The Forearm, Wrist,

Hand, and Fingers

Chapter 24

Forearm Anatomy
Radius and Ulna: Elbow
Joints: radioulnar joint (superior, middle,
and distal)
Bone: proximal radial head, olecranon
process, radial shaft, ulnar shaft, distal radius,
radial styloid process, ulnar head, ulnar styloid
Musculature: flexors& pronators (lie
anteriorly. ulnar side), extensors & supinators
(lie posteriorly, medial side)
Nerve/Blood Supply: median and radial nerve
and brachial, radial, and ulnar artery

Forearm Assessment
History
Observation
Visually inspect, including wrsit and
elbow
If no deformity present, observe while
they supinate and pronate

Palpation
Special Tests

Recognition and
Management of Forearm
Injuries
Contusion
Etiology:direct blow
Why more common to ulna?

Signs and Symptoms

Management

Forearm Splints
Etiology: repeated severe static contraction
Signs and Symptoms:dull ache between extensors,
interosseous membrane
Management: early season vs late in season?
Note: Acute / Chronic exertional compartment syndrome:
deep compartment most common and associated with
avulsions, distal radius fracture, or crushing injuries;
management same as in lower leg

 Colles fracture
Etiology: FOA, forces radius and ulna back and up
= hyperextension
Signs and Symptoms (posterior displacement)
Management
Reverse Colles = fall on back of hand

Forearm Fractures
Etiology
Signs and Symptoms: more common for radius
and ulna to fracture simultaneously
Management

Wrist, Hand, and Finger

Anatomy
Bones: carpals and metacarpals
Joints: radiocarpal, carpal, metacarpal, and
phalangeal joints
Ligaments: many at each joint in the hand
TFCC (triangular fibrocartilage complex); b/t head of
ulna and triquetrial bone

Musculature: many intrinsic and extrinsic

muscles
Blood and Nerve Supply: ulnar, median, radial
nerve and radial and ulnar superficial and deep
palmar arch arteries.

Assessment of Wrist,
Hand, and Finger Injuries
History
Observation
Palpation
Special Tests: Finklesteins test, Tinels
Sign, Phalens test, valgus and varus
stress test,
Circulatory and Neurological Evaluation
Allen test
Functional Evaluation

Special Tests
Finklesteins Test
De Quervains (tenosynovitis)
Thumb tucked inside fist with ulnar deviation
Tinels Sign
Tap over transverse carpal ligament
Pain numbness and tingling indicates median nerve disruption and
presence of carpal tunnel

Phalens Test
Carpal tunnel
Bilateral wrist flexion and press them together; pain is positive sign

Valgus/varus at wrist, MCP, and IP joints

Circulatory / neurological evaluations
Allen's test: test function of radial and ulnar arteries
Athlete makes fist 4-5 times; while holding final fist, evaluator pinches
off both arteries; hand should be blanched
Release arties individually

Recognition and Management

of Wrist, Hand, and Finger
Injuries
Wrist Sprain
Etiology
Signs and Symptoms
Management
Triangular Fibrocartilage Complex Injury
Etiology:forced hyperextension or
compression of radioulnar joint and
proximal row of carpals
Signs and Symptoms
Management

 Tenosynovitis
Etiology: repeated wrist acceleration and
deceleration
Signs and Symptoms: pain w/ passive stretching
Management: may need splinting and strengthening

Tendinitis
Etiology: repetitive pulling motions and pressure on
palm of hand
Signs and Symptoms:pain with AROM and passive
stretching
Management

Nerve Compression, Entrapment, Palsy

Etiology: median (carpal tunnel) and ulnar (pisiform
and hamate)
Signs and Symptoms:deformities(bishops, claw and
drop wrist)
Management: if chronic, may require surgical
decompression

 Carpal Tunnel
Syndrome
Tunnel = pink
Bones = white
Ligament = blue
Carpal tunnel syndrome
Etiology: repeated
flexion
Signs and Symptoms:
sensory and motor
impairment
Management

Recognition and Management

of Wrist, Hand, and Finger
Injuries
Dislocation of the
Lunate Bone
Etiology:forced
hyperextension of
wrist
Signs and
Symptoms:difficulty
with wrist and finger
flexion; may have
impaired nerves
Management:
referral for reduction

Hamate Fracture
Etiology: contact while
holding
something(racket)
Signs and Symptoms
Management
Wrist Ganglion(synovial
cyst)
Etiology:herniation of
joint capsule or tendon
Signs and Symptoms
Management

 De Quervains
Disease
Etiology:
tenosynovitis of
thumb
Signs and
Symptoms
Management

