Traumatic Wrist and Hand Pathologies

Welcome back everybody. We're going to go from anatomy of the wrist and hand into traumatic pathologies of the wrist and hand and the fingers as well. So we're going to start here with what we call Colley's fracture and this is going to be specifically a fracture to the distal radius and or ulna. Usually it's going to be the radius because that's the more weight-bearing bone of the distal forearm and when we foosh and that's the MOI here when we go into a fooshing mechanism. most of the shock absorption in the forces is going to go through the primarily weight-bearing bone, which is the radius. And what makes this specifically called a dinner fork or Colley's fracture, dinner fork being the layman's term here, is the shape or presentation of the fracture that we're going to see as the radius becomes displaced in the posterior direction, because this is usually a non-union fracture. So this presentation specifically makes a radial fracture a Colley's fracture. And because it is a non-union fracture and there's little to no chance for those bones to heal without them being in proper alignment, our typical care for this would be to splint and refer. And many times these folks are going to need to be reduced by a physician in the ER and or internally fixated in a surgery. You can also have ulnar involvement. up to 50-60% of the time, and it could, if that's the case, if there is ulnar involvement, then the TFCC could be involved as well. But typically speaking, when we think collies fracture, genitoforque fracture, we're looking at mostly the radius. In addition to a typical collies fracture presentation, which is MOI again from a FUSH, which would be this picture here, or sorry, this one here on the left, then the opposite of that would be if we FUSH, but instead of the hand being in an extended position, if we fall, which is less common, but fall with our hand in a flexed position, you can have a similar distal radial fracture, but the displacement or dislocation of the hand and, you know, distal chunk of radius there, it's going to go the other direction. So this would be called a Smith's fracture or a reverse Collius fracture. And then your deformity that you would see on inspection would be in the opposite direction. So it'd be a reverse dinner fork fracture. Okay, another thing that can happen when we foosh and fracture the distal radius is going to be a compression fracture, right? So the radius is going to be compressing into the proximal carpal row, right? We can see that space between the distal radius and the proximal carpal row is very limited because this is our main source of stability in the wrist. This open space over here in the ulna means that there's less weight-bearing capacity going through the ulna. And the TFCC is going to live largely in this gap space. So when we fall and foosh, we have our scaphoid here, which you can see is fractured right where my mouse is. And there's also a little fracture here in the distal radius. This would be essentially a buckle fracture or compression fracture of the distal radius and the scaphoid, right? So scaphoid fracture we'll get to soon here in this PowerPoint is going to have the same MOI. Fooshing with an extended hand. Same MOI as a distal radius fracture. And so all this to say is that you can possibly have both, especially in the case of a younger population in our children, because you can start to have the compression or buckle fracture presentation in the radius and also have that fracture in the scaphoid. OK, moving on from our distal radio fractures into carpal tunnel syndrome. So we went over the anatomy in pretty good depth in our previous lecture. But now we're going to apply it into the pathophysiology. So again, we have these nine tendons running through this carpal tunnel, four from the superficialis, four from the profundus, and one from the flexor pollicis longus. All of those nine tendons are running through this small, narrow carpal tunnel. And if those become inflamed, enlarged, fibrotic, or just in a compressed wrist flexed position for long periods of time, This is usually over chronic amounts of time. So think slow buildup of symptom presentation. Then that median nerve that lives in there can become affected. It has less space to live and thrive. And so it can become compressed. When that happens, the median nerve distal to that site is going to become affected. And so you can have nerve symptoms distal to that in the form of sensory symptoms or motor symptoms. Okay, so... There's our pinching site. That's the carpal tunnel. Again, it's not up here in the wrist. It's right here. on the proximal row of the carpals. So the most often symptoms that you're going to feel, or your patients are going to feel, hopefully it's not you, is going to be sensory deficits. So this would be in the specific median nerve innervation of the palm and fingers. So not just the entire palm, but specific to where the median nerve