Wrist and Hand injuries

Anatomy
• Bones
• Joints
• Ligaments
• Muscles
 Bones
• Carpals
• Metacarpals
• Phalanges
• Radius
• Ulna
 Carpals
• 2 rows, lateral to medial
– Distal
• Trapezium, trapeziod, capitate, hamate
– Proximal
• Scaphoid (navicular) lunate, triquetral, pisiform
 Metacarpals
• 5 bones
• Numbered 1 through 5
• Thumb is #1
• Pinky is #5
 Phalanges
• 5 proximal
• 4 middle
• 5 distal
 Joints
• Distal radioulnar
• Carpal
• Carpometacarpal
• Metacarpalphalangeal (MCP)
• Interphalangeal (PIP and DIP)
 Ligaments
• Ulnar collateral (ulna to carpals)
• Radial collateral (radius to carpals)
• Transverse carpal ligament (crosses volar aspect
of carpals)
• Medial collateral and lateral collateral (at IP
joints)
• Volar plate (thickened part of joint capsule)
 Muscles
• Intrinsic muscles
– Originate in the hand
– Thenar and hypothenar eminence
• Actions include abduction/adduction & opposition of
thumb
• Extrinsic muscles
– Originate outside the hand
• Actions include flexion/extension of wrist, hand, fingers
Thenar & hypothenar eminence
 Bones most often injured
• Radius
• Ulna
• Lunate (dislocation)
• Scaphoid (fracture in anatomical snuffbox)
• Metacarpals
• Phalanges
 Wrist Injuries
• Colle’s Fracture
• Sprain
• Tendonitis
• Ganglion cyst
 Colle’s Fracture
Involves the distal end of radius
Deformity
 Mechanism of Injury
• Fall on an outstretched hand
• Run into wall, etc, with wrist hyperextended
 S/S
• Visible deformity
• Swelling
• Pain
• POT - point tender
 Complications
• Tendons may be torn away from attachment site
• Median nerve damage
 Care
• Splint in position you find it
• Ice
• ER
• 1-2 month recovery time
 Wrist Sprain
• Mxn:
– Abnormal forced movement of the wrist
– Falling on hyperextended or hyperflexed wrist
– Violent torsion
Wrist Sprain
• S/S:
– Pain
– Point tenderness
– Swelling
– Difficulty moving wrist—limited ROM
• TX:
– RICE for mild/ moderate
– Physician referral to rule out fx for severe
– Splint if necessary
– Exercises for strengthening and ROM
– Tape for support
Treatment for wrist injuries
 Wrist Tendonitis
• MXN: repetitive motion at wrist—usually in
flexion/extension
– Seen more often in athletes involved ins sports with
repetitive acceleration and deceleration
• i.e. weight lifters, rowers
• S/S:
• Pain with active motion
• Pain with passive stretching
• POT over either flexor or extensor tendons
• Swelling
• TX:
• Ice
• Heat
• Analgesics
• Modify activity
• NSAIDS
• Splint
• Strengthening and ROM exercises
 Ganglion Cyst
• herniation of joint capsule, synovial sheath of
tendon or cystic structure
• MXN: Appears slowly after repeated forced
hyperextension of wrist.
– Contains clear mucous fluid
– Appears most often on dorsum of hand
 Ganglion cyst
• S/S:
• pain on dorsum of hand that increases with
wrist extension
• May feel soft and rubbery or hard
• May appear bigger with flexion of wrist
Ganglion Cyst
Ganglion cyst
Ganglion cyst
Ganglion cyst
• TX:
• Break down swelling with digital pressure and
padding
• Aspiration and chemical cauterization followed
by pressure padding
• Will usually come back
• Surgical removal
• HIT IT WITH A BOOK
 Hand injuries
• Dislocation of lunate
• Scaphoid Fracture
• Hamate Fracture
• Metacarpal Fracture—Boxer’s fracture
 Dislocation of Lunate
• MXN:
• Forced hyperextension of wrist
• S/S:
• Pain
• Swelling
• Difficulty moving wrist and fingers into flexion
• Numbness/paralysis of flexors due to pressure
of lunate on median nerve
• deformity
Lunate dislocation
Lunate Dislocation
• TX:
• Splint
• Ice
• Physician referral for reduction
• 1-2 month recovery time
 Scaphoid Fracture
• MXN:
• Fall on hyperextended wrist
• Force on outstretched hand (hyperextended
wrist) that compresses the bone between the
radius and 2nd row of carpal bones
• S/S:
• Pain and POT over the anatomical snuffbox
• Swelling
• Possible discoloration
• LOM
Scaphoid fracture
Scaphoid fracture
• TX:
• Ice
• Splint
• Physician referral
• Initial immobilization for 6 weeks
• If not recognized as fracture, could have non-
union then surgery is required
 Hamate Fracture
• MXN:
• Fall on hand
• Contact to palm of hand with sports implement
– Swinging baseball bat
