Comprehensive Wrist Joint Anatomy, MDIRT Nchanji Nkeh Keneth

COMPREHENSIVE WRIST
JOINT ANATOMY
Nchanji Nkeh Keneth
kennchanji@yahoo.com/ excellence660@gmail.com
662695118/671459765
B.TECH/HPD MDIRT
CHM Virtued Academy India(Ongoing)
LEADER
Radiology Department
St. Louis University, Mile 3 Nkwen Bamenda
Level 200 MDI, 2016/2017 Academic Year
Wednesday May 31, 2017
NCHANJI NKEH KENETH, B.TECH/HPD- MDIRT, ST LOUIS UNIHEBS,
BAMENDA, 2016/2017 ACADEMIC YEAR
1

Wrist Anatomy
• Bones
• Quiz - What bones
comprise the wrist?
• Joints
• Quiz - What joints
comprise the wrist?
2

Carpal Bones and Articulations
• Proximal Row
• Where can you palpate
these?
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
• Radiocarpal joint
• Ulnocarpal joint
• Intercarpal joints
• Distal Row
• Where can you palpate
these?
• Trapezium
• Trapezoid
• Capitate
• Hamate
• Carpometacarpal joints
(related to hand)
3

Articulations and ROM
• Distal Radioulnar joint
• Supination and Pronation – 80-90o
• Ulna moves posteriorly and laterally with pronation
• Radiocarpal joint (and Ulnocarpal joint)
• Flexion (80-90o) and Extension (75-85o)
• Radial (20o) and Ulnar (35o) Deviation
• Gliding
NCHANJI NKEH KENETH, B.TECH/HPD-
MDIRT, ST LOUIS UNIHEBS, BAMENDA,
2016/2017 ACADEMIC YEAR
4

Soft tissue of Wrist
• Ligaments
• Covered by a fibrous
capsule
• Radial and ulnar
collateral
• limit ulnar and radial
deviation; collectively
limits flexion and
extension
• Intercarpal and
Carpometacarpal
5

• Ligaments
• Dorsal – limits flexion
• Dorsal Radiocarpal
• Palmar - limit extension
• Transverse carpal
ligament
• Palmar radiocarpal
• Multiple divisions
• Palmar ulnocarpal
ligament
• Multiple divisions
6

• Cartilage
• Triangular Fibrocartilage
Complex – TFCC
• “Meniscus” between ulna
and triquetrum
• Ulnar collateral ligament
and palmar ulnocarpal
ligaments have
attachments
• Compressed with
Pronation and Extension
• Compressed with Ulnar
deviation
7

Wednesday May 31, 2017 NCHANJI NKEH KENETH, B.TECH/HPD- MDIRT, ST LOUIS UNIHEBS,
8

Muscle Tissue of Wrist
• Extensor muscles
• Extensor Retinaculum
• What’s its function?
• Muscles innervated by
radial nerve
• There are 8
• Name them…
• Flexor Muscles
• Flexor retinaculum (aka
transverse carpal
ligament)
• Two compartments
• Superficial – 4
• Deep – 3
• Name them…
• Innervated by median
and ulnar nerve
9

FLEXORSEXTENSORS
10

Wrist and Hand Anatomy
• Nerves/Vessels
• Radial & ulnar artery and veins
• Radial, ulnar, & median nerves
• Carpal Tunnel -
• Flexor Tendons - 9
• Median Nerve
11

NCHANJI NKEH KENETH, B.TECH/HPD- MDIRT, ST LOUIS
12

Wrist Injuries
• Strains
• Onset usually acute – FOOSH or Overexertion
• S/S: Active ROM limited
• Wrist Ganglion
• Herniation of the joint capsule or synovial sheath of a
tendon.
13
Tx: Bible Therapy

Wrist Injuries
UNIHEBS, BAMENDA, 2016/2017 ACADEMIC YEAR
14
• deQuervain’s Disease - thumb/wrist
• stenosing tenosynovitis of the extensor pollicis
brevis and abductor pollicis longus.
• S/S: crepitation, tenderness, strength loss.
• Special Test: = Finkelstein’s test
• Tx: RICE, NSAIDs