Scaphoid Fracture
Etiology: compression of scaphoid
b/t radius and ulna
Concerns: portion of scaphoid has
decreased vascular supply; improper
healing can occur and result in
aseptic necrosis of the scaphoid bone

Signs and Symptoms

Anatomical snuffbox pain

Management

Finger anatomy
Bones
Ligaments
PIP and DIP have the
same design
Collateral ligaments,
palmar fibrocartilage,
and loose posterior
capsule or synovial
membrane (protected
by extensor expansion)

Finger anatomy
Musculature
PIP: Flex. Digitorium Superficialis
DIP: Flex. Digitorium Profundus
PIP & DIP: Exten. Digitorium Longus (becomes
extensor expansion after MCP)

Intrinsics:
Dorsal and palmar interosseei:
Lumbricals:volar surface; MCP flex., IP exten.
Thenar (4 that act on thumb) & hypothenar
(4 that act on 5th)

Recognition and Management of

Wrist, Hand, and Finger Injuries
Contusion to hand and fingers
Etiology
Signs and Symptoms: fingernail?
Management
Bowlers Thumb
Etiology: fibrosis of the ulnar digital nerve form
pressure
Signs and Symptoms:pain, numbness, tingling
Management: pad area, decrease activity;
surgery PRN
Jersey finger
Etiology:FDP rupture, grabbing jersey
Signs and Symptoms:DIP cannot flex
Management:SURGERY

 Trigger finger or thumb

Etiology: stenosing tendon by repeated
movements
Signs and Symptoms: resistance to reextension after thumb and finger flexed
Management:possible injections; splinting
Dupuytrens Contracture
Etiology: idiopathic development of nodules in
palmer aponeurosis
Signs and Symptoms:flexion deformity; cannot
extend
Management: surgical removal

Boutonniere deformity
Etiology:rupture of
extensor tendon
dorsal to middle
phalanx; trauma to
tip of finger causes
DIP extension and PIP
flexion
Signs and Symptoms:
cannot extend
Management:splint
PIP in extension 58wks.

 Swan neck deformity

AKA
Pseudoboutonniere
Etiology:severe
hyperextension;
injury to volar
plate
Signs and
Symptoms:
hyperextension of
PIP
Management:
splint 20-30
degrees flexion 3
wks

Mallet Finger
Etiology: strike to tip
of finger, jamming
and avulsing
extensor tendon
Signs and
Symptoms: unable to
extend, may palpate
avulsed bone
Management:extensi
on splint 6-8 wks

 Gamekeepers Thumb
Etiology:UCL of
thumb; forced
abductions, an
hyperextension
Signs and
Symptoms:inabilit
y to pinch; pain
with stress
Management:splin
t 3 weeks; protect
with activity

Recognition and Management of

Wrist, Hand, and Finger Injuries
Sprains, Dislocations,
and Fractures
Etiology
Signs and Symptoms
Management
Sprains PIP and DIP
joint
Etiology
Signs and Symptoms
Management

PIP Doral Dislocation

Etiology:twist while
semiflexed
Signs and Symptoms
Management:splint in
ext
PIP Dorsal dislocation
Etiology:hyperext.
Signs and
symptoms:deformity;
inability to move
Management:reduce
and splint 20-30
degrees flex

Recognition and Management of Wrist,

Hand, and Finger Injuries

MCP dislocation
Etiology:twist an shear force
Signs and Symptoms:prox. Phalanx dorsal 60-90
degrees
Management: reduce; splint; early ROM
Metacarpal fracture
Etiology:compressive axial force
Signs and Symptoms:appear angular or rotated
Management: reduce and splint
Bennetts Fracture
Etiology:thumb CMC; axial and ABD force to
thumb
Signs and Symptoms:base of thumb painful
Management:refer to surgeon due to unstable
nature

 Distal/Middle/Proximal phalangeal fracture

Etiology:crushing force; direct trauma or twist
Signs and Symptoms: subungual hematoma
subungual hematoma
Management:drain and splint / buddy tape; control
pain
Fingernail deformity
Occur for variety of reasons:
Scaling or ridging psoriasis
Ridging or poor development hyperthyroidism
Clubbing and cyanosis-chronic respiratory disease or heart
disorder
Spooning or depression- chronic alcoholism and vitamin
deficiencies

Rehabilitation Principles for

the Forearm, Wrist, Hand, and
Fingers
General Body Conditioning
Joint Mobilization:traction and mobilization
help restore ROM

Flexibility: full ROM is measure of good rehab

Strength:equal
Neuromuscular Control:great dexterity
required

Return to Activity: Goals: full dexterity,

full ROM, full strength