Hand and wrist

What is the TFCC and what does it do

Triangular fibrocartilage complex

• articular disk between distal ulna and proximal carpals

  • attaches to the ulnar styloid process and the ulnar side of the radius

  • attaches to lunate and triquetrum

• Supports stablity of the wrist

  • major ligamentous stabilizer of the DRUJ and the ulnar carpals

• “cushion” from axial load

• allows “gliding” between distal ulna and proximal carpals

What makes up the thenar eminence

Abductor pollicis brevis

Flexor pollicis brevis

Flexor pollicis longus

Opponens pollicis

Median nerve

What makes up the hypothenar

Abductor digiti minimi

Flexor digiti minimi brevis

Opponens digiti minimi

Lumbricals

Ulnar nerve

What makes up the snuff box

Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

ROM wrist flexion

• 80-90

• tissue stretch

• lateral joint line, midline of ulna, midline of 5th

ROM wrist extension

• 75-85

• tissue stretch

• lateral joint line, midline of ulna, midline of 5th

ROM Radial deviation

• 15-20

• hard endfeel

• radioulnar joint, midline of forearm, 3rd MC

ROM Ulnar deviation

• 30-45

• bone to bone

• radioulnar joint, midline forarm, 3rd MC

ROM 1st CMC

• Flexion

  • 45-50

• Abduction

  • 60-70

ROM MCP

• Flexion

  • 85-105

  • thumb 50-55

• Extension

  • 30-45

• Ab/Adduction

  • 20-25

ROM IP

• Flexion

  • 80-90 at thumb

  • 100-120 at PIP

  • 80-90 at DIP

  • tissue stretch

• Extension

  • 0 at PIP

  • Up to 5 hyperextension at thumb IP

  • Up to 20 hyperextension at DIP

ROM pronation and supination

• 85-90

• Tissue stretch

• If painful supination

  • Distal radioulnar vs radiocarpal cause

    • Passively supinate the ulna on the radius without stress to radiocarpal joint

    • If painful = radioulnar cause

Boxers fracture

fx at 5th metacarpal

bennet’s fracture

fx at base of 1st

Most common MOI for wrist sprain

Hyperextension (FOOSH)

Scaphoid fracture

• wrist hyperextension

• radial deviate

• tender snuffbox

• crepitus

• remember occult fracture

-Preisers diesease

• osteoporosis of scaphoid

DRUJ instability (MOI and S/S)

MOI:

• Fx

• subluxation/dislocation

• TFCC tear

• Rotation with axial force

S/S:

• Wrist pain

• clicking/popping

• Weakness

• decreased ROM or painful

• “sunken” ulnar aspect of wrist/distal forearm

ST DRUJ instablility

Radioulnar glide/piano key test

• mobilize ulna on radius

• + = increased mvt

  • DRUJ instability

  • possible TFCC tear

TFCC injury

MOI

• fallen on pronated and hyperextended wrist

• twisting with palmer rotation

• forced ulnar deviation

• associated with radial distal fracture

• ulnocarpal impact syndrome

• microtrauma/degeneration

S/S:

• ulnar sided wrist pain

• tenderness btwn ulna and triquetrium

• painful crepitus or clicking with wrist ROM

• weakness

• ulnar carpal sag

• Lunotriquetral (LT) interval tenderness

• ECU tendon subluxation

• + LT ballottement or shuck test

• Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking

• Instability of the DRUJ with shucking the distal radius and ulna between the examiners fingers

• Piano key sign

  • Which is a prominent and ballottable distal ulna with full pronation of the forearm

TFCC special tests

• supination lift off test

• screwdriver test

• ulnar impaction test test

Supination lift off test

• seated

• elbows at 90

• palms up (supinated)

• they lift up to your resistance

• + = pain on ulnar side of wrist with weakness

screw driver test

• have the patient clench and ulnar deviate the wrist, and pronate and supinate the wrist

• by themself and with resistance

ulnar impaction test

• pain with wrist hyperextension and ulnar deviation and with axial compression

Lunotriquetral instability

MOI

• forced extension or extension with radial deviation

  • scaphoid induces the lunate into a further flexion stance and triquetrum extends

