Wrist/Hand Flashcards
of metacarpals and phalanges
5 metacarpals
14 phalanges (each finger with 3, thumb with 2)
-base of each met is concave and head is convex
Thumb joint
-metacarpal has saddle shaped articular surface to accommodate trapezium
8 carpal bones
Distal: trapezium, trapezoid, capitate, hamate
Proximal row: scaphoid, lunate, triquetrum
Scaphoid
- bridges the mid-carpal joint and is susceptible to fracture
- receive it’s blood supply from a distal to proximal direction making proximal portions susceptible to avascular necrosis
- long with a narrowed waist - “boat shaped” appearance
- PA view
- lateral radiograph shows normal resting alignment is flexed position compared to lunate
Lunate
- PA view - quadrangular appearance
- lateral view - more crescent shaped
- Kienbock’s disease- avascular necrosis of the lunate
Triquetrum
- large triangular shaped bone on ulnar side of proximal row
- pisiform is superimposed on the triquetrum
Hamate
- unique hook extending volarly
- hook is attachment point for flexor retinaculum on ulnar side
- painful fractures
capitate
- largest of the carpal bones
- keystone of transverse arch of wrist
Trapezoid
-very stable articulation with 2nd MC (2nd CMC joint), the capitate, and trapezium = most stable articulation of the carpus
Trapezium
- found at base of thumb - location of mobile 1st CMC joint
- distal surface is saddle joint matching the base of the MC
- most mobile bone in the distal row
Ulnar variance
- negative ulnar variance associated with Kienbock’s disease
- positive ulnar variance may lead to degenerative changes of TFCC
Triangular fibrocartilage
- meniscus
- susceptible to degenerative changes and acute tears
- attaches medially to base of ulna styloid
DIP and PIP joint supports
- articular capsule
- fibrous collateral ligaments
- thinner fan-like accessory ligaments
- volar plate
Volar plate
- thick and broad at the base of the distal bone of each joint, but form thinner long extensions onto proximal bone (“check reins”)
- volar plate of PIP joints can avulse with hyperextension injuries or dislocations
Collateral ligaments
- taut in flexion and extension for DIP
- taut only in extension for PIP
Hberden’s nodes and Bouchard’s nodes
Heberden’s nodes = DIP joint
- Bouchard’s nodes = PIP joints
- OA
MP joints
- biaxial joints with flexion/extension as well as abd/add
- collateral ligaments attach dorsolaterally on MC head and travel distally to volar lateral surface of proximal phalanx
- collateral ligament is taut in flexion, but relaxed in ext
Normative values - pronation/supination
80-90*
Normative values - wrist flex/ext
Flex - 90*
Ext - 80*
Normative values - radial/ulnar deviation
Radial - 15-20*
Ulnar - 20-30*
Normative values - MC joint flex/ext
Flex - 85-90*
Ext - 30-45*
Normative values - MC abd/add
Abd - 20-30*
Add - 0*
Normative values - PIP Flex/ext
Flex - 100-110*
Ext - 0*
Normative values - DIP Flexion
70-80*
Normative values - Thumb CMC joint flex/abd
Flex - 20*
Abd 50-55*
Normative values - thumb MCP joint flex/ext
Flex - 50-55*
Ext - 0*
Normative values - Thumb IP Joint flex/ext
Flex - 80-85*
Ext - 0*
1st CMC joint
- 1st MC and trapezium
- biaxial motion of palmar abduction
Dorsoradial ligament
- strongest ligament for the 1st CMC joint
- major stabilizer to prevent dorsal subluxation of 1st MC
50% of wrist flex/ext occurs at which joints
inter-carpal or mid-carpal joint and radiocarpal joint
Weak link of the wrist
proximal carpal row
Extrinsic extensor compartments mneumonic
221211
of extensors within each of 6 compartments
1st compartment
- APL
- EPB
- dequervain’s
2nd compartment
- ECRL
- ECRB
3rd compartment
EPL
4th compartment
ED
-EI
5th compartment
-extensor digiti minimi (or quinti)
6th compartment
- ulnar most tendon
- ECU
Extrinsic flexors of the wrist
- FCU
- FCR
- FDP
- FDS
FDS tendons stack on top of FDP tendons in 2 rows of 2
FDS tendons
- split into 2 slip with seach attaching to a ridge on the edges of the volar middle phalanx
- FDP tendon passes through the middle of these 2 slips to attach to the distal phalanx base
Pulleys
