute to function of the extrinsic mms and aids in movement but also work at balancing and modulating the forces applied to and applied from the extrinsic mms

Intrinsic

These ligaments run from carpal to carpal They have a more broad attachment More susceptible for avulsion

Intrinsic ligaments

What is problematic if the scaphoid becomes fx?

It has its own blood supply (passes it and comes up to the distal end; fx through neck of it would result in blood not being able to reach proximal portion of it) No periosteum surrounding it No mms attaches to it therefore Wolf's law does not apply

Osteochondrosis of the lunate bone Loss of blood to the bone (avascular necrosis) and when blood supply is lost that bone will begin to die Necrosis may follow trauma to bone as seen following FOOSH or laxity of the lunate bone

Kienbock's Disease

AKA osteochondrosis of the lunate

Kienbock's disease

This arch of the hand is located from the wrist to the fingertips Contributes to powerful grasping

Longitudinal Arch

What are the 3 primary arches of the hand?

Longitudinal Arch Proximal Transverse Arch Distal Transverse Arch

What ist he most commonly dislocated bone in the wrist?

Lunate

Injury to the DIP joint of any of the fingers specific to the extensor tendon that attaches to base of the distal phalanx Lost ability to actively extend DIP joint and d/t fact that flexor mms is still intact the DIP joint is pulled into flexion [Appearance is DIP in flexion] MOI: DIP joint being forced into excessive flexion when extensor mms is contracting (heavy eccentric load applied to extensor tendon) Ex: athlete reaching out to catch a ball and ball impacts tip of their finger forcing the DIP into flexion Ex: someone reaching to grab door handle when someone from other side suddenly opens door into their extended fingers

Mallet Finger

This nerve innervates: ABD pollicis brevis, FPB, Opponens pollicis, Lumbricals 1&2 Sensation to palm, digits 1-half of ring finger

Median Nerve

Wrist flexion occurs primarily at what joint?

Midcarpal joint

Fx of proximal ulna with dislocation of radial head from humerus Fx located within proximal 1/3 of ulna

Monteggia fx

Less ulna than normal: ulna is shorter than the radius Commonly associated with Kienbock disease

Negative Ulnar Variance

Internal structural framework and the enclosed axons are destroyed Corresponds to 5th degree injury to nerve An injury results from disruption in continuity of both axons and all supporting structures, including the epineurium Losing neural tubes negates potential for normal regeneration Neurofibrils can grow out from divided ends to produce a neuroma Sx: No p! MMS wasting Complete motor, sensory and sympathetic function loss

Neuotmesis

Slight damage to nerve with transient loss of conductivity Corresponds to 1st degree injury to nerve Demyelination with restoration in weeks Complete recovery is expected within ~ 12 weeks S&S: P! None or minimal mms wasting Some mms weakness Numbness Loss of proprioception

Neuropraxia

What are the 3 types of nerve injuries?

Neuropraxia Axonotmesis Neurotmesis

When examining the TFCC, what must the position of the wrist be in?

Neutral bc otherwise it is susceptible for false negative findings secondary to tautening and/or susceptible for causing injury to it

Lack of sensation or numbness within the hand from wrist down to fingers Does not correlate with neurological cause Seen in those with hysteria, leprosy, diabetes, and CRPS

Opera Glove Anesthesia

What are the positive exam findings for DeQuervain's Tenosynovitis?

PFC = warmth, swelling, and thickening over APL and EPB AROM = p! with active ABD and extension of thumb PROM = p! with classical flexion and ADD of thumb MSTT = strong and p! ABD and extension of thumb MLT = p! with lengthening of ABD and extensors Special Test = positive Finkelestein's

For the capitate-hamate articulation, what glide would you perform to promote *wrist flexion*?

Palmar glide

For the scapho-lunate articulation, what glide would you perform to promote *wrist extension*?

Palmar glide

What is the correct glide of the distal carpal row to promote *wrist flexion*?

