Hand and Wrist

Types of prehension grips?

Pinch

Three jaw/palmar grip

Latera

Types of power grips?

Cylindrical

Spheres

Hook

Ulnar Wrist Pain Differential Dx

TFCC injury

ECU tendinopathy/subluxation

Ulnar Neuritis (Guyon’s tunnel/canal syndrome)

Dorsal Wrist Differential Dx

Dorsal ganglion

Scapholunate ligament injury

Intersection syndrome

Palmer/Volar Wrist Differential Dx

Carpal Tunnel Syndrome (Median Nerve Entrapment)

Flexor Tendon Laceration

Trigger Finger

Dupuytren’s Contracture

Radial Wrist Pain Differential Dx

De Quervain’s Tenosynovitis (Basal Thumb Arthritis)

Scaphoid fracture

Proximal row of carpals from lateral to medial?

Scaphoid

Lunate

Triquetrum

Pisiform

Distal row of carpals from lateral to medial?

Trapezium

Trapezoid

Capitate

Hamate

Function of pulleys?

Prevent bowstringing

Promote efficiency in flexion

What is the significant difference between the radiocarpal and midcarpal row?

no muscular attachments

Closed pack position of wrist complex, MCP and IP =

Extension and radial deviation, MCP fully flexed, IP fully extended

Resting position of the wrist complex, MCP and IP joints =

neutral with slight ulnar deviation, MCP and IP slight flexion

MCP and IP capsular pattern?

greater limitation of flexion than extension

What nerve(s) innervate flexor pollicis brevis?

Recurrent median branch and deep ulnar branch

Complex regional pain syndrome 1 (CRPS-1)

pain triggered by noxious event, not limited to a single peripheral nerve

Complex Regional Pain Syndrome 2 (CRPS-2)

pain syndrome that involves direct partial or complete injury to a nerve or its major branches

What are both types of CRPS characterized by?

edema, stiffness, skin temperature changes, sweating

Populations commonly affected by CRPS

Females > Males

Middle age

Caucasians

De Quervain’s Syndrome

tenosynovitis of 1st compartment (abd. pollicis longus, ext. pollicis brevis) from repetitive stress resulting in thickening/narrowing of tendon sheath

Common populations affected by De Quervain’s

Women > Men

30-50 y.o.

Dominant arm

Sports with implements (gold, tennis)

Post-traumatic

Post-partum

Symptoms of DeQuervain’s Syndrome?

Gradual onset

Difficulty moving thumb and wrist when doing activities that involve grasping or pinching

Sticking or stop-and-go sensation in thumb when trying to move it

Radial sided wrist pain in 1st compartment near radial styloid

Pain near base of thumb or proximal to radial styloid

Swelling near base of thumb

Pain with resisted radial deviation, thumb extension, abduction

PROM of thumb flexion and wrist ulnar deviation

Finklestein test

wrist is neutral and thumb is quickly passively flexed

Eichoff Test

wrist in neutral, thumb is passively flexed and covers fingers, passively move wrist into ulnar deviation

(+) Finklestein and/or Eichoff Test

recreation of pain and provokes symptoms radial wrist pain

Intersection Syndrome Radial/Dorsal

pain and swelling on the dorsal aspect of wrist that increases with ulnar deviation and wrist extension

What is the mechanism of injury for intersection syndrome?

repetitive, occasionally direct trauma to 2nd compartment

What does crepitus mean in intersection syndrome?

1st compartment tendons overlap 2nd compartment tendons

Symptoms of intersection syndrome?

Localized pain and swelling proximally to radial styloid

Scaphoid Fracture mechanism?

fall on an outstretched hand (FOOSH)

Why is a scaphoid fracture considered a serious injury?

poor blood supply enters distally

Signs and symptoms of a scaphoid fracture

Pain in anatomical snuffbox

Mechanism FOOSH, old injury never better

Pain at scaphoid tubercle

Active and resistive wrist extension near end range increases pain

Resisted pronation increases symptoms

Grip strength decreased

Pain with wrist extension loading (push ups)

Signs and Symptoms of Thumb CMC Osteoarthritis

Pain with pinching, gripping, opposition activities

Palpation along 1st metacarpal to CMC

Tender distal to scaphoid

Scaphoid-snuff box tenderness in older pts w/o trauma

Stiff when resting, presents with gradual onset

CMC Grind test

axial compression with circumduction of thumb

Gamekeeper’s or Skier’s thumb (Ligament Sprain)

rupture of ulnar collateral ligament of the thumb

Mechanism of injury of a Gamekeeper’s or Skier’s Thumb?

severe, sudden valgus force on an already abducted thumb

Presentation of thumb UCL sprain (Gamekeeper’s sprain)?

Trauma catching pole when skiing or activity like playing volleyball or performing handstand

Pain and swelling at MCP

Grip weakness

Lateral pinch weakness

Valgus ligamentous stress testing provokes symptoms

Where would ulnar neuritis present?

depreesion between pisiform and hook of hamate converts into fibrosseous tunnel/tunnel of Guyon by pisohamate ligament

Populations affected by ulnar neuritis?

cyclists or manual labor via compression mechanism

Signs and Symptoms of Ulnar Neuritis?

Paresthesia’s in ring and little finger

Clawing of 4th and 5th fingers

Grip weaker due to main contributor to hand strength

Compression over Tunnel of Guyon increases symptoms

Froment’s sign

Intrinsic hand weakness

Froment’s sign

ulnar nerve is being compensated by the median nerve for a task

What is a red flag in the differential for ulnar neuritis?

pancoast tumor

Wartenberg’s Sign

persistent abduction of the littler finger due to weakness of ulnar-innervated palmar interossei muscles

What are specific signs for ulnar nerve motor deficits?

Froment’s sign

Wartenberg sign

Clawing

Why is clawing present with severe cases of ulnar neuritis?

radial nerve extrinsic musculature action overpowers intrinsic ulnar nerve musculature resting tone

What movement creates the most stability at the dorsal radio-ulnar joint?

supination

What is the primary intrinsic stabilizer of the TFCC-radioulnar complex?

deep radioulnar ligament

How to test DRUJ ligamentous stability?

push ulna toward patient to test both superficial and deep structures in both supination and pronation

(+) TFCC Fovea sign

tenderness in soft spot between ulnar styloid and FCU tendon, between volar surface of ulna and pisiform

Ulnar stress test

ulnar deviation and axial compression

TFCC impaction test

wrist in ulnar deviation with forearm in neutral and elbow flexed to 90 degrees apply axial load through the ulnar side of the hand in both supination and pronation

(+) TFCC Impaction Test

provokes medial wrist pain

Ulnar impaction = long ulna =

(+) ulnar variance