- arranged in an X - “cruciate pulleys”
- or arranged in a circle - “annular pulleys”
- 3 cruciate pulleys: C1, C2, C3
- 5 annular pulleys - A1-A5
MOST IMPORTANT: A2 and A4 - these maintain integrity of system
Dorsal interrossei
- group of 4 bipennate muscles arising from metacarpals and inserting on proximal phalanges
- abduct index and ring finers away from long finger
Palmar interossei
- group of 3 unipennate muscles arising from MC of index, ring, and small fingers
- attach to base of each proximal phalanx
- 1st palmar interossei is found on ulnar side of 2nd MC and acts to adduct index finger
- 2nd and 3rd arise from radial sides of ring and small MCs and adduct fingers towards long finger
Hypothenar intrinsic muscles
- abductor digit minimi
- flexor digiti minimi
- opponens digiti minimi
Thenar eminence
4 muscle groups:
- APB
- opponens pollicis
- FPB
- AP
Anterior interosseous nerve
- from median nerve
- innervates FPL, FDP to index and long fingers, and pronator quadratus
Ulnar nerve
- travels through cubital tunnel an dinnervates FCU and FDP to ring and small fingers
- divides into superficial and deep branch when it enters guyon’s canal
Radial nerve
- ECRL
- posterior interosseous nerve innervates all other dorsal extrinsic muscles
TTP radial styloid
- fracture
- de quervain’s
- arthritis
- radial nerve neuritis
TTP scaphoid
- fracture
- AVN
- scapholunate ligament injury
TTP thumb
- fracture
- sprain/tendon injury
- gamekeeper thumb (ulnar aspect of thumb MP joint)
TTP 1st CMC joint
-OA
TTP scaphoid-trapezium-trapezoid joint
-scaphoid-trapeziium-trapezoid synovitis or arthritis
TTP 1st dorsal compartment (APL, EPB)
- de quervain
- tendon rupture
TTP 3rd dorsal compartment (EPL)
-EPL tendon rupture or tendonitis
PROM > AROM more than 10*
-weakness or tendon adhesions
AROM = PROM
-similar and accompanied by capsular end feel = joint or capsular restriction
Grip dynamometer - 5 handle positions
-when using all 5 positions, a graph of grip measurements should form a bell shaped curve if patient exerts maximal effort and has no median or ulnar nerve injury
Finkelstein test
-De Quervain’s
+ = produes pain
-perform in stages
-sn 100%, sp 100%
Differentiating de quervain’s from intersection syndrome
- by noting location of patient’s symptoms
- in intersection syndrome, patient will c/o pain 4 cm from wrist, more proiximal than dorsal and then 1st dorsal compartment
- also test for intersection syndrome by resisting wrist extension
1st CMC grind test
- compress 1st MC into trapezium using axial load and rotate
- sn 42-53%, sp 80-93%
Scaphoid shift test
- palpate scaphoid tubercle and passively ulnar deviate and extend patient’s wrist
- while applying pressure, move into radial deviation and flexion
- relief of pressure causes scpahoid to reduce with palpable clunk
- = clunk and recreates patient’s symptoms
- sn 69%,, sp 66%
Scapholunate ballottement test
-patient’s forearm pronated
-stabilize lunate with thumb and index finger, with other hand grasp scaphoid and move scaphoid on lunate dosrally and volarly
+ = recreates patient’s pain, laxity, crepitus
Finger extension test
-patient’s wrist and MP joints flexed, resist long finger extension at MP joint
+ = pain in 3rd and 4th dorsal compartments indicates an occult dorsal wrist ganglion
-sn 100%
Scaphotrapeziototrapezoid joint instability/arthritis
-patient’s wrist and forearm in neutral
-apply pressure to scaphoid tubercle while radially and ulnar deviating the wrist
+ = pain
Lunotriquetral ballottement test
-forearm pronated, palpate lunate with 1 hand and pisotriquetral complex with other - move pisotriquetral complex dorsally and volarly while stabilizing lunate
+ = pain or laxity/clicking/crepitus
-sn 64%, sp 44%
Ulnar fovea sign
-disruptions of DRUJ ligaments
-patient’s wrist and forearm in neutral, palpate “soft spot” bw ulnar styloid, FCU tendon, volar surface of ulnar head and pisiform
+ = pain
-Sn 95%, sp 87%
TFCC load
- ulnarly deviate wrist and apply an axial load through wrist and ulna, move carpals on ulna volarly and dorsally
- = reproduces pain or leads to crepitus
