Orthopedic Examination

and

Hand and Wrist: Part 1

Treatment

of the

Edward P. Mulligan, MS, PT, SCS, ATC

VP, National Director of Clinical Education
HealthSouth Corporation Grapevine, TX
Clinical Instructor
University of Texas Southwestern PT Dept Dallas, TX

The contents of this presentation are copyrighted 2002 by continuing ED. They may not be
utilized, reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, or
by any information storage or retrieval system, without permission in writing from Edward P. Mulligan.

continuing ED

Learning Objectives
Following the completion of the inservice the participant
will be able to:
1.

2.

3.

Identify important anatomical,

morphological, and arthrokinematic
features of the wrist and hand
Describe common deformities
found in the wrist and hand
Perform a basic orthopedic exam
including ROM, strength, palpation,
special tests, and functional measures
continuing ED

Learning Objectives
Following the completion of the inservice the
participant will be able to design an effective treatment
program for:
Colles, Boxer, and Navicular Fractures

Gamekeepers thumb, Mallet Finger,

Finger Sprains
RSD, DeQuervains Tenosynovitis,
Duputryens Contracture
Neural Entrapments

and
and

CTS
Guyons Canal

continuing ED

Bony Anatomy

of the

Hand

and

Wrist

continuing ED
Two rows of eight carpal bones
Proximal row from radial to ulnar:
1. Navicular (scaphoid) base of anatomical snuffbox
2. Lunate lunar shaped bone palpable beneath the natural
concave depression in line with the 3rd metacarpal
3. Triquetrum
4. Pisiform on the anterior surface

The distal row from ulnar back to radial

1. Hamate hook palpable through hypothenar eminence. Ulnar
attachment of flexor retinaculum that covers the carpal tunnel
2. Capitate largest carpal bone
3. Trapezoid (lesser mutangular articulates with 2nd proximal
phalanx
4. Trapezium (greater multangular) articulates with the 1st
proximal phalanx (CMC saddle joint)
1-5 Metacarpals
1-5 Proximal Middle-Distal Phalanges

Distal Radioulnar Joint

Concave Surface:
Convex Surface:
Resting Position:
Closed Pack Position:
Capsular Pattern:

radius
ulna
10 supination
5 of supination
pain at extreme of
motion

continuing ED

The distal radioulnar joint works in concert with the proximal

radioulnar joint to provide pronation and supination motion.
The concave sigmoid notch on the distal end of the radius articluates
with the ulna that does not project quite as far distally.
The ulna is separated from the triquetrum by the TFCC (triangular
fibrocartilage)
The radius and ulna are connected by the interosseus membrane

Wrist Joint
Concave Surface:
Convex Surface:
Closed Pack Position:
Resting Position:
Capsular Pattern:

distal radius
proximal carpal row
full extension and
radial deviation
neutral with slight
ulnar deviation
flexion=extension

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The radiocarpal joint is supported by ligaments on the volar side that

are generally stronger, thicker, and more profuse than those on the
dorsal side.
Specifically,
The radius articulates with the navicular and lunate. The lunate and
triquetrum articluate with the triangular fibrocartilage complex
(TFCC)

MCP and IP Joints

Concave Surface:
Convex Surface:
Closed Pack Position:
Resting Position:
Capsular Pattern:

distal
proximal
Full extension
Slight flexion
Flexion > extension

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Some exceptions to the general capsular pattern of greater flexion

restriction than extension loss:
The closed pack position for the metacarpophalangeal joints is also
full flexion (in addition to full extension)
The closed pack position for the carpometacarpal joint of the thumb is
is full opposition while the resting position for the carpometacarpal
joint is midway between flex-ext and ab-adduction.

Dorsal Compartments
I
II
III
IV
V
VI

APL - EPB
ECRL - ECRB
EPL
ED - EI
EDM
ECU

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Proximal to the wrist and hand are the common extensors originating from the
lateral epicondyle: They include the bracioradialis, the extensor carpi radialis longus
and brevis, the extensor digitorum, extensor carpi ulnaris, and the extensor digiti
minimi
Extensor Compartments on the dorsum of the hand:
I Abductor Pollicus Longus and Extensor Pollicus Brevis make up the radial side of
the anatomical snuffbox. This is the comparment that is involved in DeQuervains
tenosynovitis that well talk about next week.

II contains the ECRL and ECRB. The longus inserts at the base of the 2nd
metacarpal and the brevis at the base of the 3rd.
III contains the extensor pollicus longus. This tendon takes a 45 degree angle turn
at listers tubercle on the dorsum of the radius and crosses over the top of the II
tunnel on its way to distal phalanx of the thumb forming the ulnar border of the
anatomical snuffbox
IV contain the extensor digitorum communis and the extensor indices
V contains the extensor digiti minimi
VI contains the extensor carpi ulnaris as it inserts on the 5th disatl phalanx

Dorsal Compartments
I
II
III
IV
V
VI

APL - EPB
ECRL - ECRB
EPL
ED - EI
EDM
ECU

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Flexor/Extensor Tendon Zones

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On the palmar side of the hand are the five flexor tendon zones
Zone 1 DIP flexors - orange
Zone 2 Surgical no mans land including the PIP flexors - red
Zone 3 from the proximal to the distal palmar crease where MCP
flexion takes place - purple
Zone 4 from the wrist crease to the distal palmar crease - yellow
Zone 5 tendons proximal to the wrist - aqua

Accessory Motions
Radiocarpal mobility
particularly important for
wrist extension ROM
Intercarpal mobility
important for wrist flexion
and radial deviation ROM
Radiocarpal and intercarpal
mobility equally important for
ulnar deviation ROM

continuing ED

Convex carpal row moves arthrokinematically in the opposite

direction of the intended osteokinmeatic motion of the wrist.