travels. So digits one through four, mainly one through three, but on the... Okay. In terms of motor function, We are going to commonly see this manifest itself in weakness with gripping. So most of the motor function of the median nerve into the hand supplies the thanar eminence, so the muscles controlling the thumb. And so you're going to have a weak pinch grip because of that thumb weakness. So you're going to have sensory loss, and you're also going to have weakened musculature in that thanar eminence. And if this is a chronic presentation, which it usually is, and it lasts for a long time, that weakness and lack of neurological supply to the muscles can start to actually lead to atrophy of that muscle group. That can be a very significant finding when you're examining these patients, is that that muscle group is actually withered away. This is very common and often exacerbated in our patients with rheumatoid arthritis and diabetes. And we do have some special tests for this. There's a few. Phalen's test, we'll go over that in lab, is typically going to be a positive test when we see a patient with carpal tunnel syndrome. Also, Durkin's, aka carpal compression test, is going to be positive as well. That's typically one of our most sensitive and specific tests. And then lastly, Tenell's test, when we apply that tapping over the carpal tunnel itself, that can be a positive as well. What are we going to do about it? Of course, we're going to ice activity modification in order to remove our patients from the... aggravating activities, but a night splint is going to be very common, and we can also have our patients wear that during aggravating activities. The reason why we want to wear it at night is because a lot of people sleep at night curled up on their sides or on their back with their wrists in positions of prolonged flexion, and those prolonged flexion positions place a lot of compression on that carpal tunnel, therefore aggravating a lot of people's carpal tunnel, and we're going to have a lot of night symptoms as a result. If your patient is one of those people, has a lot of night symptoms, then a splint at night will be helpful. Also, things that can help is oral steroids or in a non-conservative manner, having a corticosteroid injection. Things that we can do for rehab, which we'll get to in 6010, which will be carpal bone mobilizations, tendon and nerve gliding in order to mobilize those structures through the carpal tunnel, as well as grip strengthening exercises. And if conservative treatment fails, then a lot of times... there will be an aspiration so you're going to relieve some of the swelling or edema from the carpal tunnel or worst case scenario a fasciotomy or a surgical release of that retinaculum flexor retinaculum that sits over top of the carpal tunnel in order to remove the pressure that way so this is what that would look like there's our carpal tunnel it's been released this would be an open release because the skin is open so they're just cutting that flexor retinaculum in order to release the pressure Nowadays, what's going to be a little bit more common is going to be an arthroscopic release. Either way, you're getting the same job done, but you're just doing it arthroscopically, so you have less scarring and less trauma to the skin and the superficial fascia. Both successful at a fairly high rate, 70 to 90 percent, and is very good in relieving those sensory effects from carpal tunnel syndrome. And those motor effects are still going to need to be worked back over time. You're not just going to relieve atrophy overnight. You have to regain the strength. So when would you want to refer a patient for this kind of surgery? If their presentation has been lasting for longer than 10 months. So we're talking about a really long time, very, very chronic, continual numbness or any of those other sensory symptoms that we might feel. And if you start to see the atrophy, in the thenar eminence muscles themselves. So not just weakness, but actual atrophy of those muscles. Another thing would be symptoms occur within 30 seconds of the Phelan's test, which again, we'll go over that in lab, or if our patients are above 50 years of age because they have a less of aptitude to quickly heal and recover. Here is what some of our scars could look like in our patients from a, this would be more of a open arthroscopic sorry, an open release, excuse me, on the right here versus arthroscopic release. Okay, so both are options. And when we have these patients, not only are we going to be treating the carpal tunnel surgery, but we're going to want to be treating the incision site as well. And sorry, before I move on, check out this left hand. Look at that thanar eminence. This is a really good example, you guys, of that atrophy of the thumb musculature compared to this right hand. So this would be more of a shorter timeline presentation, you would guess, or predominantly a sensory presentation where this left hand is going to be