Kin 188 Wrist And Hand Evaluation And Injuries

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Kin 188 Wrist And Hand Evaluation And Injuries

  1. 1. KIN 188 – Prevention and Care of Athletic Injuries Wrist and Hand Evaluation and Injuries
  2. 2. Anatomy
  3. 3. Bony Anatomy <ul><li>Distal radius/ulna </li></ul><ul><ul><li>Styloid processes </li></ul></ul><ul><li>Carpal bones </li></ul><ul><ul><li>8 total (2 rows of 4, proximal/distal) </li></ul></ul><ul><li>Metacarpals </li></ul><ul><ul><li>1-5 (one = thumb, five = little finger) </li></ul></ul><ul><li>Phalanges </li></ul><ul><ul><li>14 total (proximal/middle/distal at each finger and proximal/distal at thumb) </li></ul></ul>
  4. 4. Carpal Bones <ul><li>Proximal row (lateral to medial) </li></ul><ul><ul><li>Scaphoid </li></ul></ul><ul><ul><li>Lunate </li></ul></ul><ul><ul><li>Triquetrum </li></ul></ul><ul><ul><li>Pisiform </li></ul></ul><ul><ul><li>“ Some Lovers Try Positions” </li></ul></ul><ul><li>Distal row (lateral to medial) </li></ul><ul><ul><li>Trapezium </li></ul></ul><ul><ul><li>Trapezoid </li></ul></ul><ul><ul><li>Capitate </li></ul></ul><ul><ul><li>Hamate </li></ul></ul><ul><ul><ul><li>hook </li></ul></ul></ul><ul><ul><li>“ That They Can’t Handle” </li></ul></ul>
  5. 5. Bony Anatomy
  6. 6. Bony Anatomy
  7. 7. Joint Anatomy <ul><li>Distal radioulnar joint </li></ul><ul><ul><li>Forearm pronation/supination </li></ul></ul><ul><li>Radiocarpal joint </li></ul><ul><ul><li>Allows wrist flexion/extension and radial/ulnar deviation ROM </li></ul></ul><ul><li>Intercarpal joints </li></ul><ul><ul><li>Subtle glide movements only </li></ul></ul><ul><li>Carpometacarpal joints </li></ul><ul><ul><li>Limited flexion/extension ROM </li></ul></ul><ul><li>Metacarpophalangeal (MP) joints – “knuckles” </li></ul><ul><ul><li>Flexion/extension and abduction/adduction ROM </li></ul></ul><ul><li>Proximal/distal (PIP/DIP/IP) interphalangeal joints </li></ul><ul><ul><li>Flexion/extension ROM </li></ul></ul>
  8. 8. Joint Anatomy
  9. 9. Muscular Anatomy <ul><li>Extrinsic muscles </li></ul><ul><ul><li>Flexor/pronator group from medial epicondyle of humerus </li></ul></ul><ul><ul><li>Extensor/supinator group from lateral epicondyle of humerus </li></ul></ul><ul><li>Intrinsic muscles </li></ul><ul><ul><li>Thenar eminence – thumb </li></ul></ul><ul><ul><li>Hypothenar eminence – little finger </li></ul></ul>
  10. 10. Carpal Tunnel <ul><li>Floor – proximal row of carpal bones </li></ul><ul><li>Roof – transverse carpal ligament </li></ul><ul><li>Contents (10 structures) </li></ul><ul><ul><li>Median nerve </li></ul></ul><ul><ul><li>Thumb flexor tendon </li></ul></ul><ul><ul><li>8 finger flexor tendons </li></ul></ul>
  11. 11. Evaluation
  12. 12. History <ul><li>Mechanism of injury/etiology </li></ul><ul><ul><li>Fall on outstretched hand </li></ul></ul><ul><ul><ul><li>Scaphoid fracture, wrist dislocation, forearm fracture, wrist sprain </li></ul></ul></ul><ul><ul><li>Striking object with closed fist </li></ul></ul><ul><ul><ul><li>Metacarpal fracture </li></ul></ul></ul><ul><ul><li>Forces applied to fingers/thumb </li></ul></ul><ul><ul><ul><li>Bennet’s fracture, finger sprain/dislocation, mallet finger, gamekeeper’s thumb </li></ul></ul></ul><ul><ul><li>Direct trauma </li></ul></ul><ul><ul><ul><li>Contusions, fractures </li></ul></ul></ul><ul><ul><li>Overuse/repetitive motion or activity </li></ul></ul><ul><ul><ul><li>Tendonitis, carpal tunnel syndrome </li></ul></ul></ul>