Volar or palmar glide for extension

40 degrees of extension from radiocarpal and 20 degrees from
midcarpal
Dorsal glide for flexion
Wrist flexion requires dorsal glide of the distal row (trapezium,
capitate and and hamate) on the proximal row (navicular, lunate,
and triquetrum)
40 degrees of flexion from the midcarpal and 30 or so from
radiocarpal
Radial deviation would be enhanced with an unlar glide of the
distal row on the proximal
Ulnar deviation dependent on a radial glide at both joints

Subjective History
Age, Sex, Occupation, Dominant Side
MOI traumatic vs. gradual
Injury History
Date, Immobilization, Sx

ADL Considerations
Present Status
Medical History

continuing ED

What is Chief Complaint? how does that affect function?

Age great predictor of pathology
Occupation obvious functional concerns
Handedness
MO I traumatic vs. gradual

Injury History what, when , where; immobilization what, how long

ADLs dressing, eating, writing, typing, holding, dropping, etc.
Symptom complaint
Intensity
Nature neuro, vascular, musculoskeletal adjectives
Aggravating/alleviating factors
Present Status better, same, worse
Medical History
Systems review
Medical health
Previous injuries

General Observation/Inspection
Resting Position
Fingers more flexed as you move from medial to
lateral

Cosmetic Appearance
and Symmetry
Creases
Swelling/Atrophy
Skin and Nails
Wounds or Scars
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Wrist/Hand Creases from proximal to distal

Wrist
Thenar
Proximal Palmar
Distal Palmar
Palmar Digital
Proximal Interphalangeal
Distal Interphalangeal

Dominant hand tends to be bigger and have more defined creases or

calluses

Vaso-Sudo-Pilomotor and Trophic Changes

Loss of hair
Brittle nails
palm sweating
palm sweating
Shiny or dry skin

Possible indications of peripheral

nerve injury, peripheral vascular
disease, diabetes, Raynaud's,
RSD-CRPS, etc
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Vasomotor skin color and temperature

Sudomotor sweating or dry skin
Pilomotor goosebump response
Trophic changes hair, skin, and nail changes
examples: spooned nails can mean anemia, iron deficiency,
diabetes, or local fungal infections
clubbed nails are a sign of COPD (chronic obstructive
pulmonary disease) or heart defects

These types of changes may be indicators of more serious

underlying disease or systemic pathology

Finger Nail Abnormalities

Spoon Nails
Anemia, iron deficiency,
diabetes, local fungal
infection

Clubbed Nails
COPD or heart defects

continuing ED

Upper Extremity Screening

Cervical AROM with overpressure at end range
Quadrant Testing
Functional Reach Tests
Behind Back
Behind Neck
Cross Body

Neural tension tests

Peripheral innervation muscle
weakness patterns
continuing ED

Any positive findings warrant a more thorough and complete

assessment of the area implicated during the screening

Side bending, rotation, and extension to the side of involvement

most likely to implicate cervical involvement to hand symptoms.
Functional reach patterns used as a quick screen of scapulothoracic
and glenohumeral range of motion.
Upper limb tension tests used to selectively stretch ulnar, median,
and radial peripheral nerves and see if tension on these structures
reproduces the patients chief complaint.

Osteoarthritic Enlargements

Bouchards nodes at PIP; Heberdens nodes at DIP

continuing ED

Heberdens bony nodules which typically appear on the dorsal and

lateral areas of the DIP are a common sign of osteoarthritis.
Bouchards fusiform enlargements at the PIP joints are often
associated with osteo or rheumatoid arthritis.

Common Deformities
Swan Neck
MCP and DIP flexed;
PIP extended
Intrinsic contracture,
rheumatoid arthritis, or volar
plate injury

Boutonniere
PIP flexed and DIP hyperextended
Central extensor tendon rupture
continuing ED

Common Deformities
Ulnar Drift
Bowstring effect of extensor
tendons overcome by
weakened MCP capsuoligamentous structures in
rheumatoid hands

continuing ED

Most common, but not limited to, rheumatoid arthritics

The ulnar deviation of the digits occurs due to weakening of the
capsuloligamentous structures of the MCP joints and the
accompanying bowstring effect of the extensor digitorum communis
tendons.