a very obviously this person would have had a lot of weakness on the pinch grip and just gripping in general because of the thanar eminence atrophy. OK, moving on to the TFCC. So when we have a triangular fibrocartilage complex injury, that is an injury to any or all parts of the TFCC. So that could be to the articular disc. It could be to the onocarpal ligament. It could be to the dorsal or volar radial ulnar ligaments. Or it could be to part of the ECU sheath, so the extensor carpi ulnaris. Important to note here, similar to the scaphoid, this area is a very low blood supply. Only about 15 to 20 percent, and this is of the periphery of the TCZ, has blood supply really at all. And largely this is due to being in a joint space. So it undergoes large amounts of compression. And if we think about most of our cartilaginous structures or ligamentous structures, they just don't get a lot of blood flow. So if we have an injury to this area, that's important to note because it's going to be a slow healer. So we're going to typically have to take a little bit more cautious approaches. and be a little bit more aggressive in terms of splinting and all that stuff. The TFCC is a major stabilizer of not only the carpal ulnar joint, but of the distal radial ulnar joint. And we'll get into that more on our next injury here. But this basically prevents displacement or dislocation of the ulna within the pronated position. Okay, so one test that we can see here as being a positive in the case of a TFCC injury is when the hand is in a pronated position, and... the ulna may rise posteriorly or up, and then you could have a positive piano key test in order to press that distal styloid back down. Okay, so what's our MOI specifically? Oftentimes we're going to have a foosh injury if it's done in an acute sense, and that foosh is going to be typically in a funky position. It might be in a rotated position, like a hyperpronated position. It might be in a position of ulnar deviation. Or if it's a chronic presentation, which is also common, then our patients are going to be repetitively forced into positions of ulnar deviation, pronation, and extension. So think a lot of tennis players that are doing backhand, forehand, backhand, forehand, they get a lot of ulnar deviation. This could potentially happen in our golfers as well. They have a lot of ulnar deviation as they come down in their swing to strike the ball. So a lot of those sports that do a lot of repetitive motions with ulnar deviation. this can happen. Signs and symptoms, well, they're going to have a lot of pain, tenderness, palpation over the TFCC. We've gone over that in lab of where to palpate that, but they're also going to have limited motion going into those problematic directions. So ulnar deviation could be affected, extension, that should be EXT, sorry, not ECT. Protation and supination range of motion can also be decreased and limited as a result of the pain, swelling, and apprehension going into those areas. Other special tests that we can see as being positives here is this TFCC compression test, which is shown in the picture here at the bottom right of the screen. In this test, we're applying an axial load and with ulnar deviation. So you can imagine what that's doing to this TFCC. So the axial load is already compressing it, and if that's not enough, then we are applying an ulnar deviation, which is further compressing the area, which it's not going to like. Another test is going to be the supination lift test, and we'll go over that in lab coming up. treatment, oftentimes we're going to want to splint for this in order to allow for proper healing due to that poor blood flow, especially if there is any instability noted. And in cases of high instability or low progress with healing, then there is a likelihood of surgical stabilization. Okay, so moving on, and this could be often involved with a TFCC injury or it could be separate, is a distal radial ulnar diastasis. So I think this is going to be very similar, you guys, to... a high ankle sprain, right? So the wrist joint itself is very similar to the ankle joint in that you have a cruris, so that distal radial ulnar joint looks very similar, concavity, two bones coming together, similar to the distal tibiofibular joint, and then it sits on top of a sac of carpals or tarsals in order to make up the wrist or ankle joint. So similarly in a high ankle sprain, where that can go into the anterior tibiofibular ligament, we can have sprains to this upper wrist area into the distal radial ulnar ligaments. We have a dorsal and a palmar one. And then if bad enough, that can actually radiate and become more of a separation. or a diastasis as we call it, up into the radial ulnar syndesmosis, right? We have a syndesmosis here just like we do in the lower leg. So not only can this distal ligament be sprained, but if severe enough also so can the syndesmosis. And since the TFCC is a primary stabilizer of this distal radial ulnar joint, oftentimes