Ulnocarpal instability
- suspennt’s forearm in pronation away from exam table - observe position of carpals in relation to ulnar styloid
- = ulnar aspect of carpals “sag” volarly and a prominent ulnar head
Pisiform boost test
- forearm in a vertical position and neutral rotation - push pisiform dorsally while translating ulnar head volarly
- = reproduces patient’s symptoms or excess laxity
- Sn 66%, sp 64%
Piano key sign (DRUJ instability)
- patient’s forearm in neutral, stabilize radius and press ulnar styloid in a volar direction
- when pressure is released, + = ulna will “spring” back up to its original position
Piano key test (DRUJ balottement)
- stabilize radius and apply volar and dorsal overpressure to the ulna in pronation, supination, and with forearm in a neutral position
- compare bilaterally and compare for pain/laxity
- = pain or laxity
(B) test for subluxation of DRUJ
- forearm in pronation, palpate dorsal DRUJ with index finger and place long fingers on ulnar head - rotate patient’s forearms
- compare movement between raidus and ulna between the 2 sides
- sn 90-100%
Ulnar compression test (DRUJ inflammation or arthritis)
- comperss ulnar head into sigmoid notch of radius
- combine compression with pronation and supination
- = patient’s symptoms
Extensor carpi ulnaris sublux
-palpate ECU tendon with wrist in slight ulnar deviation, have patient slowly rotate forearm
+ = ECU tendon snaps or pain
Midcarpal instability
-patient’s wrist in neutral and forearm in pronation, apply volar directed force at capitate and simaltaneously load the wrist axially and ulnarly deviate
+ = painful clunk
Pisotriquetral grind test
- palpate pisiform and apply a dorsal pressure - apply a volar counter pressure to triquetrum
- = pain
Ulnar collateral ligament stress test (skier thumb or gamekeeper thumb)
-apply a valgus stress to MP joint of thumb at 0* and 30* flexion, laxity of greater than 30-40* with valgus stress or more than 15* greater than CL side = positive for rupture
Collateral ligament stress test
- most often used to test integrity of collateral ligament of PIP joints
- examine UCL - apply valgus force to joint
- examine radial collaeral ligament - apply varus force
- perform with joint in 0* ext and 30* PIP flexion
- = pain or laxity
bunnel - littler test (intrinsic muscle tightness or contracture)
-hold patient’s wrist in extension an dMP joint of test finger in hyperextension
-measure passive PIP joint flexion
-flex MP joint and reassess PIP joint flexion
+ = PIP joint motion increases with MP joint flexion
Allen test (vascular disorder)
- ask patient to open and close fist several times while compression radial and ulnar arteries at the wrist
- ask patient to open hand - should be white and blanched
- release one of the arteries and observe bblood flow back into the hand
- repeat entire process for other artery
- = sluggish revascularization or does not revascularize
Tinel sign for CTS
- tap over median nerve at carpal tunnel
- = reproduction of paresthesia
- sn 50%, sp 77%
Tinel sign for cubital tunnel syndrome
- tap over cubital tunnel between medial condyle of humerus and olecrenon
- = paresthesia in ulnar nerve distribution
- sn 54%, sp 99%
Tinel sign for compression at superficial sensory branch of radial nerve
- tap at the radial styloid
- + = paresthesia in corresponding nerve distribution
Phalen test (CTS)
- extension patient’s elbow and allow the wrist to flex and fingers to extend for 60 seconds
- result in (+) if paresthesia develops
- sn 68%, sp 73%
OK sign (AIN lesion)
-patient makes OK sign
-look for IP joint flexion of thumb and DIP joint flexion of index finger
+ = patient brings
Froment sign
- ulnar nerve lesoin
- have patient hold index card using key pinch and try to pull card away
- positive = ip joint of thumb flexes indicating use of FPL muscle due to weakness or loss of aP and FPB (deep head) muscles
Scratch collapse test
-nerve lesion
-scratch patient’s skin over the area supplied by the nerve with suspected compression, while patient performs resisted shoulder ER bilaterally.
