What is the Triangular Fibrocartilage?
Disc overlying distal ulnar head
Disc binds end of distal radius & ulna together
Makes up a portion of TFCC complex which acts as a stabilizer of the distal radio-ulnar joint
Name all the Carpal Bones
Scaphoid Trapezium
Lunate Trapezoid
Triquetrum Capitate
Pisiform Hamate
What are the Joint of the Hand?
Carpo-metacarpal (CM) Inter-metacarpal Metacarpo-phalangeal (MCP) Inter-phalangeal (IP) - digits numbered 1-5 w/first being thumb (Knuckles = MP joints)
Describe an Inter-phalangeal joint
Proximal (PIP) & distal (DIP) & IP are hinge joints
Reinforced by articulating capsule joined by volar & collateral ligaments
What is the Wrist Retinacula?
Very thick fascial tissue
Protective pathways through which tendons, nerves & blood vessels pass
What is the job of the Flexor Retinaculum?
Protects extrinsic flexor tendons & median nerve
What is the role of the Extensor Retinaculum?
Pasageway for extrinsic muscles on the dorsal side of the wrist
What are the 3 Nerves of the hand?
Median }
Ulnar } Brachial Plexus
Radial }
What does the Median Nerve Supply?
Supplies majority of flexor & intrinsic muscle on radial side of Palm
Cutaneous sensation lateral 2/3 of Palm
How does medial nerve entrapment happen?
Strenuous/repetitive elbow motion
Pronator Teres/FDS tightness
What does the Ulnar Nerve innervate?
Innervates FCU & ulnar FDP
Cutaneous sensation of 5th & 1/2 4th on dorsal & palmar sides
What does the Radial Nerve innervate?
Superficial- skin on dorsum of hand
Deep- Innervates extensor muscles of forearm
Wrist Sprain MOI
Axial loading (FOOSH) Most common btwn scaphoid & lunate
Wrist Sprain S&Sx
TOP dorsum of hand of radio-carpal joint
Wrist Sprain Management
PIER
R/O #
Pain in ‘snuff’ box, scaphoid # indicator
Tape to prevent movement
What are the primary movements of the thumb?
Flexion Extension Opposition Abduction Circumduction
Game Keepers Thumb MOI
Tearing of UCL @ MP joint when MP near full ext & thumb forcefully abducted away from hand
Game Keepers Thumb S&Sx
Palmar aspect of thumb is swollen w/visible bruising & ⬆ ️pain or weakness w/pinching/opposition
Game Keepers Thumb Management
PIER
R/O #
Tape for instability
Valgus stress for MCP of thumb
Interphalangeal Collateral Ligament Sprain MOI
Excessive valgus/varus force/hyperextension
Interphalangeal Collateral Ligament Sprain S&Sx
Obvious deformity may or may not be present unless there is a # or a total rupture
Rapid swelling makes assessment difficult
Need to R/O dislocation or #
Interphalangeal Collateral Ligament Sprain Management
PIER Valgus/varus stress test Budding taping (2&3/4&5)
Dislocation of MC & phalanges MOI (MCP)
Rare injury
Hyperextension/shearing forces cause anterior capsule to tear allowing proximal phalanx to move backward
Dislocation of MC & phalanges MOI (PIP)
Hyperxtension & axial compression (ball hits tip of finger)
Dislocation of MC & phalanges MOI (DIP)
Usually occurs dorsally & may be associated w/an open wound
Individual often reduced their own dislocations
Dislocation of MC & phalanges S&Sx
Painful, swollen finger
Pain present at joint line
B/c of opportunity to entrap volar plates, no reduction it may lead to permanent disability
Dislocation of MC & phalanges Management
Immobilize in a wrist/finger splint in position found
When RTP, protect w/buddy taping
What is a STRAIN?
Occurs as a result of excessive overload against resistance/stretching of the tendon beyond its normal range
Jersey Finger MOI
Individual grips opponents jersey & opponent simultaneously twists to get away
Jerking motion forces individual finger to rapid to extend; rupturing FDP
Ring finger is most commonly involved
Jersey Finger S&Sx
Pain & swelling at DIP & report a popping sensation
Flex tendon disruption is indicated w/1finger lying in complete extension while others are in slight flexion
In avulsed tendon can be palpated at proximal aspect of involved finger
Jersey Finger Management
Standard acute care
Refer to physician
Tendon has retracted into Palm, surgical reattachment must happen 7-10 days post injury
Typical RTP is 6-12 weeks post op.
Mallet Finger MOI
Object hits finger while extensor tendon is taut
Avulsed lateral bands of extensor mechanism the distal attachment
Mallet Finger S&Sx
Tendon usually does not retract
Pain, swelling, lack of extensor at DIP
If left untreated, complete tears lead to permanent DIP extensor lag
Mallet Finger Management
Standard acute care
Refer to MD
Split DIP in complete extension for 6-8 weeks
Boutonnière Deformity MOI
Blunt trauma to dorsal PIP/rapid powerful flex of the joint against resistance
Central slip of extensor tendon ruptures at mid phalanx, leaving no active extensor mech. Intact over PIP
Boutonnière Deformity S&Sx
Not usually present immediately , develops over 2-3 weeks as the later slip moves in a palmar direction to cause hyperextension at MP flex at PIP & hyperextension of DIP
Boutonnière Deformity Management
Splint PIP in complete extension & refer
What is a tendonopathy?