Wrist Injuries
• Sprains
• Onset is usually acute – FOOSH or overexertion
• Often diagnosed when other injuries are ruled out
• Both active and passive ROM are effected
• S/S: Laxity, pain, swelling, limited ROM
• Pain is usually with overstretching
• Special Tests: Varus/Valgus, Carpal Glide
• PRICE, Rehabilitation, Taping for prevention
15

Wrist Injuries
• Triangular Fibrocartilage Injuries - TFCC
• Onset is usually acute
• MOI: Forced hyperextension of wrist with loading
• S/S: Pain with pronation/extension and/or ulnar
deviation; Pain with loading; Point tenderness; Swelling;
Altered joint mechanics
• Special Test: Valgus test elicits pain but no laxity and
Varus test compresses and causes pain
• Immobilization and Surgery are often necessary
16

Neural Injuries
• Carpal Tunnel Syndrome
• Compression of median nerve
• Fibrosis of the synovium of flexor tendons secondary to tenosynovitis
• MOI: Insidious onset with repetitive wrist movement (and finger
movement); Acute onset with trauma; Progressive degeneration
• S/S: numbness palmar thumb, index,
middle fingers, dull ache, weak finger
flexion (grip). May worsen with sleep.
• Poor posture may predispose.
• Special Tests: Tinel’s sign
and Phalen’s
• Tx: Conservative (PRICE, NSAIDs) and Surgical
Wednesday May 31, 2017 17

Neural Injuries
• Biker’s Palsy
• Ulnar nerve compression
• Ulnar nerve passes through tunnel of Guyon between pisiform and
hamate.
• MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar
deviation
• Tx: Padding (Gloves), Ice, NSAIDs
• Drop Wrist Syndrome
• Radial nerve compression at elbow
• Inability to extend wrist and fingers
18

Wrist Injuries
• Wrist Fractures
• Distal Radius/Ulna and Forearm Fractures
• Onset is acute
• MOI: Hyperextension or hyperflexion combined with
rotatory motion – FOOSH
• S/S: Deformity felt and observed; Crepitus
• Evaluated Neurovascular status
• Tx: Splint, Ice, Referral
19

Wrist Injuries
• Wrist Fractures
• Distal Radius/Ulna
• Colles’ Fracture
• MOI: hyperextension-fall on outstretched
• S/S: “silver fork deformity” - radius & ulna posteriorly
• Smith’s Fracture (Reverse Colles)
• MOI: hyperflexed
• S/S: “garden spade deformity” - radius
& ulna anteriorly

Wrist Injuries
• Wrist Fractures
• Scaphoid - most common carpal
• MOI: fall on outstretched hand
• S/S: wrist aches, pain in anatomical
snuff box,
painful handshake or with
overpressure
• Tx: Splint, Referral, Ice
• Plain X-rays may not be enough
• Immobilization (long and/or short) – 12
weeks
• Risk: aseptic necrosis and non-union
fractures
• Preiser’s Disease
• Surgery may be necessary

Wrist Injuries
• Wrist Dislocations
• Radius or Ulna
• Lunate is very common
• MOI: force hyperextension
• Dorsal displacement = perilunate dislocation
• Palmar displacement (total rupture) = lunate
dislocation
• S/S: Deformity, 3rd Knuckle is lower (Murphy’s sign),
Paresthesia of middle finger, weak finger flexion
• Risk: Untreated or repeated trauma
• Kienbock’s Disease
• Decreased grip, pain with ulnar deviation, weak
extension, pain with passive 3rd finger extension
• Immobilization – 6-8 weeks; Surgery may be
necessary

Wrist Injury Prevention
• Good technique!
• But…these help

24

Lumbricals
1
234
Palmar
Interossei
Dorsal
Interossei
Flexor
tendon
arrangement

Extensor Hood, Long extensor
tendon, and lateral bands
Finger flexor
tendons
Unique finger
Look at pulley
system
26

Observation
• Relaxed position of hand
• Fingers slightly flexed
• Relative shortness of finger flexors
• Skin and Nail health
• Discoloration, texture, hair patterns
• Finger alignment
• Tips of fingers should align with finger flexion
• Hand abnormalities
• Finger and metacarpal positioning
• Muscle atrophy
• Range of motion

