Chapter 24: The Forearm, Chapter 24: The Forearm, Wrist, Hand and FingerWrist, Hand and Finger

Jennifer Doherty-Restrepo, MS, LAT, ATCJennifer Doherty-Restrepo, MS, LAT, ATCAcademic Program Director, Entry-Level ATEPAcademic Program Director, Entry-Level ATEP

Florida International UniversityFlorida International UniversityAcute Care and Injury PreventionAcute Care and Injury Prevention

Anatomy of the ForearmAnatomy of the Forearm

Recognition and Management Recognition and Management of Injuries to the Forearm of Injuries to the Forearm

ContusionContusion– EtiologyEtiology

Ulnar side receives majority of blows due to arm Ulnar side receives majority of blows due to arm blocksblocks

Can be acute or chronic Can be acute or chronic

Result of direct contact or blowResult of direct contact or blow

– Signs and SymptomsSigns and SymptomsPain, swelling and hematomaPain, swelling and hematoma

If repeated blows occur, heavy fibrosis and possibly If repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematomabony callus could form w/in hematoma

Contusion (continued)Contusion (continued)– ManagementManagement

Proper care in acute stage involves RICE for at Proper care in acute stage involves RICE for at least one hour and followed up w/ additional least one hour and followed up w/ additional cryotherapycryotherapy

Protection is critical - full-length sponge rubber Protection is critical - full-length sponge rubber pad can be used to provide protective coveringpad can be used to provide protective covering

Forearm SplintsForearm Splints– EtiologyEtiology

Forearm strain - most come from severe static contractionForearm strain - most come from severe static contractionCause of splints - repeated static contractionsCause of splints - repeated static contractionsDifficult to manageDifficult to manage

– Signs and SymptomsSigns and SymptomsDull ache between extensors which cross posterior aspect of Dull ache between extensors which cross posterior aspect of forearmforearmWeakness and pain w/ contractionWeakness and pain w/ contractionPoint tenderness in interosseus membranePoint tenderness in interosseus membrane

– ManagementManagementTreat symptomaticallyTreat symptomaticallyIf occurs early in season, strengthen forearm; when it occurs late in If occurs early in season, strengthen forearm; when it occurs late in season treat w/ cryotherapy, wraps, or heatseason treat w/ cryotherapy, wraps, or heatCan develop compartment syndrome in forearm as well and should Can develop compartment syndrome in forearm as well and should be treated like lower extremitybe treated like lower extremity

Forearm FracturesForearm Fractures– EtiologyEtiology

Common in youth due to falls and direct blowsCommon in youth due to falls and direct blowsUlna and radius generally fracture individuallyUlna and radius generally fracture individuallyFracture in upper third may result in abduction deformity Fracture in upper third may result in abduction deformity Fracture in lower portion will remain relatively neutralFracture in lower portion will remain relatively neutralOlder athlete may experience greater soft tissue damage and Older athlete may experience greater soft tissue damage and greater chance of paralysis due to Volkman’s contracturegreater chance of paralysis due to Volkman’s contracture

– Signs and SymptomsSigns and SymptomsAudible pop or crack followed by moderate to severe pain, Audible pop or crack followed by moderate to severe pain, swelling, and disabilityswelling, and disabilityEdema, ecchymosis w/ possible crepitusEdema, ecchymosis w/ possible crepitus

ManagementManagement– Initially RICE Initially RICE

followed by followed by splinting until splinting until definitive care is definitive care is availableavailable

– Long term casting Long term casting followed by rehab followed by rehab planplan

Colles’ FractureColles’ Fracture– EtiologyEtiology

Occurs in lower end of Occurs in lower end of radius or ulnaradius or ulna

MOI is fall on MOI is fall on outstretched hand, outstretched hand, forcing radius and forcing radius and ulna into ulna into hyperextensionhyperextension

Less common is the Less common is the reverse Colles’ reverse Colles’ fracturefracture

– Signs and SymptomsSigns and SymptomsForward displacement of radius causing visible deformity (silver fork Forward displacement of radius causing visible deformity (silver fork deformity)deformity)When no deformity is present, injury can be passed off as bad sprainWhen no deformity is present, injury can be passed off as bad sprainExtensive bleeding and swellingExtensive bleeding and swellingTendons may be torn/avulsed and there may be median nerve Tendons may be torn/avulsed and there may be median nerve damagedamage

