hphy362 / Wrist and Hand Pathologies

Mechanism of Injury	A wrist sprain occurs when one falls on an outstretched arm which stretches or tears ligaments of the wrist.
Assessment	Tenderness at the injury site Limited Active Range of Motion Pain with movement Bruising or discoloration of the skin *Diagnosed after ruling out carpal fractures, triangular fibrocartilage tears, and other injuries of the wrist are ruled out.
Special Tests	*Range of Motion (ROM) testing is an simple special test to allow a physician, athletic trainer, etc. to diagnose a wrist sprain. The history and observatios will also help in evaluating its severity.
Treatment	*Treatment of a wrist sprain is dependent on the degree of the sprain.

Grade 1			Mild: Overstretching of ligaments in the wrist. With a grade one sprain, the individual will be able to care for themselves with the following treatment - R.I.C.E.
Grade 2			Moderate: Partial tear of ligaments and mild joint stability. Treatment includes R.I.C.E. and seeing physician.
Grade 3			Severe: Severe or complete tear of the ligaments in the wrist which will cause joint instability. Ice and see physician immediately.

Picture: Yankees Hideki Matsui sprains his

wrist when stretching out his arm to brace his fall.

(Source: http://graphics8.nytimes.com/images/2006/05/12/sports/12yanks190.1.jpg) (Source: http://healthgate.partners.org/browsing/LearningCenter.asp?fileName=11461.xml&title=Wrist%20Sprain)

Carpal Tunnel Syndrome

Mechanism of Injury	Occurs when there is an increase in pressure on the median nerve as well as the tendons in the carpal tunnel. Also can occur due to a predisposition to the disorder, in that many people are born with a smaller carpal tunnel. Thus, if there is trauma due to an injury or overuse of the extremity, swelling will occur and there will be an increase in pressure in the carpal tunnel. *A common example of this syndrome would be a receptionist who continuously types and overuses her hand and associated tendons.
Assessment	Swollen wrist Tingling in the fingers when palpating the median nerve at the wrist Loss in sensation to the 1st, 2nd, 3rd phalanges at site of touch or pin prick Numbness/Pain that is greatest at night and may wake you up *Trouble gripping objects
Special Tests	Tinel's sign - Light tapping over the median nerve to elicit a tingling feeling Phalen's test - Flexing the wrist for an extended period of time
Treatment	Ice wrist often at the onset of injury/inflammation Massage the wrist area Elevate the arm when laying down Avoid overuse of hand by placing emphasis on the uninjured hand Brace the wrist to avoid Extension/Flexion Surgery in worst cases; making an incision to the extensor retinaculum of the wrist

Picture: Compression of the median nerve from swelling/inflammation. Picture: Incision to the extensor retinaculum to relieve pressure

to the median nerve.

(Source: http://www.eorthopod.com/welcome.do) (Source: http://healthguide.howstuffworks.com/carpal-tunnel-syndrome-in-depth8.htm)

Triangular Fibrocartilage Complex Injury

Mechanism of Injury	Falling on a pronated hyper-extended wrist, or due to a fracture of the distal radius Direct blow to the medial (little finger) side of the hand or a violent twist of the wrist *Subjecting the TFCC to heavy loads, such as a forced ulnar deviation due to such activities as hitting a baseball
Assessment	Painful grinding or clicking of the wrist Weakness *Pain on the little finger side of the hand
Special Tests	None
Treatment	For acute TFCC injury, the forearm needs to be placed in a neutral position with a long cast Steroid injection for relief of symptom *Surgery in severe cases

Picture: Positive ulnar variance.

(Source: http://uwmsk.org/static/residentprojects/ulnarimpaction4.jpg)

Wrist Fractures

There are many bones in the wrist that are susceptible to fracture, however the most common are found at the most proximal portion of the hand, such as the Scaphoid bone, and the most distal portion of

the forearm, such as the radius.

Mechanism of Injury	Blunt force trauma to the proximal region of the hand as a result of bracing for a fall is the most common cause of injury Sudden contact to the hand pushing most of the force into the distal portion of the forearm (Colles fracture)
Assessment	Deformity of the wrist can occur Excruciating pain and swelling
Special Tests	*If a fracture is suspected an x-ray will be taken to get a better look at the fracture at hand
Treatment	*Make sure to apply the R.I.C.E. treatment until the injured person can seek proper medical attention

Picture: Distal radius fracture (Colles fracture) Picture: Fracture to the distal end of the radius.

(Source: http://www.eatonhand.com/hw/hw020.htm)                           (Source: http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c14a.jpg)

Ganglion Cyst

Ganglion cysts are fluid filled sacs that arise from the joint capsule or the sheath of a tendon. A ganglion cyst that arises on the back of the hand is called a dorsal ganglion. These are the most common occurring 60% - 70% of the time. Other ganglion cysts can appear on the palmar side of the hand between the thumb and the pulse point. A dorsal ganglion becomes more prominent when flexing the hand.