– Swinging tennis racquet
– Swinging golf club
Hamate fracture
Hamate fracture
• S/S:
• Wrist pain
• Weakness in wrist motion
• POT over hook of hamate
• Possible tingling, numbness due to compromise
of ulnar nerve
Hook of hamate fracture
• TX:
• Ice
• Splint
• Physician referral
• cast
 Metacarpal (Boxer’s) Fracture
• Most common of all metacarpal fractures
• Associated with martial arts/boxing

• MXN:
• direct axial force caused by punching another
person or object
• Direct impact to hand
Boxer’s fracture
Boxer’s fracture
• S/S:
• POT over the metacarpal involved
• Palpable defect in the shaft of the 5th
metacarpal (or other metacarpals)
• Swelling
• Discloration
• Pain with movement
Boxer’s fracture
Boxer’s fracture
Metacarpal fractures
• TX:
• Ice
• Splint
• Physician referral for x-ray
• Reduction and casting (3-4 weeks)
 Finger Injuries
• Mallet Finger
• Boutonniere Deformity
• Jersey Finger
• Gamekeeper’s Thumb
• Dislocation
• Fracture
• Sprain
• Subungual hematoma
 Mallet Finger
• MXN:
• Blow to tip of finger, jamming it and avulsing
the extensor tendon from its insertion at the
distal phalanx
• Can cause an avulsion fraction as well
Mallet finger
• S/S:
• Pain
• POT over dorsum of distal phalanx
• Deformity
• Unable to extend finger at DIP joint
• Avulsed bone may be palpable
Mallet finger
• TX:
• RICE
• Splint into extension 6-8 weeks
• Physician referral
Mallet finger
Mallet finger-stack splint
Stack splint
 Jersey Finger
• MXN:
• Forced extension/hyperextension of DIP joint
• Grabbing on to a jersey
• Rupture of flexor digitorum profundus tendon
and or avulsion fracture
Jersey finger
• S/S:
• POT over the volar surface of DIP joint
• DIP joint cannot flex
• Finger is in extended position
• Pain
• Swelling
• discoloration
• TX:
• Ice
• Splint
• Physician referral
• Surgery to repair rupture/avulsion
• 12 week recovery
• May have weakness with motion due to poor
gliding motion of tendon
 Boutonniere Deformity
• MXN:
• DIP joint forced into extension and PIP joint
forced into flexion
• Rupture of extensor tendon mechanism at the
PIP joint
Boutonniere deformity
Boutonniere deformity
Boutonniere deformity
• S/S:
• Pain
• POT over dorsum of PIP Joint
• Inability to extend PIP joint
• Swelling
• Discoloration
• Deformity of PIP in flexion and DIP in
extension
• TX:
• Ice
• Splint PIP joint in to extension with flexion of
DIP joint 5-8 weeks
• Physician referral
 Gamekeeper’s Thumb
• MXN:
• Forced abduction and hyperextension of the
proximal phalange of thumb
• Falling on the thumb
• Sprains UCL of 1st MP joint
Gamekeepers thumb
Gamekeepers thumb
• S/S:
• Pain
• POT over UCL of thumb
• Swelling
• Discoloration
• Instability of joint
• Unable to grip
• TX:
• Ice
• Splint
• Physician referral for x-ray to rule out avulsion
fracture
• Possible surgery
 Interphalangeal Dislocation
• Can affect PIP or DIP joint
• Axial force to the tip of the finger
• Blow to tip of finger
• Falling directly on extended finger
– May rupture tendon, avulse bone, pinch volar plate
Dislocation
Dislocation
• S/S:
• Pain
• Deformity
• Swelling
• discoloration
Dislocation
Dislocation
Dislocation
PIP dislocation
• TX:
• Physician referral for reduction & x-ray
• Splint (about 3 weeks)
• Ice
 Finger fracture
• MXN:
• Stepped on (direct force)
• Hit on the tip of finger
• Twisting/torsion
Fracture
Fracture
Finger fracture
• S/S:
• Pain
• Possible deformity
• Swelling
• Discoloration
• Crepitus
• POT
• + compression/percussion test
• TX:
• Ice
• Splint
• Physician referral
 Finger Sprain
• MXN:
• Axial force to the tip of the finger, “jamming” it
Sprain
Sprain
• S/S:
• Pain
• POT over the collateral ligaments
• Swelling
• Discoloration
• Joint instabililty
• TX:
• Ice
• Splint
• Physician referral if necessary for x-rays
 Subungual Hematoma
• MXN: direct blow to the fingernail
• S/S: throbbing pain due to accumulation of
blood under the nail
• TX: ice (water) to numb, release pressure under
nail by drilling/burning a hole it the nail
 Ring injury
• MXN: getting ring/jewelry caught on
something
• S/S: deformity, bleeding, pain, loss of body part
• Tx: find body part, control bleeding, cover
open wound, treat for shock, send to ER
Ring injury