Range of Motion
• Carpometacarpal
• Flexion (70-80o)/Extension
• Abduction (70-80o)/Adduction
• Opposition
• Metacarpophalangeal
• Flexion (85-105o)/Extension (20-35o)
• Abduction/Adduction (20-25o)
• Interphangeal joints
• Thumb flexion (80-90o)
• PIP flexion (110-120o)
• DIP flexion (80-90o)
28

Palpation
• Metacarpals and joints
• Collateral ligaments of MCPs
• Phalanges and joints
• Collateral ligaments of PIPs and DIPs
• Thenar compartment
• muscles
• Thenar webspace
• muscles
• Central compartment
• Palmar fascia and muscles
• Hypothenar compartment
• muscles

Pathology
• Tendon pathology
• Trigger Finger/Thumb
• Mallet Finger
• Boutonniere Deformity
• Jersey Finger
• Dupuytren’s Contracture
• Swan Neck Deformity
• Joint pathology
• Sprains
• Bony pathology
• Fractures
• Dislocations
Dupuytren’s Contracture
Swan Neck Deformity

Tendon pathology
• Trigger Finger or Thumb
• Etiology
• Repeated motion of fingers may cause irritation, producing tenosynovitis
• Inflammation of tendon sheath (flexor tendons of wrist, fingers and
thumb, abductor pollicis)
• Thickening forming a nodule that does not slide easily
• Signs and Symptoms
• Resistance to re-extension, produces snapping that is palpable, audible
and painful
• Palpation produces pain and lump can be felt w/in tendon sheath
• Management
• Immobilization, rest, cryotherapy and NSAID’s
• Ultrasound and ice are also beneficial
• Injection
31

Tendon pathology
• Mallet Finger (baseball or basketball finger)
• Etiology
• Caused by a blow that contacts tip of finger avulsing
extensor tendon from insertion
• Avulses extensor digitorum at distal phalanx
• Unable to extend distal end of finger (carrying at 30
degree angle)
• Point tenderness at sight of injury
• X-ray shows avulsed bone on dorsal proximal distal
phalanx
• Management
• RICE and splinting in hyperextension for 6-8 weeks
32

Tendon pathology
• Boutonniere Deformity
• Etiology
• Rupture of extensor tendon dorsal to the middle
phalanx – bone passes through central slip
• Forces DIP joint into extension and PIP into flexion
• Severe pain, obvious deformity and inability to extend DIP
joint
• Swelling, point tenderness
• Management
• Cold application, followed by splinting in PIP extension
and DIP flexion
• Splinting must be continued for 5-8 weeks

Tendon pathology
• Jersey Finger
• Etiology
• Rupture of flexor digitorum profundus tendon from
insertion on distal phalanx
• Often occurs w/ ring finger when athlete tries to grab a
jersey
• DIP can not be flexed, finger remains extended
• Pain and point tenderness over distal phalanx
• Management
• Must be surgically repaired
• Rehab requires 12 weeks and there is often poor gliding
of tendon, w/ possibility of re-rupture

Tendon pathology
• Dupuytren’s Contracture
• Etiology
• Nodules develop in palmer aponeurosis, limiting finger
extension - ultimately causing flexion deformity
• Often develops in 4th or 5th finger (flexion deformity)
• Management
• Tissue nodules must be removed as they can ultimately
interfere w/ normal hand function
Dupuytren’s Contracture

Tendon pathology
• Swan Neck Deformity Etiology
• Distal tear of volar plate or finger trauma may cause
Swan Neck deformity
• Flexed MCP, extended PIP, and flexed DIP
• Pain, swelling w/ varying degrees of hyperextension
• Tenderness over volar plate of PIP
• Indication of volar plate tear = passive hyperextension
• Management
• RICE and analgesics
• Splint in PIP 20-30 degrees of flexion/DIP extension for 3
weeks; followed by buddy taping

Joint pathology
• Sprains Phalanges
• Etiology
• Phalanges are prone to sprains caused by direct blows or
twisting
• Recognition primarily occurs through history
• Sprain symptoms - pain, severe swelling and hemorrhaging
37