Palmar glide

What is the correct glide of the proximal carpal row to promote *wrist extension*?

Palmar glide

For the scapho-trapezium articulation, what glide would you do to promote *wrist extension*?

Palmar glide (scaphoid) and dorsal glide (trapezium)

To promote ADduction of the thumb, what glide would you perform?

Palmar glide of the metacarpal *Trapezium = concave* *Metacarpal = Convex*

This carpal is one of the origins of the Transverse Carpal ligament

Pisiform

What attaches to the pisiform?

Pisohamate and pisometacarpal ligament (one ligament) Ulnar collateral ligament Volar Radiocarpal ligament (flexor retinaculum) Extensor retinaculum FCU ABD digiti minimi

More ulna than normal: ulna extends further than the radius Commonly associated with TFCC pathology (tears and degenerative change)

Positive Ulnar Variance

The dorsal portion of the TFCC becomes taut in?

Pronation

This arch of the hand is located along the distal carpal row Acts as stable base for gripping

Proximal transverse arch

This motion is convex on concave and results in a medial glide on the carpal row

Radial deviation

Active wrist extension is parked with what motion?

Radial deviation *occurs at 60 degrees of extension and continues to end ROM*

To promote extension of the thumb, what glide would you perform?

Radial glide of the metacarpal *Metacarpal = concave* *Trapezium = convex*

This joint attaches the radius to the scaphoid and lunate

Radio-carpal joint

Wrist extension occurs primarily at what joint?

Radiocarpal joint

What is the most commonly fx bone of the wrist?

Scaphoid

What are your 8 carpal bones?

Scaphoid Lunate Triquetrium Pisiform Trapzeium Trapezoid Capitate Hamate

What does wrist extension get paired with radial deviation?

Scaphoid becomes closed packed with the 4 bones of the distal row

Most commonly fx carpal bone and commonly results from fall on open hand with wrist in extension and radially deviated Bridges proximal and distal rows of carpal bones Load to DF wrist as it fall onto outstretched hand Complain of p! over anatomical snuffbox; often overlooked and dismissed as sprain as its not visible on radiograph; swollen wrist after fall Avascular necrosis as well as delayed and non unions are potential complications Three factors that contribute to limited vascularity of scaphoid? Blood supply enters from distal pole No mms attachment Covered with articular cartilage If scaphoid fx present which motions hurt? Wrist extension and Radial deviation Initial X-rays often unremarkable

Scaphoid fx

Most commonly torn carpal ligament Dx often missed MOI is FOOSH and pt likely to report p! over dorsal scapho-lunate area P! may be exacerbated with passive wrist extension Pressure over scaphoid tuberosity elicits p! Greatest p! over dorsal Scapholunate area (accentuated with wrist extension) X-rays shows widening of Scapholunate joint space by at least 3 mm with wrist in weight bearing Gripping causes P!

Scapholunate dissociation

Transverse fx through distal radius but distal segment will have volar displacement MOI: FOOSH but individual's forearm is more in pronation or falling on flexed wrist; impact to posterior side of distal radius

Smiths Fx

The palmar portion of the TFCC becomes taut in?

Supination

D/t displacement of lateral bands at PIP joints in the dorsal direction Results in PIP joint being pulled into extension while MCP and DIP are in flexion

Swann Neck Deformity

This attaches to the lateral surface of the ulnar styloid and medal aspect of the distal radius

TFCC (triangulo-fibro-cartilage-complex)

DRUJ injuries and distal forearm fx frequently includes damage here or acute and degenerative injuries to it may occur indecently of other injuries Sx: Deep ulnar sided p! P! with pronation P! with supination P! with forceful gripping Clicking with motions that may create a shearing of it Extension may be provocative, particularly at end ranges and with ulnar deviation Possible P! with direct palpation Perform medial glide of pisiform to stretch/tension it could compress median nerve

TFCC injury

What is normal variance?

