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Chapter 12 Wrist and Hand Injuries

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									      Chapter 12

Wrist and Hand Injuries

       By: Karla Coras
               Objectives
• Understand the basic anatomy of the hand and
  wrist.
• Explain the various types of wrist and hand
  injuries.
• Understand common mechanisms that cause the
  injuries.
• Understand the signs and symptoms of wrist
  and hand fractures.
Anatomy of the Wrist and Hand
 – Contains many bones, muscles,
   ligaments, nerves and blood vessels.
           Bones and Joints
– Wrist is joint between
  arm & hand
– Made up of eight
  irregularly shaped
  carpal bones
    • Carpal bones
      articulate between
      the radius & ulna of
      the arm & the
      metacarpal of the
      hand to allow wrist
      movement
      Carpal Bones continued
– Scaphoid (navicular)
  carpal bone is of
  particular importance
   • Has a blood supply on
     only one end
   • Therefore has
     difficultly healing
     when fractured
   • Scaphoid sits in a
     depression at the wrist
     called “anatomical
     snuffbox”
– METACARPALS are
  numbered 1-5, 1           Bones of Hand
  beginning at thumb

– Proximal ends of the
  metatcarpals articulate
  (touch) with the carpal
  bones

– Distal ends of five
  metacarpal bones join
  with proximal phalanx
  of each finger/thumb
– Phalanges/Pha    Bones of Hand
  lanx/Fingers
– Total of 14
  phalanges
  bones
  (proximal,
  middle, distal
  phalanx)
– Thumb only
  has proximal
  & distal
  phalanx
• Thumb has two
  joints, metacarpal       Joints of Hand
  phalangeal joint
  (MCP) &
  interphalangeal
  joint (IP)

• Fingers 2-5 have         IP
  metacarpal joints
  (MCP), proximal
  interphalangeal          MCP
  joints (PIP), & distal
  interphalangeal
  joints (DIP)
Joints of the Hand
Muscles
    – Wrist & hand movements
      controlled by many
      different muscles
    – Extensor muscles of
      forearm, located
      posteriorly (lateral)
        • Extend wrist & fingers
    – Flexor muscles of forearm
      located anteriorly
      (medial)
        • Flex wrist & fingers
             Ligaments
– Many intricate
  ligaments of hand &
  wrist, because of the
  many bones that are
  connected

– Wrist is stabilized by
  collateral ligaments
  medially & laterally
         Ligaments
–The ulnar
collateral ligament
(UCL) connects the
distal end of the
ulna with the
triquetral &
pisiform bones
            Ligaments
– The radial
  collateral
  ligament (RCL)
  attaches the
  distal end of the
  radius to
  trapezium &
  scaphoid bones
                  Ligaments
– Flexor retinaculum
  (AKA: “transverse carpal
  ligament”)
    • Located on anterior
      aspect of the carpal
      bones
    • Lies over wrist flexor
      tendons & median
      nerve
    • Stabilize the carpal
      bones
    • Protects flexor
      tendons & median
      nerve (carpal tunnel)
          Ligaments
– Thumb has several important
  ligaments

– Most noteable at the MCP jt.

– Located on the medial and
  lateral sides (collaterals), UCL
  & RCL

– The fingers/phalanges 2-5 at
  the DIP jt. And PIP jt. have the
  same ligaments, UCL & RCL

– DIP jt. and PIP jt. also have a
  ligament on the volar surface
  (palm) called Volar Plate.
     Ligaments
– Thumb at MCP Jt. & Finger at the DIP
  Jt. & PIP Jt.
   • Ulnar collateral ligament in
      particular
   • AKA: “medial collateral ligaments”
   • Located on medial aspect of
      thumb/fingers
   • Radial collateral ligament
   • AKA: “lateral collateral ligament”
   • Located on lateral aspect of
      thumb/fingers
   • Ligaments provide medial & lateral
      stability to the joint of thumb &
      fingers
Preventing Wrist and Hand
         Injuries
                 – Includes commonly
                   used protective gear &
                   equipment
                 – Braces, tape, gloves,
                   padding, plastic splints
                 – Rules of sports dictate
                   the usage of such
                   protective equipment
                 – Use common sense
                 – Proper strength &
                   conditioning
    Treating Wrist and Hand Injuries
             and Conditions
Ligaments injuries
•   Wrist sprains
     – Occur from overuse, falls, &
        forceful twisting motions
     – Overstretching of a ligament
          • Excessive radial deviation
            will injure ligament on
            medial side (ulnar/medial
            collateral lig.)
          • Excessive ulnar deviation
            will injure ligament on
            lateral side (radial/lateral
            collateral lig.)
   Signs, Symptoms, and Treatment
            of Wrist Sprains
– Complain of pain , possible
  decrease ROM, decrease
  wrist & grip strength some
  swelling
– Treatment should include
  PRICE
– Taping may be recommended
  with return to activity
– Rehab should focus on
  reestablishing normal ROM
  and strengthening of wrist
  flexor/extensors & grip
  strength. (IMPRESS)
  Triangular Fibrocartilage Complex
           Injuries (TFCC)
• Identified as a problem among
  athletes who sprain their wrist
• Piece of cartilage located between
  ulna and carpal bones
• Cartilage acts as a cushion
• Injured with forceful rotation or
  hyperextension of wrist
• Treatment includes rest,
  immobilization, restoration of
  motion and strength
• TFCC in some instances needs to be
  surgically repaired
       Dislocation of Lunate
– Caused from falling on
  an outstretched hand
– Either flexed or
  extended during impact
– Most commonly
  dislocated carpal bone
– Deformity & pain,
  swelling & decreased
  ROM
– Splint, ice & refer so
  dislocation can be
  reduced
             Ganglion Cyst
– Pocket of fluid
  develops within the
  sheath/ weaken of
  the joint capsule
– Treatment includes
  ice/modification
  of activity
– Refer to physician
  if condition persists
– Drainage or
  surgery may be
  needed
         Gamekeeper’s Thumb
– Sprain to thumb ulnar
  (medial) collateral
  ligament @ MCP jt.
– AKA “skier’s thumb”
– Falling on hand, thumb
  is forced into abduction
– Pain, swelling, &
  instability may be
  present
– Splint, ice refer for x-
  rays to rule out avulsion
  fracture
– Surgery may be
  necessary
Interphalangeal Collateral Ligament
                         UCL & RCL
              Sprain
– Collateral ligaments are
  located on each side of
  the interphalangeal
  joints @ PIP & DIP jt.
– Radial & Ulnar collateral
  ligaments provide                           collateral
  stability to the joints
– Sprained when stressed
  beyond their normal           Volar plate
  limits
    • Tip of finger is hit by
      a ball
    • Jamming finger into
      another person or
      object
Interphalangeal Collateral Ligament
              Sprain
–   Injury can be painful and disabling
–   Joint can swell and become discolored
–   X-rays may be necessary to rule out a fracture
–   Ice, compression wrap/tape, and “buddy taping” with
    return to activity
           Dislocations
Proximal Interphalangeal (PIP) Joint
                And
 Metacarpal Phalangeal (MCP) Joint
 – Capsular/ligaments
   tears will occur
 – Fractures may also
   occur, i.e., avulsion
   fractures
 – Dislocations should be
   reduced by physician