+ = brief loss of muscle resistance
Tendon injury - surgery
read about this
most commonly fractured bone in the body
- distal phalanx of digits
Tuft fractures
- distal phalanx fractures
- often comminuted
Mallet finger deformity
- terminal tendon of extensor mechanism is disrupted
- could be just soft tissue or could be bone avulsed
Jersey finger injury
- volar surface of distal phalanx
- tear of the insertion of FDP
- commonly occurs on ring finger
- MOI: active fisting action of the fingers (grabbing a jersey) following by an agressive force into finger ext
Phalangeal fractures
- 50% of hand fractures
- stable fractures can be buddy taped
Angle of proximal phalanx shaft fractures
volar direction in part due to tension from intrinsic motors
Boxer fracture
- most common metacarpal fracture
- metacarpal neck fracture (most commonly small finger)
- MOI: punch with clinched fist into a solid object
- flexion of distal fragment
Metacarpal shaft fractures
-typically displaced with the apex-dorsal due to pull of intrinsic muscles
Bennett fracture
-fracture dislocation of thumb metacarpal - intraarticular CMC joint
Rolando fracture
- base of thumb MC
- 2 or more fragments on the articular surface
- comminuted
Scaphoid fracture
- 70% occur at waist of bone
- most frequently fractured carpal bone
- can result in SNAC wrist deformity
SNAC
scaphononunion advanced collapse wrist deformity
Hamate fracture
- occur at the hook most often due to compressive force transmitted through the base of the palm or shear during forceful torque of the wrist
- conventional radiographs don’t show the fracture
- carpal tunnel view (wrist and fingers in full extension and beam angled through carpal tunnel) is required
Colles fracture
- extraarticular fracture occurring 1.5-2 inches proximal to articular surface of distal radius
- dorsal angulation with traction injury to volar surface of bone
4 basic stages of ligament tears leading to lunate instability
- minor sprain to palmar aspect of SL ligament without total disruption
- continuing force, causing dissociation of the SL ligament
- continuing hyperextension causes additional force through the wrist
- radioscaphocapitate ligament forces the capitate to collapse into radiocarpal space and push lunate in palmar direction
Lunate frequently spontaneously reduces leaving little evidence of dislocation other than recurring pain
S/S associated with most common patterns of the SL dissociation
- TTP over scaphoid tuberosity, waist, or scapholunate joint line
- laxity of the scapholunate joint during a ballotment test
- significant scaphoid shift exam
- radiographic evidence
Symptoms:
- pain on radial side of wrist at rest or w/ activity
- complaints of decreased grip strength
UCL sprain of thumb
- hyperextension with radial deviation
- “skier’s thumb” = acute version
- “gamekeepers thumb” also used to refer to this
PIP joint sprain grades
I - produce tensile stress in a collateral ligament, but do not disrupt the coninuity of the ligament
II - more unstable and involve a complete ligament tear or avulsion, but still stable during AROM
III - complete ligament rupture as well as an injury to the volar plate or dorsal capsule
Ganglion cysts
- most common soft tissue mass in wrist and hand
- 10-15% associated with predisposing traumatic event
- begin small and gradually increase in size
- most common develops at the SL joint
Dupuytren disease
- fibropoliferative disease of digital and palmar fascia
- cords form and extend distally and proximally
- cords shorten and thicken causing flexion contractures
- painful and self limiting
- genetic and environmental factors
- male, northern European descent
de Quervain’s
- APL and ePB
- thickening of tendon sheaths and accumulation of mucopolysaccharides
- clinical presentation includes c/o pain, tenderness, finkelstein’s, resisted thumb extension
Trigger finger
-stenosiing tendovaginitis that includes snapping or locking of finger or thumb during flexion w/ or w/o pain
Nerve injuries
-review