This is the articulation b/t the radius and the ulna Radial styloid process to the ulnar styloid process is relatively flat line meaning it should be perfect slope along the way to accommodate the carpals

What comprises the distal carpal row?

Trapezium Trapezoid Capitate Hamate

What comprises the lateral distal row?

Trapezium and Trapezoid

Which bone is not common to pathology bc of its small size and stability?

Trapezoid

How can the median nerve get compressed?

Trauma, ergonomics, edema/effusion, flexor tightness, displaced lunate, tight retinaculum

Onset of swelling within the tendon, thickening of tendon or fibrosis of tendon (FDS tendon) FDS required to glide under A1 pulley of finger Active flexion causes thickened portion of tendon to travel to proximal side of A1 pulley and get caught or stuck resulting in finger being locked in flexion and usually requires pt to unlock it with other hand Unlocking resembles difficulty in pulling trigger of gun with sudden give in motion Often mistaken as pathology at PIP joint bc upon release (un-triggering) the nodule moves towards PIP joint once able to extend Tenderness with palpation is mistakenly considered to be specific to PIP joint rather than tendon

Trigger Finger/Trigger Thumb

Stenosing tendinopathy, commonly considered tenosynovitis but presents with common symptom of catching and/or locking of finger in flexion, along with possibility of P! complaints

Trigger Finger/Trigger Thumb

Result of swelling around flexor tendons, formation of nodule within flexor tendon, or thickening of fibrous sheath of flexor tendons resulting in finger being stuck in flexion and unable to extend finger When pt actively flexes fingers, their flexors tendon will glide within the fingers ligamentous pulleys (A1 pulley) resulting in the finger to be stuck in flexion To unstick the finger the pt needs to passively extend the finger forcing the thickened aspect of the tendon to pass the A1 pulley

Trigger finger

What is the 2nd most commonly fx carpal of the wrist d/t FOOSH?

Triquetrium

T/F Carpal's don't have articulation to the ulna bc of the TFCC

True

T/F Grip strength is decreased if the wrist is not positioned in neutral position

True

T/F The capitate is not commonly fx but could be d/t high force Similar blood component to that of the scaphoid

True

T/F The location of the trapezium is susceptible to hypermobilities and OA

True

T/F about prognosis of CRPS ~80% of pt with CRPS have spontaneous relief of S&Sx within 18 months No criteria have been establish to predict outcome 50-80% have disability secondary to p! and or limited ROM Long duration of symptoms, presence of tropic changes, presence of cold RSD are associated with higher chances of poor outcomes

True

This nerve innervates: Palmaris Brevis, ABD digiti minimi, FDM, Opponens digiti minimi, Lumbricals 5&6, FPB, ADD pollicis, Dorsal and Palmar Interossei Sensation: 1/2 of ring and pinky dorsal and palmar side Runs through Guyon's Tunnel, Belly of FCU, and Cubital Tunnel Found via all intra-carpal techniques which involve both hamate and triquetrium

Ulnar Nerve

This motion is convex on concave and results in a lateral glide on the carpal row

Ulnar deviation

To promote flexion of the thumb, what glide would you perform?

Ulnar glide of the metacarpal *Metacarpal = concave* *Trapezium = convex*

From ~ 60 degrees extension to end ROM, the lunate and triquetrium move in a _____ glide with the scaphoid and 4 bones of the distal row virtually stopped moving

Volar

Form of a compartment syndrome within the forearm d/t increased pressure (e.g. direct trauma to area that causes edema or from cast being too tight) Increased pressure and compression will do the same to neuromuscular components within forearm leading to decreased sensation and decreased blood flow (ischemia) and leads to fibrosis of mms and soft tissues Compartment pressures of 50mm Hg are associated with 70% decrease in blood flow Sx: swelling and c/o tightness, diminished pulses and capillary refill, most common acute involves forearm and leg, measurement of pressure remains controversial

Volkman's Ischmeic Contracture