Mechanism of Injury *No known cause has been found but it is suggested that previous trauma breaks down tissues of the joint and forms small cysts. These then join to make a larger more distinguishable structure. This may indicate a flaw in the joint capsule that allows the cyst to bulge out.

Assessment
*Ganglion cysts usually appear as bumps that change size due to the constant refilling and leakage of fluid. The more active the wrist the larger the bump.

*The bump may disappear completely to come back again at a later time.

*Most ganglion cysts cause some degree of pain especially following trauma. But, 35% or ganglion cysts are asymptomatic save appearance.

*The pain is usually a nonstop aching pain worsened by motion.

*Weakness of the fingers may be felt if the ganglion is connected to a tendon.
                *Ganglion cysts may also limit the wrist's range of motion as certain movements may be painful.

Special Tests None

Treatment
*Surgery is initially not needed because the cyst is non cancerous.

*Ganglions tend to disappear and reappear over time.

*Surgery in severe cases of pain may be necessary, although this does not guarantee the cyst will not return.

Picture: Dorsal ganglion cyst

(Source: http://www.andreaharner.com/archives/nr55551984.jpg)

Hand Pathologies

Scaphoid Fracture

Mechanism of Injury	A scaphoid fracture usually happens from a fall on an outstretched hand, with the majority of the weight landing on the heel of the hand. More specifically, the hand is extended and forced into dorsiflexion, which compresses the radial side of the hand and causes the fracture. This fracture is the most common fracture of the carpal bones.
Assessment	Pain on radial (thumb) side of the wrist Swelling at the wrist Difficulty grasping certain objects Tenderness in the anatomical snuff box
Special Tests	Scaphoid Compression Test - Compress a patients thumb along the line of the first metatarsal Pronation of the wrist followed with ulnar deviation - This technique can also help with determining a scaphoid fracture
Treatment	*It is hard to detect if there is a fracture opposed to a sprain in many cases, as a fracture can sometimes show up on an x-ray only weeks later. But if a fracture is detected a cast or splint will usually be used to help heal the fracture. Surgery may be necessary depending on the severity of the fracture.

Picture: Most common carpal fracture with braced fall (Scaphoid bone). Picture: Fracture of the Scaphoid bone.

(Source: www.handuniversity.com/topics.asp?Topic_ID=30) (Source: http://www.gentili.net/images/400/wristscaphoidfxx1600.jpg)

Metacarpal Fractures

Metacarpal fractures are the breaking of the bones which make up the palm of the hand. These bones connect the phalanges (fingers) to the carpal bones, and which create the arch of the hand.

At the time of injury, one or more metacarpals can be fractured, which will compromise the use of the hand. The most common metacarpal fracture is the Boxer's Fracture, which is the fracture

of the distal metacarpal-phalangeal joint of the little finger.

Mechanism of Injury	Direct or indirect trauma Direction and amount of force applied to the finger will determine the site of fracture
Assessment	Severe pain at the time of injury Experience pain and swelling on the back of the hand Bruising of the hand If the fracture is a complete fracture, deformity will be apparent
Special Tests	*Palpate the region of suspected injury
Treatment	If bones are still aligned after fracture, use the R.I.C.E. treatment and make sure to stabilize the injured finger by splinting/bandaging for about 4 weeks Fractures that displace the bone and/or associate more than one metacarpal may result in surgery *After the metacarpal(s) has been allowed to heal, it is important to go through flexion/extension to keep the finger(s) full ROM

Picture: Oblique fracture to the 4th metacarpal.

(Source: http://wheelessonline.com/image2/i1/metsp2.jpg)

Perilunate and Lunate Dislocations

A lunate dislocation is the most severe of carpal instabilities. Usually a dislocation disrupts the stability of many carpal ligaments. If a perilunate or lunate dislocation is determined, one

must also suspect that there is a scaphoid fracture associated with the injury.

Mechanism of Injury	Perilunate Dislocation results from force on a hyperextended wrist (falling on outstretched hand) Lunate dislocation is a further extension from a hyperextended perilunate which results in a tear of the dorsal ligaments
Assessment	Pain in the radius about the palmar/dorsal side of the wrist Protrusion may be visible just proximal to the 3rd metacarpal Swelling Tenderness
Special Tests	None
Treatment	*Immobilize the wrist by placing it in a cast for ~ 3 wks during which time, finger, elbow and shoulder exercises are advocated

Picture: Dislocation of the Lunate bone volarly with respect to the carpals.