the TFCC can be involved here. So what are we going to find? So tenderness to palpation, on the dorsum of the hand, pain with active pronation, supination, compression, right? If you apply an axial load to that hand, that will cause a lot of pain in the distal radial ulnar joint, and maybe even extending up into the syndesmotic region of the wrist itself, or of the forearm. You're going to also probably see a lot of pain and laxity if we do a distal radial ulnar joint play assessment, and that is because there's a high likelihood of, here's our dorsal radial ulnar ligament, that could be compromised, or our palmar radial ulnar ligament, that can be compromised as well. Okay, moving on. So another injury that we can have from a FUSH mechanism, this would be just moving down more into the carpal area rather than of the distal radius and ulna TFCC area, is one, and this is a really common one, maybe the most common one in terms of fractures that we're going to see with a FUSH, is a scaphoid fracture. Depending on the source that you look, this could be either the most commonly fractured bone in the body or the second most commonly fractured bone in the body. So this is one that you need to be very familiar with for obvious reasons. You're going to see it a lot. And it's going to hide because it's a small bone. And similar to a lot of other small bones and tarsal bones and bones that live in joint spaces like this, there's a low blood supply. So this is very important to identify early on. Okay, so... When we have a FUSH injury, let's get into a little bit more of that MOI. The scaphoid is going to be compressed majorly between the distal radius and the distal row of carpals. So there's a high amount of compression between those bones, which can lead to the cracking and the fracturing. Because of the poor blood supply to the scaphoid, it is often a low or poor healing rate to this bone. So that is why it's important to identify it early, refer our patients out for an x-ray so that they may be properly splinted or even casted in order to allow for proper healing. If our patients are not splinted and casted appropriately, then healing will be stunted or non-existent because of overuse and therefore continued lack of activity modification in the area is going to slow down the healing or prevent it altogether. Oftentimes, this immobilization is going to be required, and it is going to last up to six weeks, just like we would see with most fractures. And then we're going to want to strengthen it, apply any protective tape or bracing to it in order to continue to provide it support after that casting. Okay, one thing I want to point out here is a particular palpation. So we've gone over this in lab, but again, can't hurt to review because this is a very common fracture site. The scaphoid is going to live. on this lateral aspect of the wrist joint inside the anatomical snuff box. So if you're at home right now and not driving, please don't be driving and do this, but go ahead and just abduct your thumb out to the side and you will see your anatomical snuff box become prominent as those tendons raise up. Now stick your other thumb within that anatomical snuff box right here and only deviate the wrist and you will feel a bone. It's probably going to be a little bit tender just on the norm. Okay, that bone that kind of pops up into your palpating thumb as you ulnarly deviate is your scaphoid. As you radially deviate, you'll kind of feel it like almost like slip away into the abyss. That's your scaphoid. That's the easiest way you're going to palpate this bone. Okay, so this is what it's going to look like right here. So there's your outcropping of three. So on a cadaveric dissection, there's your scaphoid. It's very deep in there at the base of the thumb, right? So right proximal to the trapezium. In the case of surgical fixation, right, if splinting is not enough or if you have a displaced fracture of the scaphoid, then oftentimes you're going to need to have your patient get a screw or like a basically plate, not so much because it's a really small area. But a little screw is going to be inserted into that scaphoid in order to restore alignment, which is going to be what we see here. So this picture on the left is going to be pretty much a live surgery picture. And then on the right, this is after. four months of healing. And so you can see that union has been accomplished very nicely. So these patients are always going to go for follow-up x-rays in order to ensure that that union is happening. And it's also happening with proper alignment, which is what the screw is for. Again, this is not going to happen in our patients unless we refer. So we have to make sure we catch these. Moving on from scaphoid fractures to the next carpal bone over in the proximal row, that would be your lunate, right? Scaphoid, lunate. tricletrum pisiform, that's our proximal row. One common injury we can see here, and this is also, you guessed it, going to