Joint pathology
• Gamekeeper’s Thumb
• Etiology
• Sprain of UCL of MCP joint of the thumb
• Mechanism is forceful abduction of proximal phalanx occasionally
combined w/ hyperextension
• Pain over UCL in addition to weak and painful pinch
• Management
• Immediate follow-up must occur
• If instability exists, athlete should be referred to orthopedist
• If stable, X-ray should be performed to rule out fracture
• Thumb splint should be applied for protection for 3 weeks or until pain
free
• Splint should extend from wrist to end of thumb in neutral position
• Thumb spica should be used following splinting for support

Joint pathology
• Sprains of Interphalangeal Joints of Fingers
• Etiology
• Can include collateral ligament, volar plate, extensor slip tears
• Occurs w/ axial loading or valgus/varus stresses
• Pain, swelling, point tenderness, instability
• Valgus and varus tests may be possible
• Management
• RICE, X-ray examination and possible splinting
• Splint at 30-40 degrees of flexion for 10 days
• If sprain is to the DIP, splinting for a few days in full extension may assist
healing process
• Taping can be used for support

Joint pathology
• PIP Dorsal Dislocation
• Etiology
• Hyperextension that disrupts
volar plate at middle phalanx
• Pain and swelling over PIP
• Obvious deformity, disability
and possible avulsion
• Management
• Treated w/ RICE, splinting and
analgesics followed by
reduction
• After reduction, finger is
splinted at 20-30 degrees of
flexion for 3 weeks --
followed by buddy taping
• PIP Palmar Dislocation
• Etiology
• Caused by twist while it is
semiflexed
• Pain and swelling over PIP;
point tenderness over dorsal
side
• Finger displays angular or
rotational deformity
• Management
• Treat w/ RICE, splinting and
analgesics followed by
reduction
• Splint in full extension for 4-5
weeks after which it is
protected for 6-8 weeks
during activity

Open Dislocation

Joint pathology
• MCP Dislocation
• Etiology
• Caused by twisting or shearing force
• Pain, swelling and stiffness at MCP joint
• Proximal phalanx is angulated at 60-90 degrees
• Management
• RICE, following reduction splinting in slight flexion (3 weeks)
• Buddy taping following splinting
• Therapy

Bony Pathology
• Metacarpal Fracture
• Etiology
• Direct axial force or compressive force
• Fractures of the 5th metacarpal = Boxer’s Fracture
• Pain and swelling; possible angular or rotational
deformity
• Management
• RICE, analgesics are given followed by X-ray examinations
• Deformity is reduced, followed by splinting - 4 weeks of
splinting after which therapy starts
• Unstable fracture may need to be surgically pinned

45

Bony pathology
• Bennett’s Fracture
• Etiology
• Occurs at carpometacarpal joint of the thumb as a result
of an axial and abduction force to the thumb
• CMC may appeared to be deformed - X-ray will indicate
fracture
• Athlete will complain of pain and swelling over the base
of the thumb
• Management
• Structurally unstable and must be referred to an
orthopedic surgeon
• Surgery and immobilization – season ending

Bony pathology
• Distal Phalangeal Fracture
• Etiology
• Crushing force
• Complaint of pain and swelling of distal phalanx
• Subungual hematoma is often seen in this condition
• Management
• RICE and analgesics are given
• Protective splint is applied as a means for pain relief
• Subungual hematoma is drained

Bony pathology
• Middle Phalangeal Fracture
• Etiology
• Occurs from direct trauma or twist
• Pain and swelling w/ tenderness over middle phalanx
• Possible deformity; X-ray will show bone displacement
• Management
• RICE and analgesics
• No deformity - buddy tape w/ splint for activity
• Deformity - immobilization for 3-4 weeks and a
protective splint for an additional 9-10 weeks during
activity

Bony pathology
• Proximal Phalangeal Fracture
• Etiology
• May be spiral or angular
• Complaint of pain, swelling, deformity
• Inspection reveals varying degrees of deformity
• Management
• RICE and analgesics are given as needed
• Fracture stability is maintained by immobilization of the wrist
in slight extension, MCP in 70 degrees of flexion and buddy
taping