Tendon Deformities
Duputryens
Palmar fascia contracture
in older adults

Trigger Finger
Thick flexor tendon sheath
causing stenosis
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Duputryens - Insidious onset and contracture of the palmar fascia

resulting in a fixed flexion deformity of the MCP and PIPS. It is
usually more pronounced on the ulnar (4-5th) side of the hand.
Most prominent in those of 50-70 year old males of Scandinavian
descent
Trigger Finger sometimes referred to as digital tenovagninits
tenosans
Tender nodule with catching symptom may indicate a thick flexor
tendon sheat or tenosynovitis causing a stenotic affect with flexion of
the finger or thumb.
Tendon will initially stick, and then suddenly let go, often with an
audible snap.
The condition is most common in middle-aged women and is often
associated with rheumatoid arthritis.

Neurological Deformities
Claw Hand
Intrinsic minus deformity 2ary
to loss of intrinsics and
dominance of long extensors
Cupping and arches lost
Often due to median & ulnar
nerve injury

Ape Hand
Median nerve palsy
Thenar atrophy
Unable to oppose

continuing ED

Claw Hand
This intrinsic minus deformity results from the loss of intrinsic
muscle function and the dominance of the extrinsic, long extensors
action at the proximal phalanges.
As a result the MCPs are hyperextended, the PIPs and DIPS are
flexed causing a cupping affect where the transverse and
longitudinal arches of the palm are lost
Ape Hand
The ape hand occurs secondary to a median nerve palsy causing
thenar atropy and the thumb falling back in line with the other fingers
due to the relatively unopposed action of the thumb extensors.
The deformity is called and ape hand because of the loss of the
opposable thumb

Neurological Deformities
Bishops Hand

Wrist Drop
Radial nerve palsy
wrist extensor
paralysis

Flexed 4/5th fingers with

hypothenar wasting 2ary
to ulnar nerve palsy

continuing ED

Bishops Hand
The Benediction Hand deformity is caused by an ulnar nerve palsy
where the hypothenar, interossei, and two medial lumbricale muscles
lose innervation.
Flexion of the 4-5th fingers is the obvious change due to the
unopposed action of the intrinsic muscles on the ulnar side of the
hand
Wrist Drop
The wrist drop is the classic sign of a radial nerve palsy. The wrist
and fingers can not be extended and hand becomes relatively
dyfunctional.

Range of Motion
Forearm Pronation-Supination
Wrist Flexion-Extension
Wrist Radial-Ulnar Deviation
Digital Flexion-Extension
Thumb Motions
Functional Positions

continuing ED

Both bubble inclinometers and goniometers have been found

effective.
+ 5-8 intratester variation for wrist flexion-extension
+ 6-10 intertester variation for wrist flexion-extension
Dorsal goniometer placement generally accepted as preferred
method for finger IP flexion-extension assessment
Individual digit measurements assume that the wrist is in a neutral
position to eliminate the influence the extrinsic musculature as the
wrist changes position

Strength
Manual Muscle Testing
Power Grip
Chuck Pinch
Lateral Key Pinch
Tip Pinch

continuing ED

Manual Muscle Testing understand reliability and limitation of

manual muscle testing generally poor reliability above grade of 3.
The intent of checking in the initial evaluation is not to precisely
determine strength but to see if strengthening should be a part of the
rehab program.

Grip and Pinch Strength Assessment

Power Grip

Chuck Pinch

Thumb-Index
Pulp Pinch

Lateral (Key) Pinch

(three-finger or
digital prehension)

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Power Grip
Sitting, arm at side, elbow 90 degrees, forearm neutral
Three trials averaged and recorded in inch-pounds or kilograms
15-20% deficit on non-dominant side is expected or normal
Altered positions to specifically challenge contractile lesions
Chuck Pinch (three-finger pinch or digital prehension like holding a pencil
Lateral or Key Pinch like holding cards or turning a key
Tip pulp to pulp tip pinch with 3 > 2 > 4 > 5 strength
Lots of normative data available by sex, occupation, handedness, etc

Grip Strength Normals

Grip Strength

Small hand

Big hand

kg

40
30
20
10
0
1

grip size

continuing ED

kg strength on y axis; grip size on x axis

Plotting the strength by the grip size handle spacing should result in a
bell shaped curve as the active insufficiecy of the flexors is present
with grip #1 and passive insufficiency with grip#5.
Consequently, the curve can move to the right with a big hand and to
the left with a small hand.
Non-bell shaped curves or variations greater than 20% in test-retest
situations may indicate the patient is not consistently giving their best
effort.