be from a FUSH mechanism, is going to be what we call a lunate instability injury, or oftentimes a lunate dislocation. It could be a subluxation, it could be a sprain, and in worst case scenario, or in a severe case, it's going to be a lunate dislocation. And similarly to how the scaphoid is compressed on a FUSH from the distal radius, Well, that distal radius can also compress the lunate, which, for whatever reason, instead of often fracturing it, usually it displaces it in a volar direction or in a palmar direction. So when that moves anteriorly or in a palmar direction, we can lose our integrity of that joint. It can possibly even compress the median nerve, which is running through that carpal tunnel right over top or volarly. to that lunate, and in that case, with lunate dislocation, you may start to see sensory changes in the first and second fingers as a result. Not always, of course, but if you do start to see that, then think, okay, maybe there's a lunate dislocation that's protruding forward and shrinking the space in the carpal tunnel. This x-ray picture here is a really good one. This red bone here is the lunate yellow highlighted around the radius, and then the blue would be indicating more of the distal carpal row. Okay, so this is a normal presentation in an x-ray. This is a healthy hand, no fracture or dislocation. And in this picture on the right, you have a dislocated lunate that has literally popped out forward. Okay, and it's not going to be so obvious. You're not going to see an obvious deformity when you're just looking at the, you know, proximal palm and wrist. But on x-ray, on this side view, or frontal plane view, coronal view, it will be very obvious. And also you're going to see it. specific presentation called Murphy's sign when you look at this patient's fists or a knuckle alignment from this view. So this person has a lunate dislocation on their left hand and you can tell because this third knuckle, so the knuckle of your middle finger, this MCP here becomes sunken or depressed. So it becomes in line with the second and the fourth MCP or knuckles. And if you see here on the healthy side, this is not normal. The third MCP should be a little bit raised or sitting in a dorsal position to the rest. It should be the most tall knuckle. But in the case of a lunate instability or dislocation, that anterior falling or displacement of the lunate is going to drag down the metacarpal with it because they're all connected. And so you're going to have a falling of that third metacarpal. Yeah, third metacarpal, excuse me. And that's called a Murphy's sign. Okay. Other things that the patient might report is they're going to have pain, instability with things like gripping, with pushups. Just getting into that extended position is going to be very difficult and painful because that was their MOI. Does that make sense? And they might even report a feeling of instability during some of these activities. Here's another picture of how the bones can displace in different ways. So there's your hyperextension mechanism and then your lunate can come down. forward. Oftentimes for treatment, we are going to want to immobilize this. If it is fully dislocated, they need to be reduced first. This can often be done by a physician or a chiropractor, assuming that we've referred out or sorry, ruled out a fracture, right? We don't want to reduce anything before ruling out a fracture. But once they've been reduced, or if it's a low grade sprain and no reduction is necessary, then a splint is going to be very helpful in order to let that. ligament area heal with proper alignment. If it's a full tear, you may need to refer out for surgical intervention in order to repair that ligament. Okay, and then another test that we can do in order to identify this would be called the Blotman test. So the Blotman test we were going to go over in lab, and you can do this basically as a joint play assessment between any intercarpal joint. This is not specific to the lunate. You can do it even between a distal radius and ulna. But when we apply it to this pathology, then we are going to do it on the lunate, and oftentimes the carpal that sits next to it, which would be the triquetrum. If we do the Blotment test to the lunotricretial joint, then it is called the lunotricretial Blotment test. Okay, so that makes sense. And all it is, is we're doing a shear force, so we're basically shearing the lunate in relation to the tricretium or the other way around. So the tricretium in relation to the lunate in an anterior to posterior direction. If you have excessive movement relative to the contralateral side, then that would indicate... instability or even a dislocation of that lunate. Okay, moving on to the next carpal. Okay, so now we're going into more of the distal row of the carpals when we talk about the hamate. The most common injury to the hamate that we're going to see in our athletes is going to be a hook of the hamate fracture. Okay, so the hamate