– ManagementManagementCold compress, splint wrist and refer to physicianCold compress, splint wrist and refer to physicianX-ray and immobilizationX-ray and immobilizationSevere sprains should be treated as fracturesSevere sprains should be treated as fracturesWithout complications a Colles’ fracture will keep an athlete out for 1-Without complications a Colles’ fracture will keep an athlete out for 1-2 months2 monthsIn children, injury may cause lower epiphyseal separationIn children, injury may cause lower epiphyseal separation

Anatomy of the Wrist, Hand Anatomy of the Wrist, Hand and Fingersand Fingers

Recognition and Management Recognition and Management of Injuries to the Wrist, Hand of Injuries to the Wrist, Hand

and Fingersand Fingers

Wrist SprainsWrist Sprains– EtiologyEtiology

Most common wrist injuryMost common wrist injury

Arises from any abnormal, forced movementArises from any abnormal, forced movement

Falling on hyperextended wrist, violent flexion or Falling on hyperextended wrist, violent flexion or torsiontorsion

Multiple incidents may disrupt blood supplyMultiple incidents may disrupt blood supply

– Signs and SymptomsSigns and SymptomsPain, swelling and difficulty w/ movementPain, swelling and difficulty w/ movement

– ManagementManagementRefer to physician for X-ray if severeRefer to physician for X-ray if severe

RICE, splint and analgesicsRICE, splint and analgesics

Have athlete begin strengthening soon after injuryHave athlete begin strengthening soon after injury

Tape for support can benefit healing and prevent Tape for support can benefit healing and prevent further injuryfurther injury

Triangular Fibrocartilage Complex (TFCC) InjuryTriangular Fibrocartilage Complex (TFCC) Injury– EtiologyEtiology

Occurs through forced hyperextension, falling on Occurs through forced hyperextension, falling on outstretched handoutstretched hand

Violent twist or torque of the wristViolent twist or torque of the wrist

Often associated w/ sprain of UCLOften associated w/ sprain of UCL

– Signs and SymptomsSigns and SymptomsPain along ulnar side of wrist, difficulty w/ wrist extension, Pain along ulnar side of wrist, difficulty w/ wrist extension, possible clickingpossible clicking

Swelling is possible, not much initiallySwelling is possible, not much initially

Athlete may not report injury immediatelyAthlete may not report injury immediately

– ManagementManagementReferred to physician for treatmentReferred to physician for treatment

Treatment will require immobilization initially for Treatment will require immobilization initially for 4 weeks4 weeks

Immobilization should be followed by period of Immobilization should be followed by period of strengthening and ROM activitiesstrengthening and ROM activities

Surgical intervention may be required if Surgical intervention may be required if conservative treatments failconservative treatments fail

TenosynovitisTenosynovitis– EtiologyEtiology

Cause of repetitive wrist accelerations and decelerationsCause of repetitive wrist accelerations and decelerationsRepetitive overuse of wrist tendons and sheathsRepetitive overuse of wrist tendons and sheaths

– Signs and SymptomsSigns and SymptomsPain w/ use or pain in passive stretchingPain w/ use or pain in passive stretchingTenderness and swelling over tendonTenderness and swelling over tendon

– ManagementManagementAcute pain and inflammation treated w/ ice massage 4x daily for Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and restfirst 48-72 hours, NSAID’s and restWhen swelling has subsided, ROM is promoted w/ contrast bathWhen swelling has subsided, ROM is promoted w/ contrast bathUltrasound and phonphoresis can be usedUltrasound and phonphoresis can be usedPRE can be instituted once swelling and pain subsidedPRE can be instituted once swelling and pain subsided

TendinitisTendinitis– EtiologyEtiology

Repetitive pulling movements; repetitive pressure on palms Repetitive pulling movements; repetitive pressure on palms (cycling) (cycling) Primary cause is overuse of the wristPrimary cause is overuse of the wrist

– Signs and SymptomsSigns and SymptomsPain on active use or passive stretchingPain on active use or passive stretchingIsometric resistance to involved tendon produces pain, Isometric resistance to involved tendon produces pain, weakness or bothweakness or both

– ManagementManagementAcute pain and inflammation treated w/ ice massage 4x daily for Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID’s and restfirst 48-72 hours, NSAID’s and restWhen swelling has subsided, ROM is promoted w/ contrast bathWhen swelling has subsided, ROM is promoted w/ contrast bathPRE can be instituted once swelling and pain subsided (high PRE can be instituted once swelling and pain subsided (high rep, low resistance)rep, low resistance)

Nerve Compression, Entrapment, PalsyNerve Compression, Entrapment, Palsy– EtiologyEtiology

Median and ulnar nerve compression Median and ulnar nerve compression Result of direct trauma to nervesResult of direct trauma to nerves