Lacerations
• Superficial location of tendons and nerves
predisposes athletes to damage form shallow
lacerations.
• Any laceration to the fascia below the cutaneous
layer should receive a referral
• R/O trauma to tendons and nerves
• Prevent infection
• Suture to ensure minimal scarring

Finger Nail Pathology
• Subungual Hematoma
• MOI: finger caught between two surfaces
• Presents with bleeding under nail bed
• Draining – Drill or Cauterize
• Paronychia
• Infection around fingernail beds
• S/S: Redness, pain, drainage
• Warm soaks (Betadine), Antibiotic, Referral
• Changes in normal appearance - indicative of a number of different
diseases
• Scaling or ridging = psoriasis
• Ridging and poor development = hyperthyroidism
• Clubbing and cyanosis = congenital heart disorders or chronic respiratory
disease
• Spooning or depression = chronic alcoholism or vitamin deficiency

Prevention of Hand Injuries
• Protection
• Gloves, Grips, Braces
• Proper Technique
• Sport and Ergonomics
• Physical Conditioning
• Reps and Sets for muscles of Hand
• Theraputty, Wrist curls/extensions, Fist pumps
52

Problem Solving
Putting it together with
Case studies
53

54

55
History
• What is the cause of pain?
• Mechanism of injury?
• Previous history?
• Location, duration and intensity of pain?
• Creptitus, numbness, distortion in temperature?
• Sounds or sensations?
• Technique changes?
• Weakness or fatigue?
• What provides relief?

Observation
• Functional Evaluation
• Range of motion in all movements of wrist should be
assessed
• Active, resistive and passive motions should be assessed and
compared bilaterally
• Wrist - flexion, extension, radial and ulnar deviation
• Wrist “attitude”
• How do the carpals and metacarpals align with the distal radius
and ulna?
• Is there symmetry?
• How are those tendons looking?
• Is there a palmaris longus? - 10% of population it is absent
• Become a “palm reader”?
56

Palpation
• Bony and Soft Tissue Palpation
• Are they where they should be?
• Do they feel like they should feel?
• Circulatory and Neurological Evaluation
• Hands should be felt for temperature
• Cold hands indicate decreased circulation
• Take pulse – radial artery
• Pinching fingernails can also help detect circulatory problems
(capillary refill)
• Hand’s neurological functioning should also be tested
(sensation and motor functioning)

Is it nerve?
58
What test is this?
What other test is
common for nerve
injury?
How else can you
detect a neural injury?

Is it the ligaments or joints?
59
Which tests are these?
What are some distinguishing
characteristics of a ligament or joint
injury?

Is it muscle or tendon?
60
What test assesses
these structures?
What are some distinguishing
characteristics of a muscle
injury?
How do you assess the function
of a muscle?

Is it bone?
61
What is are distinguishing signs of a potential fractures?

Case study #1
• A 28 year old woman complains of pain in the right
hand over the last 3 months. She reports numerous
FOOSH incidents and currently works as a cashier at
a grocery store. The pain awakens her at night and
is relieved only by vigorous rubbing of her hand and
motion of the fingers and wrist. There is some
tingling in the index and middle fingers. What is
your assessment plan?

Case study #2
• A 18 year old boy reports with wrist pain and
swelling on the dorsum of his wrist and hand. He
notes the pain is more near the base of the thumb.
He is an active weightlifter. He says he tripped and
experienced a FOOSH while playing recreational
football. He states that after the injury the wrist
hurt, he rested 2 days and iced, the pain decreased,
but then with weightlifting the swelling has
developed the last 5 days. Now it is very swollen
and painful. What is your assessment plan?

Case study #3
• A 22 year old golfer comes to you with pain along
his right medial wrist. He reports that while on
spring break he went skiing and had a FOOSH. The
wrist was achy but didn’t bother after a few hours
especially since he put snow on it for 20 minutes.
Now that he has returned to school and golf
practice he is having trouble controlling his drives
and long iron shots because of pain in his wrist at
the top of the swing. What is your assessment
plan?

REFERENCES
1. CINDY TROWBRIDGE, ANATOMY OF WRIST JOIN
2. ANATOMY AND PHYSIOLOGY IN HEALTH AND
ILLNESS, WAUGH GRANT
65

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