  13. 13. History <ul><li>Unusual sounds/sensations at time of injury </li></ul><ul><li>History of previous injury/surgery </li></ul><ul><li>Change in activity </li></ul><ul><ul><li>Intensity, duration, frequency, biomechanics/technique, equipment </li></ul></ul><ul><li>Acute/gradual onset of symptoms </li></ul><ul><ul><li>Macrotraumatic vs. microtruamatic </li></ul></ul><ul><li>Characterize pain </li></ul><ul><ul><li>Location (point with 1 finger) </li></ul></ul><ul><ul><li>Dull, sharp, burning, throbbing, etc. </li></ul></ul><ul><ul><li>Rate on scale (1-10) </li></ul></ul><ul><ul><li>What increases or decreases? </li></ul></ul><ul><li>Treatment, medication, evaluation to date </li></ul>
  14. 14. Inspection/Observation <ul><li>ALWAYS compare bilaterally </li></ul><ul><li>Obvious deformity </li></ul><ul><ul><li>Swan neck deformity – flexor tendon from middle phalanx </li></ul></ul><ul><ul><li>Boutonniere deformity – extensor tendon from middle phalanx </li></ul></ul><ul><ul><li>Mallet finger – extensor tendon from distal phalanx </li></ul></ul><ul><li>Bleeding </li></ul><ul><li>Discoloration/ecchymosis </li></ul><ul><li>Swelling </li></ul><ul><ul><li>Immediate vs. gradual, amount </li></ul></ul><ul><li>Scars </li></ul>
  15. 15. Palpation <ul><li>Radial styloid process </li></ul><ul><li>Ulnar styloid process </li></ul><ul><li>Carpal bones </li></ul><ul><li>“ Anatomic snuffbox” </li></ul><ul><li>Metacarpals </li></ul><ul><ul><li>Head/shaft/base </li></ul></ul><ul><li>MP joints </li></ul><ul><li>Phalanges </li></ul><ul><ul><li>Proximal/middle/distal </li></ul></ul><ul><li>PIP joints </li></ul><ul><li>DIP joints </li></ul><ul><li>Flexor carpi ulnaris </li></ul><ul><li>Flexor carpi radialis </li></ul><ul><li>Palmaris longus tendon </li></ul><ul><li>Thenar eminence </li></ul><ul><li>Hypothenar eminence </li></ul>
  16. 16. Special Tests <ul><li>ROM </li></ul><ul><ul><li>Active – patient/athlete moves joint </li></ul></ul><ul><ul><li>Passive – clinician moves joint, evaluates end feel </li></ul></ul><ul><ul><li>Resistive – proximal stabilization and distal application of resistance (“break” test vs. resistance through ROM) </li></ul></ul><ul><li>Neurovascular </li></ul><ul><li>Special tests </li></ul>
  17. 17. Range of Motion <ul><li>Wrist flexion/extension </li></ul><ul><ul><li>Flexion – 85-90 degrees, extension – 75-85 degrees </li></ul></ul><ul><li>Wrist radial/ulnar deviation </li></ul><ul><ul><li>Radial – 20 degrees, ulnar – 35 degrees </li></ul></ul><ul><li>Finger flexion/extension </li></ul><ul><ul><li>Flexion – MP 85-105 degrees, PIP 110-120 degrees, DIP 80-90 degrees </li></ul></ul><ul><ul><li>Extension – MP 20-30 degrees, PIP/DIP 0 degrees </li></ul></ul><ul><li>Finger abduction/adduction </li></ul><ul><ul><li>Midline is middle finger, motion at MP joints </li></ul></ul><ul><ul><li>20-25 degrees each direction </li></ul></ul>
