Chapter 24: The Forearm, Wrist, Hand and FingerJennifer Doherty-Restrepo, MS, LAT, ATCAcademic Program Director, Entry-Level ATEPFlorida International UniversityAcute Care and Injury Prevention

Anatomy of the Forearm

Recognition and Management of Injuries to the Forearm ContusionEtiologyUlnar side receives majority of blows due to arm blocksCan be acute or chronic Result of direct contact or blowSigns and SymptomsPain, swelling and hematomaIf repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematoma

Contusion (continued)ManagementProper care in acute stage involves RICE for at least one hour and followed up w/ additional cryotherapyProtection is critical - full-length sponge rubber pad can be used to provide protective covering

Forearm SplintsEtiologyForearm strain - most come from severe static contractionCause of splints - repeated static contractionsDifficult to manageSigns and SymptomsDull ache between extensors which cross posterior aspect of forearmWeakness and pain w/ contractionPoint tenderness in interosseus membraneManagementTreat symptomaticallyIf occurs early in season, strengthen forearm; when it occurs late in season treat w/ cryotherapy, wraps, or heatCan develop compartment syndrome in forearm as well and should be treated like lower extremity

Forearm FracturesEtiologyCommon in youth due to falls and direct blowsUlna and radius generally fracture individuallyFracture in upper third may result in abduction deformity Fracture in lower portion will remain relatively neutralOlder athlete may experience greater soft tissue damage and greater chance of paralysis due to Volkmans contractureSigns and SymptomsAudible pop or crack followed by moderate to severe pain, swelling, and disabilityEdema, ecchymosis w/ possible crepitus

ManagementInitially RICE followed by splinting until definitive care is availableLong term casting followed by rehab plan

Colles FractureEtiologyOccurs in lower end of radius or ulnaMOI is fall on outstretched hand, forcing radius and ulna into hyperextensionLess common is the reverse Colles fracture

Signs and SymptomsForward displacement of radius causing visible deformity (silver fork deformity)When no deformity is present, injury can be passed off as bad sprainExtensive bleeding and swellingTendons may be torn/avulsed and there may be median nerve damageManagementCold compress, splint wrist and refer to physicianX-ray and immobilizationSevere sprains should be treated as fracturesWithout complications a Colles fracture will keep an athlete out for 1-2 monthsIn children, injury may cause lower epiphyseal separation

Anatomy of the Wrist, Hand and Fingers

Recognition and Management of Injuries to the Wrist, Hand and FingersWrist SprainsEtiologyMost common wrist injuryArises from any abnormal, forced movementFalling on hyperextended wrist, violent flexion or torsionMultiple incidents may disrupt blood supplySigns and SymptomsPain, swelling and difficulty w/ movement

ManagementRefer to physician for X-ray if severeRICE, splint and analgesicsHave athlete begin strengthening soon after injuryTape for support can benefit healing and prevent further injury

Triangular Fibrocartilage Complex (TFCC) InjuryEtiologyOccurs through forced hyperextension, falling on outstretched handViolent twist or torque of the wristOften associated w/ sprain of UCLSigns and SymptomsPain along ulnar side of wrist, difficulty w/ wrist extension, possible clickingSwelling is possible, not much initiallyAthlete may not report injury immediately

ManagementReferred to physician for treatmentTreatment will require immobilization initially for 4 weeksImmobilization should be followed by period of strengthening and ROM activitiesSurgical intervention may be required if conservative treatments fail

TenosynovitisEtiologyCause of repetitive wrist accelerations and decelerationsRepetitive overuse of wrist tendons and sheathsSigns and SymptomsPain w/ use or pain in passive stretchingTenderness and swelling over tendonManagementAcute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAIDs and restWhen swelling has subsided, ROM is promoted w/ contrast bathUltrasound and phonphoresis can be usedPRE can be instituted once swelling and pain subsided

TendinitisEtiologyRepetitive pulling movements; repetitive pressure on palms (cycling) Primary cause is overuse of the wristSigns and SymptomsPain on active use or passive stretchingIsometric resistance to involved tendon produces pain, weakness or bothManagementAcute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAIDs and restWhen swelling has subsided, ROM is promoted w/ contrast bathPRE can be instituted once swelling and pain subsided (high rep, low resistance)