Individual involved in strenuous/repetitive tasks often inflame tendon & tendon sheaths in wrist & hand
Tendon injury can be acute or chronic
Overuse can lead to derangement of both mechanical & physiological components of a normal tendon
Trigger Finger MOI
Snapping flexor tendon, multiple/severe traumas to palmar aspect of hand/indiv who perform repeated mov’t/clenching of fingers
Repeated trauma & inflam’n lead to thickening of tendon sheath
Nodule can form & grow within thickened synovium
Trigger Finger S&Sx
Locking action
Painful popping when flexed PIP jt. is passively returned to extension
Palpable crepitus may indicate systemic disease
Trigger Finger Management
Resisting splinting when necessary
Find cause, treat cause
DeQuervain Tenosynovitus MOI
Indiv who uses forceful grasp, combined w/repetitive use of thumb k ulnar deviation
Motion places high demand on AbPL & EPB
These 2 tendons share a single sheath
DeQuervain Tenosynovitus S&Sx
Pain over radial styloid & ⬆️ w/wrist & thumb motion
TOP over tendons
Thumb motion & snapping
(+ve) Finklesteins test
DeQuervain Tenosynovitus Management
Find cause, treat cause
Thumb spica
Surgery may be warranted
Dupuytren Contracture MOI
Idiopathic
Nodules appear in palmar aponeurosis
Limited finger extension & eventually causes a flex deformity
Dupuytren Contracture S&Sx
Fixed flexed deformity occurring on ring or 5th finger
Finger cannot be extended
Dupuytren Contracture Management
Surgical removal of nodule
Ganglion Cyst MOI
Benign tumor masses typically seen on dorsal aspect of wrist
Ganglion Cyst S&Sx
Cyst contains jelly like colourless fluid & is freely mobile & palpable
Occurs spontaneously
Discomfort from pressure may occur as ganglion ⬆️ in size
Ganglion Cyst Management
Rx is symptomatic
Surgical removal
Fingertip Injuries (subungual hematoma) MOI
Direct trauma to nail bed can result in blood under nail
Fingertip Injuries (subungual hematoma) S&Sx
⬆️ pressure under nail bed which can lead to throbbing pain
Fingertip Injuries (subungual hematoma) Management
R/O #
Soak in ice water 10-15 mins to numb area
If throbbing persists, draining may help
MD for drainage
Paronychia MOI
Infection along nail fold
Seen w/hangnail
Paronychia S&Sx
Nail fold becomes red, swollen & painful
Can produce purulent drainage
Paronychia Management
Warm water soaks
Severe cases, MD may recommend antibodies
What is Carpal Tunnel Syndrome
- Formed by volar capsule w/roof formed by transverse retinacular lig’t
- accommodates median nerve, finger flexors
- irritation of synovial sheath can produce swelling/edema that puts pressure on median nerve
- repetitive movements/positions
Carpal Tunnel Syndrome S&Sx
Pain awakens individual at night, relieved w/’shaking’ out hands
Pain, numbness, burning sensation along median nerve distribution
Pinch & grip strength limited
(+ve) phalen, carpal tunnel compression & tinnel sign
Diminished sensitivity to pain & weak thumb abduction
Carpal Tunnel Syndrome Management
Refer to MD
Find cause, treat cause
Night splint/brace
Ulnar Tunnel Syndrome MOI
Compression of ulnar nerve as it passes around hook of hamate
Frequent w/Cyclist
Ulnar Tunnel Syndrome S&Sx
Motor sensory/mixed Sx
Numbness along ulnar nerve distribution
(+ve) pinch grip for thumb & index finger
(+ve) Tinel sign over pisiform
Ulnar Tunnel Syndrome Management
NSAIDs & avoidance of activity
Cyclists Palsy MOI
Linked to ulnar nerve entrapment
Biker leans on handle bars for extended period of time
Cyclists Palsy S&Sx
Swelling in hypothenar eminence
Sx mimic ulnar nerve entrapment but disappears after ride
Cyclists Palsy Management
Properly padded handle bars
Wearing padded gloves
Varying hand positions
Scaphoid # MOI
70% of carpal #
FOOSH
Scaphoid # S&Sx
Pain in ‘snuff box’
Pain ⬆️ w/extension & radial deviation
Scaphoid # Management
Standard acute care
Immobilize
Poor blood supply = ⬆️ healing time
Boxer # MOI
of distal metaphysis or neck of 4th & 5th MC
Boxer # S&Sx
Sudden pain, inability to grip
TOP over # site
Boxer # Management
Standard acute care
Refer to MD