Palpation
Tenderness, temperature, crepitation, nodules,
anomalies, etc
Bony Landmarks
Soft Tissues
Pulses

Check scars for

mobility and
sensitivity
continuing ED

Bony Landmarks
Radial Styloid
Navicular at base of snuffbox; particularly with UD
Trapezium just distal to navicular; palpale with thumb F/E
Listers tubercle ridge 1/3 of the way across radius; in line with 3rd metacarpal
Capitate depression in extension distal to Listers and in line with 3rd metacarpal
Lunate proximal to capitate; palpable on wrist flexion
Ulnar Styloid posteromedial; lateral groove holds ECU
Triquetrum just distal to ulnar styloid; more palpable in RD
Pisiform sesamoid bone within the FCU on top of triquetrum; at level of wrist crease
Hook of Hamate thumb distal phalanx length from wrist crease; deep in hypothenar
area

Soft Tissue Landmarks

Snuffbox Dorsal Compartment Borders
Tunnel 1 radially containing APL and EPB and Tunnel 3 ulnarly containing EPL
Tunnel 2 is palpable with clenched fist just radial to Listers tubercle
Palmaris Longus (if present) 1st and 5th digits touch and then flex wrist
Radial artery palpable between FCU and palmaris longus
Ulnar artery palpable is just proximal to the pisiform at the wrist crease

Special Tests - Ligamentous

Valgus Stress 1st MCP
UCL laxity

Murphys Sign
indication of lunate
dislocation

continuing ED

UCL Valgus Stress

Valgus stress on the 1st MCP evaluates the integrity of the ulnar
collateral ligament.
The 1st metacarpal is stabilized in extension and the proximal phalanx
is stressed in a radial direction. More than 30-35 degrees would
indicate a complete rupture of the ulnar and accessory collateral
ligaments. To isolate the the UCL the test is repeated with the thumb
flexed to 30 degrees.
Murphys Sign
An indicator of lunar instability. Normally, with a closed fist, the 3rd
knuckle (head of the metacarpal) projects further distally or dorsally.
If its equal to the 2nd and 4th the test is positive

Special Tests - Range of Motion

Bunnel-Littler (Intrinsic +)
Capsular vs. intrinsic muscular limitation in PIP flexion

Retinacular Test
Capsular vs. retinacular limitation in DIP flexion

continuing ED

Bunnel-Littler tests evaluates the source of PIP flexion motion

limitation.
The MCP is held in an extended position and you passively flex the
PIP. Repeat test with MCP flexed. If no change in motion it indicated
capsular resteriction to motion at the PIP joint MOBILIZE.
If the motion increases when the MCP is flexed it indicates tightness
in the intrinsic (lumbricale) muscles. Treatment is to STRETCH
Retinacular Test
Proximal phalanx stabilized in extension; assess DIP flexion; if no
change in motion the retinacular collateral ligaments or the capsule is
tight; if motion increases with PIP placed in more flexion; the
retinacular collaterals are tight but capsule of DIP is normal

Special Tests - Musculotendinous

Finkelstein
Sweater Finger
Isolated FDS-FDP Tests

FDS-FDP Isolation
Finkelsteins Test

continuing ED

Finkelsteins Test
Thumb flexed into palm, followed by ulnar deviation. Symptom
reproduction in the 1st dorsal compartment is a positive test.
No studies on reliability, validity, sensitivity, or sensitivity found on
a MedLine search, however, my personal opinion would be high
sensitivity and low specificity.
To avoid false positives, compare discomfort with the uninvolved
side.
Sweater Finger Sign patient is asked to make a fist. If distal
phalanx does not close it is indicative of a FDP tendon rupture.
Most common in ring finger.
Also called the jersey sign. Sweater is what the jersey is called in
hockey

Special Tests - Vascular

Allens Test
Volumetric Displacement

continuing ED

To assess the patency of the radial and ulnar arteries

Patient asked to open and closed hand multiple times and squeezed tightly into a fist
Pressure applied over both arteries
Palm is now blanched. Release one artery and monitor for capillary refill as the
color of the hand returns. Should occur with 5 seconds
Repeat with opposite artery.

Special Tests - Vascular

Allens Test
Volumetric Displacement

continuing ED

Allens Test - To assess the patency of the radial and ulnar arteries
1. Patient asked to open and closed hand multiple times and squeezed tightly into a fist
2. Pressure applied over both arteries
3. Palm is now blanched. Release one artery and monitor for capillary refill as the color of the hand
returns. Should occur with 5 seconds
4. Repeat with opposite artery.

Volumetric Displacement
10 ml difference is considered normal between dominant and non-dominant hands
J Hand Ther. 2003 Oct-Dec;16(4):292-9. The intertester and intratester reliability of hand volumetrics.
Farrell K, Johnson A, Duncan H, Offenbacker T, Curry C.
The purpose of this study was to examine the intertester and intratester reliability of hand volumetric measurements
comparing two different protocols.. Results for both protocols revealed very high intertester reliability (ICC=0.99) whether
using the first measurement or the mean of three measurements. Intratester reliability was also very high (ICC=0.99) using
either protocol. Standard error of measurement values are included and additional variables, which may affect the reliability
of hand volumetrics, are discussed. The authors conclude that there is high reliability with volumetric measurements.
Dodds RL, Nielsen KA, Shirley AG, Stefaniak H, Falconio MJ, Moyers PA. Work. 2004;22(2):107-10.
Test-retest reliability of the commercial volumeter.
OBJECTIVE: The purpose of this study was to improve the standardization of the current protocol for measuring hand
volume with the commercial volumeter. METHOD: A repeated-measures design was used to determine test-retest
reliability of the new protocol of measuring hand volume with the commercial volumeter. The new protocol used a heightadjustable table and external trunk support of the participant in order to maintain consistency of web-space pressure
between the first and second measurement. A 1 ml micropipette was used to obtain a more accurate volume reading. An
intraclass correlation (2,1), repeated measures ANOVA, and standard error of measurement were used to determine the
results of this study. RESULTS: This study confirmed the test-retest reliability of the commercial volumeter and decreased
the standard error of measurement to 3~ml as opposed to the current standard of 10 ml. CONCLUSION: Clinically, this
study is significant in that occupational and physical therapists can detect more subtle change in hand volume