is going to be able to be palpated from both the dorsal side of the hand and the palmar side, but we are going to palpate the hook of the hamate from the palmar side of the hand. So that lives. at the base of the hypothenar eminence. Okay, so we've palpated this one in lab already. I want you to palpate that on yourself. This is a really good one to be familiar with. Scaphoid, hook of hammy, and the lunate, those are going to be the three most commonly injured carpal bones that you're going to see in your athletes. So you need to be very good at palpating them in order to identify injury to those areas. How do we potentially injure our hook of the hammy? Usually it's with a fracture. And that is either it could potentially be from a foosh where you land with a lot of weight on your hypothenar eminence specifically. And that hook of the hammock could just become compressed and fractured. But probably more commonly, it's going to be due to trauma having to do with the sporting motion. So this is going to be really common in our swinging, bat sports, racket sports, club sports. Right. So baseball, tennis and golf. So how that's going to look is oftentimes the knob. of either the golf club, the baseball bat, or the tennis racket can compress either acutely in a high load or chronically, repetitively over time, it can be, if it's placed right over that hook of the handmate, that chronic repetitive compression can actually lead to a fracture. And so if you think about golfers that are constantly doing ulnar deviation, right, then they're... adding compression onto that ulnar side of their hand. Tennis players, same thing. When we're doing backhands especially, and in baseball players, that bottom hand on the bat can sit right on that knob, and a funky pitch where, say, maybe they foul a ball off the end of the bat adds a lot of vibration into the bat. A lot of force is going to go down into the base of the hand, and that force can be transmitted specifically to that hook of the hammy, and over the course of time, you can start to have a fracture develop there. Okay, so these patients are going to present with a lot of tenderness to palpation over that hook of the handmaid, as you could probably guess. And they're also going to have significant amount of wrist pain and weakness. What do we do in this case? Well, of course, we're going to need to refer out because we need to have an x-ray in order to rule this in. We're going to splint these folks. And in the case of a displaced fracture or a non-union fracture, then there's going to be a surgery required here. Down the road, after they've recovered from their fracture or surgery and they're easing back into their sports, they are going to potentially be a little bit sensitive to the knob of that club or bat resting on that area again. And so oftentimes, a donut pad can be helpful to place over that hook of the hammy in order to offload or just spread out the compressive forces around the hook of the hammy, rather than having them be centered into the hook of the hammy. This can be very helpful, but keep in mind... these athletes are very fine-tuned and touch-oriented, and they might not like the feel of having a padding there, right? They might feel like that's actually going to worsen their performance at their sport, and so you might have to look into other things, maybe a more padded glove, especially in the case of tennis, or sorry, in the case of golf or baseball. And in the case of baseball specifically, we're going down a little bit of a niche rabbit hole here, but changing or... offering to change their bat type from a typical round bat knob into what we call an axe handle bat, which is more of an axe handle shape. And so the portion that articulates with the palm is going to be more of a flat surface rather than having a knob squishing right into the hand. But again, the player may or may not actually like this kind of bat, so all we can do is suggest these things, and then hopefully they take us up on it because we know the benefit of those things. Okay, so here's a nice MRI hookahaminate fracture right here, where you can see at the base of that hook, good fracture there. That's from a golfer. Okay, we're going to move into finger pathologies here. So we hit a lot of wrists, then we did a lot of carpals, now we're going to end on finger pathologies. So hang with me here. This is the last section of this, and then we are actually done with the upper extremity overall, guys. We did shoulder, elbow, wrist, hand, and now into fingers. We're almost there. A lot of finger stuff, though. First thing we're going to talk about is called gamekeeper's thumb. This can also be called skier's thumb. That's another one. But gamekeeper's thumb, so think about goalies. That's going to be common here. The etiology or the MOI is going to be forced thumb abduction or hyperabduction. So a valgus force, essentially, you can think of to the thumb. So it is a sprain or tear of the onocollateral