– Signs and SymptomsSigns and SymptomsSharp or burning pain associated w/ skin sensitivity or paresthesiaSharp or burning pain associated w/ skin sensitivity or paresthesiaMay result in benediction/ bishop’s deformityMay result in benediction/ bishop’s deformity(damage to the ulnar nerve) or claw hand deformity (damage to both (damage to the ulnar nerve) or claw hand deformity (damage to both nerves)nerves)Palsy of radial nerve produces drop wrist deformity caused by Palsy of radial nerve produces drop wrist deformity caused by paralysis of extensor musclesparalysis of extensor musclesPalsy of median nerve can cause ape hand (thumb pulled back in line Palsy of median nerve can cause ape hand (thumb pulled back in line w/ other fingers)w/ other fingers)

– ManagementManagementChronic entrapment may cause irreversible damageChronic entrapment may cause irreversible damageSurgical decompression may be necessarySurgical decompression may be necessary

Carpal Tunnel SyndromeCarpal Tunnel Syndrome– EtiologyEtiology

Compression of median nerve due to inflammation of tendons Compression of median nerve due to inflammation of tendons and sheaths of carpal tunneland sheaths of carpal tunnelResult of repeated wrist flexion or direct trauma to anterior Result of repeated wrist flexion or direct trauma to anterior aspect of wristaspect of wrist

– Signs and SymptomsSigns and SymptomsSensory and motor deficits (tingling, numbness and Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumbparesthesia); weakness in thumb

– ManagementManagementConservative treatment - rest, immobilization, NSAID’sConservative treatment - rest, immobilization, NSAID’sIf symptoms persist, corticosteroid injection may be necessary or If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligamentsurgical decompression of transverse carpal ligament

Dislocation of Lunate BoneDislocation of Lunate Bone– EtiologyEtiology

Forceful hyperextension or fall on outstretched hand Forceful hyperextension or fall on outstretched hand

– Signs and SymptomsSigns and SymptomsPain, swelling, and difficulty executing wrist and finger flexionPain, swelling, and difficulty executing wrist and finger flexion

Numbness/paralysis of flexor muscles due to pressure on Numbness/paralysis of flexor muscles due to pressure on median nervemedian nerve

– ManagementManagementTreat as acute, and sent to physician for reductionTreat as acute, and sent to physician for reduction

If not recognized, bone deterioration could occur, requiring If not recognized, bone deterioration could occur, requiring surgical removalsurgical removal

Usual recovery is 1-2 monthsUsual recovery is 1-2 months

Scaphoid FractureScaphoid Fracture– EtiologyEtiology

Caused by force on outstretched hand, compressing scaphoid Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bonesbetween radius and second row of carpal bonesOften fails to heal due to poor blood supplyOften fails to heal due to poor blood supply

– Signs and SymptomsSigns and SymptomsSwelling, severe pain in anatomical snuff boxSwelling, severe pain in anatomical snuff boxPresents like wrist sprainPresents like wrist sprainPain w/ radial flexionPain w/ radial flexion

– ManagementManagementMust be splinted and referred for X-ray prior to castingMust be splinted and referred for X-ray prior to castingImmobilization lasts 6 weeks and is followed by strengthening and Immobilization lasts 6 weeks and is followed by strengthening and protective tapeprotective tapeWrist requires protection against impact loading for 3 additional Wrist requires protection against impact loading for 3 additional monthsmonths

Hamate FractureHamate Fracture– EtiologyEtiology

Occurs as a result of a fall or more commonly from contact Occurs as a result of a fall or more commonly from contact while athlete is holding an implementwhile athlete is holding an implement

– Signs and SymptomsSigns and SymptomsWrist pain and weakness, along w/ point tendernessWrist pain and weakness, along w/ point tenderness

Pull of muscular attachment can cause non-unionPull of muscular attachment can cause non-union

– ManagementManagementCasting wrist and thumb is treatment of choiceCasting wrist and thumb is treatment of choice

Hook of hamate can be protected w/ doughnut pad to take Hook of hamate can be protected w/ doughnut pad to take pressure off areapressure off area

Wrist GanglionWrist Ganglion– EtiologyEtiology

Synovial cyst (herniation of joint capsule or synovial sheath of tendon)Synovial cyst (herniation of joint capsule or synovial sheath of tendon)Generally appears following wrist strainGenerally appears following wrist strain

– Signs and SymptomsSigns and SymptomsAppear on back of wrist generallyAppear on back of wrist generallyOccasional pain w/ lump at siteOccasional pain w/ lump at sitePain increases w/ usePain increases w/ useMay feel soft, rubbery or very hardMay feel soft, rubbery or very hard