(Source: http://www.learningradiology.com/notes/bonenotes/perilunatedislocatepage.htm)

Finger Pathologies

Injury to Collateral Ligaments

There are collateral ligaments are on the lateral and medial aspects of the phalanges. There function is to prevent vargus and valgus stress, and increase overall stability of

the interphalangeal (IP) joints. There are two interphalangeal joints, proximal (PIP) and distal (DIP), on digits two through five while digit one (thumb) only has one IP joint.

Mechanism of Injury	*Hyperextension that can be a result of rolling over the arm.
Assessment	*Localized tenderness at the affected collateral ligament
Special Tests	With the MCP joint at 90 degrees flexion, apply a lateral stress to the joint to test its laxity. Apply both varus and valgus stresses to the joint. If testing the PIP joint, put the joint into 30 degrees of flexion and apply a lateral stress. Again apply both varus and valgus stresses. *Make sure to compare bilaterally to the contralateral ligaments
Treatment	Refer to a physician if: the joint is unstable, there is an avulsion fracture, or the patient is a child (due to the growth plate and further growing) Buddy Tape the finger to the adjacent finger for 2-4 weeks if the above conditions do not apply

(Source: http://www.eorthopod.com/images/ContentImages/hand/finger_PIPinjury/finger_PIPinjury_cause02.jpg)

Boutonniere Deformity

A tear in the extensor tendon that causes an imbalance between the Flexor Pollicis Longus and Extensor Pollicis Longus tendons of the finger. The PIP joint is hyperflexed

while the DIP is hyperextended.

Mechanism of Injury	Strong external force impacting a bent finger Laceration to the top of the finger *Rheumatoid Arthritis
Assessment	Swelling and/or pain at the PIP joint Inability to straighten the PIP joint and bend the distal phalanx
Special Tests	Loss of ~20 degrees or greater during active extension of the PIP joint Elson's test - Hand flat on the table with pressure applied to the middle phalanx. Positive test would result in an inability to extend the PIP joint
Treatment	Stability - Splint at the PIP joint to keep the proximal and middle phalanx straight throughout the healing process (~ 3-6wks) Exercise - Stretching exercises to increase the strength and flexibility of the finger *Surgery - In extreme cases surgery is necessary for severed tendons, a displaced bone fragment, or little improvement with splint

Picture: Top image is normal, while the bottom depicts a Boutonniere Deformity.

(Source: http://www.davidlnelson.md/Boutonniere.htm) (Source: http://images.google.com/imgres?imgurl=http://www.eatonhand.com/jpg/1410002.jpg)

Finger Fractures

A finger fracture is a minor trauma but may become serious if the person does not seek medical treatment. The improper alignment of a finger, caused by a fracture, can remain in that

position if not treated correctly.

Mechanism of Injury	Any sport (more commonly contact) Sudden forceful pull or twist of the finger
Assessment	Inability to move finger through full ROM Swelling Tenderness/Pain Alignment is off when compared bilaterally to uninjured fingers
Special Tests	*Palpate the region of suspected injury
Treatment	If bones are still aligned after fracture, use the R.I.C.E. treatment and make sure to stabilize the injured finger by splinting/bandaging for about 4 weeks Fractures that displace the bone and/or associate more than one phalanx may result in surger *After the phalanx has been allowed to heal, it is important to go through flexion/extension to keep the finger's full ROM

Picture: Fracture to the middle shaft of the 2nd phalanx.

(Source: http://healthgate.partners.org/images/si55550711_ma.jpg)

Mallet Finger

This injury is the result of hyperextending the extensor digitorum tendon about the DIP joint. With this injury it is common for the extensor tendon to pull off a piece of bone

at the onset of tear, commonly known as an avulsion fracture.

Mechanism of Injury	Blunt force trauma to the tip of the distal phalanx Contact sports that rely on catching a ball is the most common cause of injury (baseball, basketball, football, etc.)
Assessment	Extreme amounts of pain Swelling Bruising Distal phalanx may be bent inferior to the middle phalanx *Blood accumulation underneath the fingernail
Special Tests	If the finger is jammed, a Mallet injury is suspected Inability to extend the distal phalanx is a good indicator that an avulsion fracture is present *An x-ray is needed to determine if the extensor digitorum tendon pulled off a piece of bone
Treatment	Apply an ice pack over the site of injury immediately Create a splint to keep the finger straight and stable until it can be seen by a medical examiner

(Source: http://www.med.umich.edu/1libr/sma/sma_malletfi_art.htm) (Source: http://orthoinfo.aaos.org/fact/images/cons1_397_151.gif)

Thumb Pathologies

DeQuervain's Syndrome

Swelling and inflammation about the Extensor Pollicis Brevis and Abductor Pollicis Longus tendons resulting in compression to the tendon's sheath.