ligament of the thumb, right? So right through there. And then this is what our patients are going to look like maybe after. due to that instability, they're going to have a ton of abduction through that first MCP joint. Okay. So that ulnar collateral ligament of the first MCP joint. This is often common in our gamekeepers or our goalies, because think when they try to maybe catch a ball, it's coming at them with a high amount of velocity. If they miss it a little bit and it just bends their thumb back rather than hitting the palm of their hand nicely, then that could tweak their thumb back into this position. and sprain or tear that ligament. It can also happen in your skiers because if you fall on, say, a ski pole, then the thumb can become hyper abducted on the ski pole as you see here in the picture. So this can happen in multiple ways, but those are the common ones. And often we're going to see certain signs and symptoms. So of course, pain, tendon distal palpation over that ligament, over that medial aspect of the first MCP. and a lot of pain with abduction, especially passive abduction of the thumb. That's not going to feel good because it's going to put a lot of tensile stress on that ligament and aspect of the joint. Other things that we're going to see is inability to snap your fingers. So snap your fingers right now, and just notice what kind of force, hold the snap position. Before you let the finger snap, hold that position, that pinch grip position. What kind of force is going through that first MCP of your thumb? it's a valgus force, right? So if you have pain and inability to snap the fingers, that can be indicative of an injury to this area. And of course, we can apply a valgus stress test even to that ligament itself. So if we do that and we notice pain and laxity relative to the contralateral thumb, that can be indicative of a UCL injury to the thumb. What are we going to do? Just like any ligament injury, in a mild case, right? So a low grade sprain, maybe a grade one, we're going to treat symptomatically. We're going to rice. We're going to work on range of motion, blah, blah, blah. In a moderate case, so we have some laxity and some damage to the ligament, we are going to immobilize. So think tape, splint. You can maybe even cast this thumb. In a severe case, a full tear, oftentimes a surgery may be required to fix it. Or if not, you could potentially work it back, but this person will forever have this laxity presentation. the thumb. Okay, moving on to a Bennett's fracture. So this is a fracture specifically to the trapezium, so the bone, the carpal bone, distal carpal bone that sits at the base of the thumb or the base of that first CMC, but it's not just isolated to the trapezium. Oftentimes a Bennett's fracture can extend into the articular surface of the first CMC. So this could be a fracture going between the first CMC, so the proximal metacarpal of the thumb, and the trapezium itself. This will oftentimes be due to an axial load, so either a foosh or potentially jamming the thumb very hard, or think maybe a baseball catcher that is often catching high velocity pitches and maybe catches one, he or she catches one, at the at the base of the thumb over and over and over. that high velocity pitch can start to degrade and weaken and fracture that area of the thumb. Oftentimes, this fracture, because it involves articular surface and can extend across the joint line, oftentimes this type of fracture will require an ORIF, which stands for open reduction internal fixation. It could also require arthroscopic fixation. But what we mean by that, reduction fixation. Reduction meaning... If the bones are malunion or displaced, those need to be reduced and realigned. And open fixation means that they're going to be maintained in alignment via a pin or a screw. Okay, so this is going to be really common in a Bennett's fracture injury to see a reduction of that fracture and a screw or pin in order to maintain alignment. So again, very important to refer these patients out for an x-ray because then they start that domino. trickle effect of, okay, now we're seeing a physician, we have the x-ray, now they go, oh man, you have a Benis fracture, we need to start the line of you know, basically lining up a surgery in this case. Moving on to finger dislocations slash fractures. How is that going to happen? Usually it's going to be with a crushing blow. It's going to be an axial blow, right? So think maybe rebounding a basketball with a straight finger or potentially trying to catch a ball with a straight finger and that ball or potentially another opponent's body part. It's a blow to the tip of the finger. Okay, in that case, you can have a... maldirection, right? So this would be, in this picture, is a dislocation of the distal phalanx of the second digit, excuse me. And oftentimes this longitudinal force not only acts as a compression force, but with a rotation force as well. So that's how we can have a fracture as