                      1st Metacarpophalangeal Jt. Dislocation
      Dislocation of Proximal
 Interphalangeal Joint (PIP) or the
Metacarpal Phalangeal Joint (MCP)
– Dislocation to the PIP jt.
  or MCP jt.
– Movement usually
  dorsal (posterior/top of
  hand) or volar
  (anterior/palm of hand)
– Tiny tendons, nerves,
  and blood vessels may
  also be injured


                               PIP jt. Dislocation
    Muscle and Tendon Injuries

– Repetitive stress and stretching will cause muscles
  to strain
– Numerous small muscle around the wrist, hand
  and fingers
– Common signs and symptoms
   • Pain, swelling, weakness, and inability to move
– PRICE for treatment
– Rehab to include stretching and strengthening of
  involved muscles
– Taping for protection upon return to play
                  Tendonitis
– Defined as inflammation of the tendon
– Caused from overuse , stretching or an impact
– Avoid repetitive activities
– Strengthen the weakened muscles and improve
  flexibility
– Treatment (PRICE)
        De Quervain’s Tendonitis
– Affects the thumb
– Abductor Pollicis Longus and Extensor Pollicis Brevis
  tendons
– Caused from overuse, repeated radial deviation of the
  wrist
– Treat by decreasing the causing activity
– Athlete may present with pain and crepitation
– PRICE method of care
                     Mallet Finger
• Results from finger tip
  receiving direct impact
• Extensor tendon is torn
  from the bone
• Finger tip remains in
  flexion at DIP joint
• Athlete can not lift
  (extend) finger tip
• Pain and swelling may be
  present
• Splint finger into full
  extension and refer to
  physician
           Mallet Finger Treatment

– Two courses of action:
    • Surgically treat or keep
      splinted
– The tendon can heal
  back to the bone if kept
  still and extended
– If tendon retracts too far
  from its attachment,
  surgery is needed
Jersey Finger
        – Similar to mallet finger
        – Flexor tendon tears from the
          finger tip
        – Inability to flex the DIP jt.
        – Occurs when the finger is
          quickly forced back into
          extension from a flexed
          position
        – Example is grabbing
          someone’s jersey
        – Pain and swelling may be
          present
        – Ice and splint, refer for
          x-ray to rule out fracture
        – Physician may have to perform
          surgery
      Boutonniere Deformity
– Occurs at the proximal
  interphalangeal jt. (PIP
  jt.)
– Hard impact over the PIP
  jt. may cause this injury
– Tearing of the joint
  capsule and the extensor
  tendons fall laterally (to
  the sides)
– With the tendon in the           Boutonniere
  lateral position, they
  contract and force
                                    Deformity
  flexion of the PIP jt.
– Distal interphalangeal jt
  (DIP jt) is
  hyperextended
– Metatcarpal phalangeal
  jt. (MCP jt) is
  hyperextended
– Pain and swelling will be
  present
– Splinting may help allow
  proper healing, if not      Opposite injury is called a “swan neck
  surgery will be required    deformity”
                Bone injuries
– Any bone on the hand or wrist can fracture from direct
  impact
– Swelling, pain, deformity, and disability are common with
  fractures
– Two complications associated with fractures
– Non union and death of the bone (avascular necrosis)
– Avascular necrosis is death to the bone due to lack of
  blood supply
– In the wrist, the scaphoid bone is most associated with both
  conditions
– Always splint and refer fractures of hand and wrist to MD
         Metacarpal Fractures




Don’t step on my hand! Ouch, that hurts!
Phalange Fractures
Non Union Scaphoid Fracture
Boxer’s Fracture
          Usually occurs to the 4th & 5th Metacarpals




                                  5th Metacarpal
    Don’t punch walls!            Fracture
                    Colles Fracture




Don’ fall on a
out stretched
hand !                          Silver Fork (dinner)
Ouch, that hurts!               Deformity

								
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