  18. 18. Range of Motion
  19. 19. Range of Motion <ul><li>Thumb flexion/extension </li></ul><ul><ul><li>Flexion – 60-70 degrees, extension – 0 degrees </li></ul></ul><ul><li>Thumb abduction/adduction </li></ul><ul><ul><li>Abduction – 70-80 degrees, adduction – 0 degrees </li></ul></ul><ul><li>Thumb opposition </li></ul><ul><ul><li>Touch thumb to little finger </li></ul></ul>
  20. 20. Neurovascular <ul><li>Neurological evalation </li></ul><ul><ul><li>Nerve root level and peripheral nerve sensory and motor distributions from cervical spine/brachial plexus </li></ul></ul><ul><li>Vascular evaluation </li></ul><ul><ul><li>Skin temperature/color </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Radial pulse </li></ul></ul>
  21. 21. Special Tests <ul><li>Varus/valgus stress tests to MP/IP/PIP/DIP joints – medial/lateral collateral ligament injuries </li></ul><ul><li>Metacarpal longitudinal stress – fractures (“false joint”) </li></ul><ul><li>Phalen’s test – carpal tunnel syndrome </li></ul><ul><li>Tinel sign – carpal tunnel syndrome </li></ul><ul><li>Intercarpal glides – wrist sprain </li></ul>
  22. 22. Injuries
  23. 23. Wrist Injuries <ul><li>Wrist sprains </li></ul><ul><ul><li>Hyperextension or hyperflexion mechnisms </li></ul></ul><ul><li>Carpal tunnel syndrome </li></ul><ul><ul><li>Compression of median nerve in tunnel </li></ul></ul><ul><ul><ul><li>Evaluate with Phalen’s test/tinel sign </li></ul></ul></ul><ul><li>Distal radius/ulna fracture </li></ul><ul><ul><li>Usually from fall on outstretched arm </li></ul></ul><ul><ul><li>Colles fracture – dorsal displacement of fracture fragments </li></ul></ul><ul><li>Scaphoid fracture </li></ul><ul><ul><li>Most commonly fractured carpal bone, usually from hyperextension mechanism </li></ul></ul><ul><ul><li>Poor blood supply often results in non-union and subsequent surgery </li></ul></ul>
  24. 24. Wrist Injuries
  25. 25. Hand and Finger Injuries <ul><li>Metacarpal fracture </li></ul><ul><ul><li>4 th and 5 th metacarpals most commonly injured (Boxer’s fracture) </li></ul></ul><ul><li>Deformities/tendon injuries </li></ul><ul><ul><li>“ Swan neck” deformity (flexor tendon from middle phalanx), “boutonniere” deformity (extensor tendon from middle phalanx) </li></ul></ul><ul><li>Finger fractures </li></ul><ul><ul><li>Distal phalanx most commonly fractured, avulsion fractures from flexor (mallet finger) and extensor (jersey finger) tendon attachments </li></ul></ul><ul><li>Dislocations </li></ul><ul><ul><li>Obvious deformity present, refer for x-ray prior to reduction </li></ul></ul>
  26. 26. Metacarpal Fractures
  27. 27. Deformities
  28. 28. Finger Fractures
  29. 29. Finger Dislocations
  30. 30. Thumb Injuries <ul><li>Sprains </li></ul><ul><ul><li>Medial collateral ligament of thumb (1 st MP joint) is most common area </li></ul></ul><ul><ul><li>Called “gamekeeper’s thumb” – hyperextension and hyperabduction </li></ul></ul><ul><li>Fractures </li></ul><ul><ul><li>If fracture extends into joint surface (carpometacarpal joint), referred to as Bennet’s fracture </li></ul></ul>
  31. 31. Thumb Injuries

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