  • disruption of the LT ligaments

• S/S

  • wrist pain, clicking, decreased ROM, decreased strength

  • TTP lunotriquetral joing

  • lunotriquetral shear maneuver (reagans’s test)

  • shuck test/kleinmans test

  • compression test: displacement of the triquetrum ulnarly during radioulnar deviation, which is also painful

LT ballottement/reagan’s test

• stabliize the triquetrium and mobilize the lunate A/P

  • others say to stablize lunate and mob triq

  • + pain, lax, crepitus

  • = instability of LT ligaments

LT shear test/kleinmans test/shuck test

• patients forearm in a vertical position

• the examinar places on finger on the posterior/dorsal part of the lunate

• and with this contralateral thumb placed palmar,

• pushes the pisiform (triquetrum) dorsal

• which causes pain in the lunotriquetral joint

Scapholunate instability

MOI:

• hyperextension

  • usually with ulnar deviation

S/S:

• TTP just distal to listers tubercle

• generalized wrist pain, weakness, and decreased ROM

• Watson’s/scaphoid shift test

• finger extension/scaphoid shuck test

Watson/scaphoid shift test

• seated, elbow resting on table

• forearm pronated

• passive full ulnar deviation with slight ext while holding MCs

• Press thumb against palmar surface of scaphoid

• Passive radial deciatioin with slight flex while maintaining scaphoid stabilizatioin

  • if neg, your thumb will be “pushed away” by pts scaphoid

• + test = pain and/or shifting

• = scapholunate instability or fx scaphoid

Scapholunate ballottement test

• stabilize the lunate and mobilize the scaphoid

  • or vise versa

• + = pain, clunck, grinding

• =SL instability

Finger extension/scaphoid shuch test

• the patients wrist is held in flexion

• active finger extension vs resistance is tested

  • + = pain due to:

    • parascaphoid injury

    • radial carpal, or midcarpal instability

Allens

• Patient makes a fist (quickly) several times to pump out the blood then hold fist

• ATC compresses radial and ulnar artery

• They open their hand, which should be pale

• Release one side then repeat test

• + delayed flushing

• =occlusion of artery

Tinel’s

• Tap over median nerve in carpal tunnel

• + pain, numbness, tingling

• = median nerve/CTS

• perform other tests for median nerve as this may just show median nerve irritation

Phalens

• PT flexes wrists and pushes back of hands together - hold for 1 minute

• + numbness, tingling

• = CTS

Froments sign

• they grasp a piece of papter btwn thumb and index finger

• you try to pull paper away

• + = distal phalanx of thumb flexes (MCP may also hyperextend)

• = paralysis of AdP (ulnar nerve lesion)

Finkelstein’s

• Tuck thumb in fist

• Ulnar deviation

• + pain

• = tenosynovitis of AbPL and EPB = “DeQuervain’s”

Bunnel - littlers test

• Intrinsic mucles (interossei and lumbricals) vs joint capsule tightness

• Intrinsic muscle

  • MCP in extension and try to flex PIP (always passively)

  • If PIP can flex intrinsics are not tight

  • If PIP CANT flex intrinsincs or capsule is tight

• Capsule

  • MCP in flexioin and try to flex PIP

  • If PIP now moves into flexion intrinsics are tight

  • If PIP still does not flex capsule is tight

Dorsal tunnel 1

AbPL and EPB

-Radial border of the snuff box

-Dequervain’s stenosing tenosynovitis

Dorsal tunnel 2

ECRL, ECRB

-Make a fist, feel radial side of listers tubercle

Dorsal tunnel 3

EPL

-ulnar border of snuffbox

-runs along listers tubercle to angle twd thumb

-possible ruptures with colle’s fx and rh. arthritis

Dorsal tunnel 4

EDC, EI

-b/t tunnel 3 and radioulnar joint

-palpate EDC tendon with fingers extended

-EI palpate with flex and ext of index finger

extensor digitorum communis

Extensor Indicis

Dorsal tunnel 5

EDM

-overlies radioulnar joint

-indention lateral to ulnar styloid

-EDM palpate with 5th finger extension

Dorsal tunnel 6

ECU

-groove bt apex of ulnar styloid process and ulnar head

-extend wrist with ulnar deviation to palpate easier

-torn or sublux with sup, ulnar dev, and flex