Nerve Compression, Entrapment, PalsyEtiologyMedian and ulnar nerve compression Result of direct trauma to nervesSigns and SymptomsSharp or burning pain associated w/ skin sensitivity or paresthesiaMay result in benediction/ bishops deformity(damage to the ulnar nerve) or claw hand deformity (damage to both nerves)Palsy of radial nerve produces drop wrist deformity caused by paralysis of extensor musclesPalsy of median nerve can cause ape hand (thumb pulled back in line w/ other fingers)ManagementChronic entrapment may cause irreversible damageSurgical decompression may be necessary

Carpal Tunnel SyndromeEtiologyCompression of median nerve due to inflammation of tendons and sheaths of carpal tunnelResult of repeated wrist flexion or direct trauma to anterior aspect of wristSigns and SymptomsSensory and motor deficits (tingling, numbness and paresthesia); weakness in thumbManagementConservative treatment - rest, immobilization, NSAIDsIf symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament

Dislocation of Lunate BoneEtiologyForceful hyperextension or fall on outstretched hand Signs and SymptomsPain, swelling, and difficulty executing wrist and finger flexionNumbness/paralysis of flexor muscles due to pressure on median nerveManagementTreat as acute, and sent to physician for reductionIf not recognized, bone deterioration could occur, requiring surgical removalUsual recovery is 1-2 months

Scaphoid FractureEtiologyCaused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bonesOften fails to heal due to poor blood supplySigns and SymptomsSwelling, severe pain in anatomical snuff boxPresents like wrist sprainPain w/ radial flexionManagementMust be splinted and referred for X-ray prior to castingImmobilization lasts 6 weeks and is followed by strengthening and protective tapeWrist requires protection against impact loading for 3 additional months

Hamate FractureEtiologyOccurs as a result of a fall or more commonly from contact while athlete is holding an implementSigns and SymptomsWrist pain and weakness, along w/ point tendernessPull of muscular attachment can cause non-unionManagementCasting wrist and thumb is treatment of choiceHook of hamate can be protected w/ doughnut pad to take pressure off area

Wrist GanglionEtiologySynovial cyst (herniation of joint capsule or synovial sheath of tendon)Generally appears following wrist strainSigns and SymptomsAppear on back of wrist generallyOccasional pain w/ lump at sitePain increases w/ useMay feel soft, rubbery or very hardManagementOld method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healingNew approach includes aspiration, chemical cauterization w/ subsequent pressure from padUltrasound can be used to reduce sizeSurgical removal is most effective treatment method

Bowlers ThumbEtiologyPerineural fibrosis of subcutaneous ulnar digital nerve of thumbPressure from bowling ball on thumbSigns and SymptomsPain, tingling during pressure on irritated area and numbnessManagementPadding, decrease amount of bowlingIf condition continues, surgery may be required

Mallet Finger EtiologyCaused by a blow that contacts tip of finger avulsing extensor tendon from insertionSigns and SymptomsPain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanxUnable to extend distal end of finger (carrying at 30 degree angle)Point tenderness at sight of injuryManagementRICE and splinting for 6-8 weeks

Boutonniere DeformityEtiologyRupture of extensor tendon dorsal to the middle phalanx Forces DIP joint into extension and PIP into flexionSigns and SymptomsSevere pain, obvious deformity and inability to extend DIP jointSwelling, point tendernessManagementCold application, followed by splintingSplinting must be continued for 5-8 weeksAthlete is encouraged to flex distal phalanx

Jersey FingerEtiologyRupture of flexor digitorum profundus tendon from insertion on distal phalanxOften occurs w/ ring finger when athlete tries to grab a jerseySigns and SymptomsDIP can not be flexed, finger remains extendedPain and point tenderness over distal phalanxManagementMust be surgically repairedRehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture

Sprains, Dislocations and Fractures of PhalangesEtiologyPhalanges are prone to sprains caused by direct blows or twistingMOI is also similar to that which causes fractures and dislocationsSigns and SymptomsRecognition primarily occurs through historySprain symptoms - pain, severe swelling and hematoma

Gamekeepers ThumbEtiologySprain of UCL of MCP joint of the thumbMechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextensionSigns and SymptomsPain over UCL in addition to weak and painful pinchManagementImmediate follow-up must occurIf instability exists, athlete should be referred to orthopedistIf stable, X-ray should be performed to rule out fractureThumb splint should be applied for protection for 3 weeks or until pain free