Wrist & Hand Anatomy & Pathology

What do the wrist and hand do?

Make final “fine tuning” adjustments to best interact with objects.

Manipulate objects

Triangular Fibrocartilage Complex Sprain

• fact that both the distal end of the ulna and the proximal surface of the triquetrum are convex

• distal radio-ulna joint is a small articulation designed for great mobility but poor stability

First, the TFCC has an anterior and posterior ligament running between the distal radius and ulna to keep the two bones approximated. Between these two ligaments is a biconcave fibrocartilage structure that sits between the distal ulna and the triquetrum. The biconcave shape increases surface contact for both the ulna and triquetrum, providing some added stability and also helping to dissipate compressive loading through the medial wrist.

Problems of Tissue Load Tolerance - tensile - ligament/capsule

• Anterior wrist ligament sprains

• Posterior wrist ligament sprains

• Collateral ligament sprains

• Ulnar collateral ligament sprain of the thumb

• Triangular Fibrocartilage Complex Sprain

• Finger ligament/capsular sprains

Problems of Tissue Load Tolerance - tensile - tendon

extensor tendon rupture

Problems of Tissue Load Tolerance- compressive - articular

osteoarthritis

Anterior Wrist Ligament Sprain - etiology

Acute or repeated excessive stress with the wrist going into extension

Anterior Wrist Ligament Sprain - implications

Pain

Possible wrist instability

Possible decreased tolerance to weight bearing activities with an extended wrist

Anterior Wrist Ligament Sprain - key clinical features

• Pain and tenderness over the medial carpus

• Pain with passive wrist extension

• Possible hypermobility with palmer glide of radiocarpal joint or intercarpal joints

• Pain with weight bearing through extended wrist

Posterior Wrist Ligament Sprain - etiology

Acute or repeated excessive stress with the wrist going into flexion

Posterior Wrist Ligament Sprain - implications

Pain

Possible wrist instability

Posterior Wrist Ligament Sprain - key clinical features

• Pain and tenderness over the dorsal carpus

• Pain with passive wrist flexion

• Possible hypermobility with dorsal glide of radiocarpal joint or intercarpal joints

Collateral Ligament Sprains - etiology

Acute or repeated excessive stress into radial or especially ulnar deviation

Collateral Ligament Sprains - implications

Pain

Possible wrist instability

Collateral Ligament Sprains - key clinical features

• Pain and tenderness over the radial or ulnar aspect of the radiocarpal joint

• Pain with passive wrist radial or ulnar deviation

• Possible hypermobility with radial or ulnar glide of radiocarpal joint

Triangular Fibrocartilage Complex Sprains - etiology

Acute or repeated excessive stress with wrist extension and radial deviation

Triangular Fibrocartilage Complex Sprains - implications

Pain

Possible wrist instability

Possible decrease weight bearing tolerance with the wrist in extension

Triangular Fibrocartilage Complex Sprains - key clinical features

• Pain and tenderness over the radioulnar joint and/or ulnar aspect of the wrist

• Pain with passive wrist ulnar deviation and/or extension

• Possible hypermobility with radioulnar glides

• Often associated with clicking in the wrist

Ulnar Collateral Ligament of the Thumb Sprain - etiology

Acute or repeated excessive stress with thumb extension

Ulnar Collateral Ligament of the Thumb Sprain - implications

• Pain

• Possible thumb instability

• Decreased grip

• Development of OA

Ulnar Collateral Ligament of the Thumb Sprain - key clinical features

• Pain and tenderness over the dorsal aspect of the thumb CMC joint

• Pain with passive thumb extension

• Possible hypermobility with dorsal glide of the CMC joint

Ulnar Collateral Ligament Sprain - Also know as:

Gamekeeper’s thumb

Skier’s thumb

Rupture of the Extensor Tendon - etiology

Generally from acute or excessive flexion of the DIP

Rupture of the Extensor Tendon - implications

Inability to extend the DIP

Possible pain if not complete rupture or if avulsion occurs

Rupture of the Extensor Tendon - key clinical features

• Observation of mallet finger deformity

• Inability to extend the DIP joint

• Possible pain and tenderness over the dorsal aspect of the DIP joint

Osteoarthrosis - etiology

Unclear, several theories exist

• Altered loading

• Altered chemical balance

• Altered vascularization

Osteoarthrosis - implications

Pain

Decreased motion

Decreased strength

Osteoarthrosis - key clinical features

• Pain and tenderness in joint over joint lines

• Decreased load tolerance

• Stiff and achy in morning or with prolonged immobility that improves with light activity/motion but is exacerbated by more intense activity/motion

• Period of edema

Problems of Chemical/Ischemic Pain - inflammatory

tenosynovitis

Problems of Chemical/Ischemic Pain - ischemic pain

Carpal Tunnel Syndrome

Other Median Nerve Entrapments

Guyon’s Canal Syndrome

Tenosynovitis - etiology

Inflammation of the synovial sheath

Tenosynovitis - implications

Pain

Decreased grip

Possible trigger finger

Tenosynovitis - key clinical features

• Pain on radial aspect of wrist and forearm with ulnar deviation (DeQuervain’s Syndrome)

• Painful inability to extend finger from a full fist followed by sudden and rapid extension (Trigger finger)

• Possible pain and tenderness over the affected tendons

Carpal Tunnel Syndrome - etiology

Decreased space in the carpal tunnel

Carpal Tunnel Syndrome - implications

Pain

Paresthesias

Decreased sensation

Decreased hand strength

Carpal Tunnel Syndrome - key clinical features

• Pain and paresthesias at night that improve with shaking hand

• Decreased sensation in pad of the thumb with thenar eminance sensation spared

• Reproduction of symptoms with tests that decrease space on carpal tunnel

Guyon’s Canal Syndrome - etiology

Compression of the ulnar nerve within or at the exit of Guyon’s canal

Guyon’s Canal Syndrome - implications

Pain

Paresthesias

Decreased sensation

Decreased hand strength

Guyon’s Canal Syndrome - key clinical features

• Pain and paresthesias in the medial hand and fingers

• Decreased sensation medial 2 fingers and hand with dorsal aspect of medial hand spared

• Weakness of intrinsic hand muscles