Special Tests - Neurological

Phalens

Tinels

Froments Sign

continuing ED

Phalens Test prolonged wrist flexion (one minute) producing paraesthias or symptom
reproduction in the median nerve distribution. Can also do reverse phalens
(hyperextension prayer test)
Tinels tapping percussion produces tingiling and distal radiation of symptoms. Tinels is
also used to evaluate extent of sensory nerve regeneration
Froments tests for integrity of ulnar nerve. Can hold paper in pinch grip through
innervation of adductor pollicus. Pulp to pulp finger flexion subsitution (use of FPL) would
indicate an ulnar nerve injury.
Priganc VW, Henry SM. The relationship among five common carpal tunnel syndrome tests and the severity of
carpal tunnel syndrome. Hand Ther. 2003 Jul-Sep;16(3):225-36
.The purpose of this research was to examine the relationship among clinical carpal tunnel syndrome (CTS) tests and the
severity of CTS. A total of 66 subjects with electrodiagnostically confirmed CTS were tested on five CTS tests, then
classified according to the severity of CTS. An association was found between testing positive on Phalen's test and the
severity of CTS (p < 0.05). In contrast, no association was found between the severity of CTS and results on Tinel's sign,
manual version of the carpal compression test (mCCT), Katz-Stirrat hand diagram, or carpal tunnel outcomes assessment
tool. The more severe the CTS, the more likely one is to test positive on Phalen's test. Tinel's sign and the mCCT are not
influenced by the severity of CTS. This study suggests that Tinel's sign and mCCT may not be useful in assessing the
effectiveness of treatment. The Katz-Stirrat hand diagram and the carpal tunnel outcomes assessment tool are not influenced
by the severity of CTS, indicating that numerous factors can influence a patient's response on subjective questionnaires.

Walters C, Rice V. An evaluation of provocative testing in the diagnosis of carpal tunnel syndrome. Mil Med.
2002 Aug;167(8):647-52..
Carpal tunnel syndrome is a commonly known neurological entrapment disorder seen by primary care providers and
occupational therapists. The purposes of this pilot study were to (1) identify the evaluation methods that primary care
providers and occupational therapists use to diagnose carpal tunnel syndrome; (2) describe the procedures for evaluations
that practitioners use in common; and (3) compare the frequencies of diagnostic results achieved with nerve conduction
velocity testing vs. provocative testing. Three family care practitioners, two physician assistants, and four occupational
therapists at four clinical sites participated over 4 months. Fifty-five subjects' hands (77 hands; 22 bilateral) were examined.
Patients' ages ranged from 24 to 61 years, with mean of 42.5 years. Chi2 and Fisher's exact tests were used to examine
diagnostic results. Practitioners differed slightly in evaluation methods and procedures used. The Tinel's sign results agreed
with 57% (motor) and 64% (sensory) of positive nerve conduction velocity results (p > 0.05), whereas Phalen's test agreed
with 83% (motor) and 85% (sensory) (p < 0.05). Although these results indicate that Phalen's test is more sensitive, they also
accentuate the need for standardized testing based on the proposed use of the test results (screening vs. treatment).

Semmes-Weinstein Monofilament Sensory Exam

Threshold test that
measures stimulus
intensity

Normal Light Touch

Diminished Light Touch
Diminished Protective Sensation
Loss of Protective Sensation
Anesthetic

1.65-2.83
3.22-3.61
3.84-4.31
4.56-6.65
> 6.65

continuing ED

Sensory Exam to assess Light Touch

20 nylon monofilaments with different diameters (but the same
length). These monofilaments require different amount of force to
bend based on their thickness
The filament is applied perpendicular to the skin until it bends and the
therapist determines what is the minimal threshold that is detected by
the patient
Normative data is available

Special Tests - Neurological

Two-Point Discrimination

continuing ED

Functional discriminative touch test that correlates well with hand

use and ability.