– ManagementManagementOld method was to first break down the swelling through distal pressure Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healingand then apply pressure pad to encourage healingNew approach includes aspiration, chemical cauterization w/ New approach includes aspiration, chemical cauterization w/ subsequent pressure from padsubsequent pressure from padUltrasound can be used to reduce sizeUltrasound can be used to reduce sizeSurgical removal is most effective treatment method Surgical removal is most effective treatment method

Bowler’s ThumbBowler’s Thumb– EtiologyEtiology

Perineural fibrosis of subcutaneous ulnar digital nerve of Perineural fibrosis of subcutaneous ulnar digital nerve of thumbthumb

Pressure from bowling ball on thumbPressure from bowling ball on thumb

– Signs and SymptomsSigns and SymptomsPain, tingling during pressure on irritated area and Pain, tingling during pressure on irritated area and numbnessnumbness

– ManagementManagementPadding, decrease amount of bowlingPadding, decrease amount of bowling

If condition continues, surgery may be requiredIf condition continues, surgery may be required

Mallet Finger Mallet Finger – EtiologyEtiology

Caused by a blow that contacts tip of finger avulsing extensor Caused by a blow that contacts tip of finger avulsing extensor tendon from insertiontendon from insertion

– Signs and SymptomsSigns and SymptomsPain at DIP; X-ray shows avulsed bone on dorsal proximal Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanxdistal phalanx

Unable to extend distal end of finger (carrying at 30 degree Unable to extend distal end of finger (carrying at 30 degree angle)angle)

Point tenderness at sight of injuryPoint tenderness at sight of injury

– ManagementManagementRICE and splinting for 6-8 weeksRICE and splinting for 6-8 weeks

Boutonniere DeformityBoutonniere Deformity– EtiologyEtiology

Rupture of extensor tendon dorsal to the middle phalanxRupture of extensor tendon dorsal to the middle phalanxForces DIP joint into extension and PIP into flexionForces DIP joint into extension and PIP into flexion

– Signs and SymptomsSigns and SymptomsSevere pain, obvious deformity and inability to extend DIP jointSevere pain, obvious deformity and inability to extend DIP joint

Swelling, point tendernessSwelling, point tenderness

– ManagementManagementCold application, followed by splintingCold application, followed by splinting

Splinting must be continued for 5-8 weeksSplinting must be continued for 5-8 weeks

Athlete is encouraged to flex distal phalanxAthlete is encouraged to flex distal phalanx

Jersey FingerJersey Finger– EtiologyEtiology

Rupture of flexor digitorum profundus tendon from insertion on Rupture of flexor digitorum profundus tendon from insertion on distal phalanxdistal phalanx

Often occurs w/ ring finger when athlete tries to grab a jerseyOften occurs w/ ring finger when athlete tries to grab a jersey

– Signs and SymptomsSigns and SymptomsDIP can not be flexed, finger remains extendedDIP can not be flexed, finger remains extended

Pain and point tenderness over distal phalanxPain and point tenderness over distal phalanx

– ManagementManagementMust be surgically repairedMust be surgically repaired

Rehab requires 12 weeks and there is often poor gliding of Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupturetendon, w/ possibility of re-rupture

Sprains, Dislocations and Fractures of Sprains, Dislocations and Fractures of PhalangesPhalanges– EtiologyEtiology

Phalanges are prone to sprains caused by Phalanges are prone to sprains caused by direct blows or twistingdirect blows or twistingMOI is also similar to that which causes fractures MOI is also similar to that which causes fractures and dislocationsand dislocations

– Signs and SymptomsSigns and SymptomsRecognition primarily occurs through historyRecognition primarily occurs through historySprain symptoms - pain, severe swelling and Sprain symptoms - pain, severe swelling and hematomahematoma

Gamekeeper’s ThumbGamekeeper’s Thumb– EtiologyEtiology

Sprain of UCL of MCP joint of the thumbSprain of UCL of MCP joint of the thumbMechanism is forceful abduction of proximal phalanx Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextensionoccasionally combined w/ hyperextension

– Signs and SymptomsSigns and SymptomsPain over UCL in addition to weak and painful pinchPain over UCL in addition to weak and painful pinch

– ManagementManagementImmediate follow-up must occurImmediate follow-up must occurIf instability exists, athlete should be referred to If instability exists, athlete should be referred to orthopedistorthopedistIf stable, X-ray should be performed to rule out fractureIf stable, X-ray should be performed to rule out fractureThumb splint should be applied for protection for 3 Thumb splint should be applied for protection for 3 weeks or until pain free weeks or until pain free