Mechanism of Injury	The most common cause of injury stems from repetitive use of the wrist.
Assessment	Aching pain on the lateral aspect of the wrist and at the base of the 1st phalanx Tenderness at the base of the 1st phalanx
Special Tests	*Finkelstein Test - Oppose the 1st phalanx and put the 2nd - 5th phalanges in flexion over the 1st phalanx, adducting the wrist. A positive test is indicative of pain at the onset of adduction.
Treatment	Non-steroidal Anti-Inflammatory Drugs (NSAIDS) for mild symptoms Corticosteroid injection into tendon sheath

Picture: Finkelstein Test.

(Source: http://www.weissortho.com/commoninjuries.html) (Source: http://medicine.ucsd.edu/clinicalmed/Upper-Finkelstein.jpg)

Thumb Sprains

Your thumb ligaments can have partial or complete tears when you sprain them. This can cause a person to lose all function or partial function of there thumb with grasping objects.

Mechanism of Injury	A thumb sprain usually occurs from jamming your thumb into an object (i.e. the ground, a ball, or a person) or violently hyperextending one of its joints.
Assessment	Pain when thumb is bent backwards Laxity and instability at the joint Pain with movement Swelling and bruising at injury site
Special Tests	Valgus/Varus test. For a varus test, abduct the 1st phalanx and place your index finger on the medial side, at the distal portion of the 1st phalanx. With your thumb create a fulcrum by positioning it on the lateral side, at the head of the proximal portion of the patients thumb. (see picture below for further clarification)
Treatment	R.I.C.E. is used as an initial treatment (the first 48 hours) before consulting a doctor. If the patient experiences significant pain and swelling after 24-48 hours after the injury, X-rays can be taken to ensure no bones have been fractured.

(Source: http://www.utahmountainbiking.com/firstaid/thumbspr.htm) (Source: http://health.yahoo.com/topic/emergency/symptoms/article/healthwise/popup/tp12844)

Metacarpophalangeal (MCP) Joint Dislocation

MCP Joint dislocations usually occur at the fifth MCP joint or at the thumb. These can be common in sports involving catching a ball such as football or a goalkeeper in soccer.

When a joint is dislocated the proper alignment of the thumb is altered.

Mechanism of Injury	This injury occurs when there is a force applied when the thumb is in abduction and the ulnar collateral ligament is compromised.
Assessment	Tingling sensation apprehension with any movement of the joint *deformities can be sometimes seen if the Joint is still dislocated and has not been reduced
Special Tests	Test for sensations. Test circulation with capillary refill test. To do this add pressure to the tip of the nail bed for about 3 seconds and watch the color change from white to red which would indicate proper blood flow. Testing of the collateral ligaments is necessary to see if they partially or completely tore
Treatment	A doctor should assisst in reducing the dislocation but many times the joint will just sublux and go back into place itself. If the joint is continusly dislocating, surgery can be used to help stabilze the joint and reduce the risk of future dislocations.

Picture: Dislocation of the left 5th MCP joint.

(Source: http://www.ams.ac.ir/AIM/0583/0015.htm)

Thumb Fractures

Mechanism of Injury	Caused by direct stress, such as when one falls on an outstretched arm.
Assessment	Severe pain at fracture site Limited movement at joint Swelling Tenderness *Numbness and coldness in thumb
Special Tests	*You should consult a doctor immediately if a thumb fracture or any other type of fracture is suspected. They will examine the thumb and then usually order an X-ray to be taken.
Treatment	*If the bone has not been displaced significantly, a small cast can be made to hold the bone in place to assist with the healing process. This cast should be worn for about four to six weeks. An orthopedic surgeon will examine the fracture to evaluate if surgery is necessary depending on the severity of the injury at hand.

Picture: Fracture to the proximal base of the 5th phalanx.

(Source: http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow70.JPG)

References

Starkey C, Ryan J. Evaluation of Orthopedic and Athletic Injuries 2nd Edition.F.A. Davis Company 2002.

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Wrist and Hand Pathologies

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Mechanism of Injury	*No known cause has been found but it is suggested that previous trauma breaks down tissues of the joint and forms small cysts. These then join to make a larger more distinguishable structure. This may indicate a flaw in the joint capsule that allows the cyst to bulge out.
Assessment	Ganglion cysts usually appear as bumps that change size due to the constant refilling and leakage of fluid. The more active the wrist the larger the bump. The bump may disappear completely to come back again at a later time. Most ganglion cysts cause some degree of pain especially following trauma. But, 35% or ganglion cysts are asymptomatic save appearance. The pain is usually a nonstop aching pain worsened by motion. Weakness of the fingers may be felt if the ganglion is connected to a tendon. Ganglion cysts may also limit the wrist's range of motion as certain movements may be painful.
Special Tests	None
Treatment	Surgery is initially not needed because the cyst is non cancerous. Ganglions tend to disappear and reappear over time. *Surgery in severe cases of pain may be necessary, although this does not guarantee the cyst will not return.