Sensory Abilities

C
T1 5

C
C8 C 6
7

Discrimination

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Discrimination
Normal = less than 6 mm; require 6mm to wind watch or sew with
needle and thread
Picture has mean and range at each anatomical location
6-10 mm is fair
11-15 mm is poor

Peripheral Nerve Sensory Innervation

Median
Radial
Ulnar

continuing ED
Median

Sensory branch of median nerve provides sensation to the palmar surfce of the
lateral 3 fingers
Motor branch of median nerve innervates (the precision nerve) the pronator teres,
FPL, of FDP, pronator quadratus, FDS, FCR. It passes through the carpal tunnel
to innervate the thenar muscles and the 1st and 2nd lumbricales.
2nd distal phalanx most purely median nerve
Radial
Supplies sensation to the radial aspect of the forearm and the radial aspect of the
dorsum of the hand
Back of the web space between thumb and index fingers
The prepartory radial nerve (stabilizes the wrist in extension) innervates the
supinator, brachioradialis, ECRB/L,. Distally, the motor branch of the posterior
interossues nerve innervates the ED, ECU, EI, EDM, EPB, and APL.
Dorsal web space most purely radial nerve
Ulnar
The ulnar power nerve passes through the cubital tunnel at the elbow and
innervateds the FCU and 3-4th FDP. Passes through Guyons canal at the wrist
and divides into a sensory and motor branch.
Sensory branch serves the medial 1 fingers. The motor branch innervates the
hypothenar muscles, the 3-4th lumbricales, the interossei, and the adductor pollicus.
Lateral distal 5th phalanx most purely ulnar nerve

Functional Tests
Purdue Pegboard
Fine motor coordination

Minnesota Rate of
Manipulation
Gross coordination and
dexterity
continuing ED

Purdue Pegboard Test

This test assesses fine motor coordination with the use of small pins,
washers, and collars. Assessment categories include one hand, both
hands, alternating hands, or assembly.
Performance is timed and compared with normal values based on
sex and occupation.
Minnesota Rate of Manipulation Test

This test for gross coordination and dexterity involves placing,

turning, displacing, one-hand turning and displacing, and two-hand
turning and displacing. The activities are also timed and compared to
standardized norms.

Intervention
Designing effective treatment programs for:
Colles, Boxer, and Navicular Fractures
Gamekeepers thumb, Mallet Finger,
and Finger Sprains
RSD, DeQuervains Tenosynovitis,
and Duputryens Contracture
Neural Entrapments
CTS
Guyons Canal

continuing ED

Colles Fracture
Transverse fracture of distal radius
FOOSH
most common fracture > 40
especially in women
Dinner Fork deformity
proximal fragment displaced
volarly and laterally

continuing ED

A transverse fracture of the radius (colles fracture) usually happens

after a fall on an outstretched hand with the wrist in a dorsiflexed
position and the forearm pronated. The lunate acts as a wedge to
shear the radius off in a dorsal direction. The momentum of the body
weight causes the distal fragment to displace radially and rotate in a
supinatory direction with respect to the proximal bone end.
It is most common in elderly women and results in a dinner fork
deformity, so named because of the volar and lateral displacement of
the proximal fragement cause the wrist and hand to look like a dinner
fork.

Other Distal Radius Fractures

Smiths
a reversed Colles fx with volar
displacement of the distal
radius
garden spade deformity from a
fall on the back of the hand

Bartons
Intra-articular fx of the radial
shaft with dorsal displacement
of the dorsal lip of the radius

Colles

Smith

Chauffeurs
Radial styolid fx with various
associated ligamentous and/or
carpal fxs

Barton

continuing ED

The Colles Fracture has an extension mechnism of injury while Smiths

fracture is a hyperflexon mechanism.

Colles Fracture
Monitor for adequate blood supply
Watch for signs of infection or
pseudo-motor change (RSD)
In most cases treated with
closed reduction with 3-4 weeks
(older patient) or 4-8 weeks (younger patient) cast immobilization with wrist in slight palmar flexion and 15-20 of
ulnar deviation
External fixation may be necessary if the fracture involves
the articular surface or cannot be stabilized with external
support
Place on general conditioning program
continuing ED

Important to keep the fingers free to allow for full motion

Dynamic external fixation devices are sometimes used to allow
early motion while maintaining radial length
These fractures usually heal with some residual malalignment that
may limit wrist motion

Colles Fracture
Whirlpool ROM or Paraffin bath as precursor to treatment
AROM exercise
Allotta littlebits
Include the entire UE

Graded mobilization when fx has

bony union
PNF Stretching
Myofascial Massage
Grip, prehension, dexterity, and strengthening activities as
ROM improves
continuing ED

Particular emphasis on wrist extension, ulnar deviation, and forearm

supination as these motions are typically hard to get back following a
colles fracture.

Navicular Fracture

continuing ED

Fracture at waist of navicular (scaphoid)

Navicular Fracture Mechanism

of

Injury

FOOSH
Forced hyperextension
with the wrist in ulnar
deviation
Common football injury

continuing ED

Also common in skateboarders

Navicular Fracture Presentation

Pseudo wrist sprain
Snuffbox swelling
Painful wrist motion and
power grip
Snuffbox tenderness is
considered a navicular
fracture until x-ray
negative 3-4 weeks later

continuing ED

Navicular Fracture Management

Rigid plaster immobilization with thumb
spica for 8-12 weeks
Notorious for non-union secondary to
poor blood supply to proximal pole
Surgical intervention may be necessary
for displaced fractures or bone grafting
at 6 months if no evidence of bony
union
Post-immobilization rehab focuses on
regaining strength and motion
continuing ED

ORIF may be used to accelerate healing and allow earlier motion

Boxers Fracture
Fracture of the neck of 4th or 5th
metacarpal
Metacarpal head tilts in volar direction
causing hyperextened MCP
Metacarpal head angulates and rotates

continuing ED

Red line shows significant angulation to the fracture of the 5th

metacarpal

Boxers Fracture Mechanism of Injury

continuing ED

Closed fist punching against an immovable resistance the bar

room brawl fracture

Boxer Fracture
Signs/Symptoms
Depressed knuckle
Swelling over fracture
site
MCP joint in hyperextension

continuing ED

Boxer Fracture Immobilization

Impact fracture with minimal
angulation
compression dressing for one week
then gradual ROM

> 40 angulation
closed reduction with 3-4 weeks
immobilization; possible ORIF

Immobilized in MCP flexion with

4-5th metacarpals buddied
together to prevent rotation
continuing ED

Management is dependent on degree of rotational angulation

deformity

Boxer Fracture Post-Immobilization Rehab

Whirlpool ROM
AROM to unaffected digits
Restoration of ROM following
immobilization
Functional strengthening
activities

continuing ED

Gamekeepers Thumb
Injury to UCL of 1st MCPJ
Fall on outstretched thumb
common skiing injury
where pole levers thumb
into abd/extension

S/S
point tenderness
thenar swelling
limited and painful active/passive thumb abduction

continuing ED

Gamekeepers Thumb Management

Grade I-II
Immobilization for 2-6 weeks
Protected ROM and
progressive strengthening

Grade III
Unstable thumb requires
surgical repair

continuing ED

Mallet Finger
Trauma at DIP resulting
in avulsion of distal phalanx
or extensor tendon rupture
MOI
forced flexion at fingertip

Pain/swelling at distal digit

Decreased active DIP
extension
continuing ED

Mallet Finger
Acute Immobilization Phase
Splint with DIP in mild
hyperextension and PIP
unrestricted

Post Immobilization
Careful progression of
DIP flexion range at 6-8
weeks post injury
Splint should be worn an additional 6-8 weeks
during activity
continuing ED

Mallet Finger

continuing ED

Swan neck deformities are possible if not treated appropriately

Finger Sprain
Dorsal PIP Dislocation
hyperextension
mechanism causing
volar plate injury

ecchymosis and
tenderness at base of
middle phalanx
continuing ED

PIP Dislocation Immobilization

Dorsal blocking splint that
blocks the last 30 of
extension with full PIP
flexion ROM allowed
Extension block gradually
reduced over 3-4 weeks
Buddy taping should
continue after full ROM is
achieved
continuing ED

DeQuervains Tenosynovitis
Tenosynovitis of the 1st dorsal compartment where
EPB and APL cross the radial styloid
Crepitation with thumb/wrist movement
Thickened tendon sheath with pain radiating into thumb
Provocation with thumb flexion/radial deviation

continuing ED

DeQuervains Tenosynovitis
Signs/Symptoms
pain and tenderness to
palpation in area of radial styloid
pain with repetitive thumb and or
wrist motions

+ Finklesteins test
possible + ULTT for radial nerve
continuing ED

Finklesteins test tends to be highly sensitive but not very specific

DeQuervains Tenosynovitis
Acute Immobilization Phase
2-6 wks gutter splint immobilization
with prevention of radial deviation
and thumb flexion
I.C.E.
Iontophoresis

continuing ED

DeQuervains Tenosynovitis
Acute Immobilization Phase
2-6 wks gutter splint immobilization
with prevention of radial deviation
and thumb flexion
I.C.E.
Iontophoresis

Post Immobilization Phase

Regain ROM and UE strength
Grip, prehension, and dexterity activities
Ensure normal joint mobility/stability
continuing ED

Carpal Tunnel Syndrome

Compression neuropathy of median nerve
Confirmed by EMG/NCV
R/O
cervical radiculopathy
TOS
Pronator teres syndrome
compression neuropathy of
median nerve at elbow

continuing ED

Specificity and sensitivity of the electrodiagnostic studies approached

90%

CTS Signs and Symptoms

pain, tingling, and numbness in median distribution
hand goes to sleep
weakness and clumsiness of thumb, index, and middle
finger
thenar atrophy if chronic
nocturnal symptoms often
present first
+ ULTT for median nerve

continuing ED

CTS Contributing Factors

Space Occupying Predisposition
Carpal Fractures
Colles Fractures
DJD Osteophytes

continuing ED

CTS Contributing Factors

General Medical Status
Rheumatoid Arthritis
Pregnancy
Diabetes
Obesity

continuing ED

CTS Contributing Factors

Gender Preference
Women > Men

continuing ED

CTS Contributing Factors

Environmental Influences
Cumulative overuse
Postural dysfunction

continuing ED

Carpal Tunnel Syndrome

Acute Immobilization Phase
Ice
Rest
NSAID
Cortisone/Lidocaine Injections
Cock-up wrist splint at night

continuing ED

The neutral wrist splint is particularly helpful at night but should be

weaned as the inflammatory symptoms subside.

Thermotherapy Rationale
Ice analgesic and anti-inflammatory effect
Heat increase blood flow and facilitate tissue readiness for flexor
tendon gliding

Carpal Tunnel Syndrome

Post Immobilization Phase
Ionto/Phonophoresis
Maintain wrist mobility and ROM
soft tissue and joint mobilization
AROM
Neural-tendon glides

Cervical Screen
Regain functional strength
Ergonomic Awareness and
Modification Strategies
continuing ED

Carpal Tunnel Surgery

Endoscopic
two small incisions to release
the carpal ligament under
telescopic visualization

Percutaneous Open

continuing ED

If conservative management fails a carpal tunnel release is

usually pretty successful.

Carpal Tunnel Surgery

Endoscopic
two small incisions to release
the carpal ligament under
telescopic visualization

Percutaneous Open
2-3 incision to perform
resection under direct
visualization

continuing ED

Carpal Tunnel Release Post-Op Management

Wound Care - Scar Management
Cock-up Splint
Tendon/Nerve Glides
Pain Control Modalities
Edema Control
Post-op Care
No lifting, squeezing, bending, repetitive motions, etc

Ergonomic adjustments

UE progressive strengthening can begin at 6-8 wks

continuing ED

Wound Care - surgical scar treated with elastomer or silicone gel in

addition to soft tissue massage/mobilization
Cock-up Post-op Splint usually used for 1-2 weeks; volar wrist
splint in 0 degrees in extension continues for night wear or during
strenuous activities
Edema Control tubigrip stockinette, elevation, and retrograde
massage

Tendon Gliding Exercises

Straight
Straight

Hook
Hook

Fist
Fist

Tabletop
Tabletop

Straight Fist

continuing ED

Median Nerve Mobilization

wrist neutral; finger
& thumb extended

extend fingers
extend thumb

passive
stretch to
thumb

extend wrist
supinate forearm

continuing ED

Median Nerve Mobilization

Proximal Joint Positioning
Forearm
Elbow
Shoulder
Scapula
Cervical Spine

continuing ED

Proximally:
Forearm supinated
Elbow extended
Shoulder abducted externally rotated
Scapula depressed
Cervical spine lateral flexion away from side of involvement

Guyons Canal Syndrome

Handlebar Palsy
Entrapment neuropathy of ulnar nerve in
distal ulnar tunnel

Signs/Symptoms
medial palmar paraesthia
weakness in 3-4th lumbricales and
adductor pollicus

Management
Immobilization or Rest; NSAIDs; and
minimize repetitive stress or posture

continuing ED

Dupuytrens Contracture
Progressive fibrotic contracture
of the palmar aponeurosis
Associated conditions include
plantar fibromatosis and
peyronies disease

Unknown etiology
Often bilateral
Scandinavian descent?

continuing ED

Dupuytrens Contracture Signs/Symptoms

Minimal pain complaint
Isolated nodules form,
harden, and reabsorb at
the base of the ulnar fingers
Overlying palmar skin
adheres to fascia with strong fibrous cords
Deformity flexion contracture of fingers
continuing ED

Management of Dupuytrens Contracture

Conservative Treatment
Focus is on improvement in hand
function (not curative)
AROM
Passive Stretching Exercises
Extension Splinting

continuing ED

Post-Op Management of
Dupuytrens Contracture Surgical Fasciectomy
Acute

Wound care
Edema Control
Extension Splinting
ROM

Sub-Acute

Scar management
Desensitization/massage
A/PROM
Functional Strengthening
continuing ED

Complex Regional Pain Syndrome (RSD)

spastic vasomotor component
sudomotor autonomic
hyperactivity
trophic changes
skin becomes shiny/smooth

constant, deep, diffuse,

intense pain
hypersensitivity often disproportionate to the trauma
cold intolerance
Sudeks osteoporosis from disuse
continuing ED

Reflex Sympathetic Dystrophy

Medical Management
lidocaine or cortisone
injections
sympathetic blocks

continuing ED

Complex Regional Pain Syndrome

RSD Management
early recognition and EDUCATION
pain management
heat vs. cold; contrast, TNS

pain free AROM

edema management
elevation, retrograde massage, intermittent compression, JOBST
or isotoner glove

progressive stress loading

desensitization - fluidotherapy, massage, or particle/texture
aerobic conditioning and UE ROM
continuing ED

Generally these patients do not tolerate manual therapy techniques

as well

Rehabilitation Considerations
Modalities
Manual Therapy

joint mobilization
soft tissue techniques
scar management
desensitization

Strengthening
Total Arm Strength
dexterity and materials handling

ADL Activities
stress loading

Splinting
continuing ED

Modalities

what is the physiological rationale?

pain control - edema management - therapeutic preparation

Whirlpool
Paraffin
Electrotherapy
Ultrasound
Iontophoresis
Thermotherapy
continuing ED

Rehabilitation Aides

continuing ED

Stress Loading
A specific set of exercise activities
designed to improve function
Scrub
progressive (compressive) weightbearing ADL activities

Carry
progressive (destructive) non-weight bearing
ADL activities

continuing ED

Desensitization
Percussion (Tapping)
Friction Massage
Vibration
Rubbing

continuing ED

continuing ED