well. Distal phalanx is going to be the most commonly affected because that is where this blow is going to be starting from. But middle phalanx, not so much. Proximal phalanx can be affected as well, especially in the presence of a twisting or rotational force that is applied to the finger. Okay, so what are these patients going to feel? They're going to feel a pop. They're going to be tender to palpation over the affected phalanx. You may see some swelling. In the case of a dislocation, you will see a deformity into the direction of dislocation. And you can apply some of your fracture tests to these folks in order to rule out fracture, such as your percussion tests, compression tests, tuning fork. And we'll go down the line there. Now, just keep in mind, these tests themselves are not highly accurate clinical tests. So they can be helpful. You do not want to rely on them. And just because you have some negatives here, don't assume that you have no fracture. It's still helpful, especially in the case of dislocation, to refer our patients out to have an x-ray because that can be very common with a dislocation. And we can have a lot of false negatives with these tests. So complications of finger fractures. So oftentimes in the case of a twisting or rotational fracture, then there may need to be a fixation of that bony fracture. So if there's a deformity into the metacarpal proximal phalanx, then surgery may be required because phalanxes and fingers in general do not tolerate twisting or rotational forces very well at all. And so they can become fractured very easily and you may need a plate in order to do so. So spiral fractures can occur here. Angulated fractures can occur. And if they're bad enough, they can become non-union. Okay. So in those cases, our patients would often need a surgery. And this, I just want to point out that you guys should be extra sensitive with referring our younger or youth athletes out for x-rays. Really in any case of suspected fracture. but especially in the hand and fingers because the likelihood is so high for them to have growth plate involvement. And that's really important to catch early on. So that's going to need to be treated differently than an adult with a fracture that is not to the growth plate. OK, moving on to what we in layman's terms know as Jersey finger. So Jersey finger. or profundus finger or sweater sign, there's a few names for it. Jersey finger is gonna be the most common thing we talk about. It's really, that's layman's terms, right? So what is it really? It's a rupture of the flexor digitorum profundus tendon. Profundus tendon, we can see here at the bottom, is the deep one, right? It's gonna go all the way down and flex and take action and flexion of the dip joint of your finger. So the distal interphalangeal phalanx joint. As opposed to the flexor digitorum superficialis, which acts and flexes at the pip joint. Okay, so when we have a flexor digitorum profundus rupture, that is often going to be from an excessive eccentric load to that dip joint itself. That often happens. Imagine if a football player or really any athlete is trying to make a tackle or grab onto another player, grab onto that jersey, and you say maybe you get your finger caught in there as that. player is breaking away or running away, the eccentric load, or even as you're trying to pull down that player, the eccentric load on the finger is going to be very, very high, right? You're pulling down an entire player or that jersey on that person is breaking away from you. So that eccentric load can be excessive and too high on the tendon itself. And so that tendon can rip and rupture at some point. Either it could be distally into the finger, it could be proximally in the finger, or it could happen in the palm itself. In any case, we are going to see a similar presentation where these patients are unable to make a fist, and when they try to make a fist, the involved finger cannot flex, especially being said at that dip joint, right? So you can see here in this bottom picture, there's decent flexion here of the pip joint, but there is zero flexion at the dip joint. So that's how you know that the profundus tendon specifically has been involved and ruptured here. Okay, so in these cases, we want to splint and refer. Surgery is going to be somewhat common in these cases. But in any case, this is not our decision. We want to refer out to let an orthopedic or hand surgeon make that call. The reason why maybe you're not going to see surgeries in every case is depending on the location of the tear will determine the successful rate or prediction rate of the surgery itself. There are certain areas that respond to surgery better because there are certain areas that are going to have a little bit more stiffness or problems. with the recovery portion of things. So they're going to be notorious for extended healing times and have a lot of complications. So think tears in these red areas right here. That is going to be biggest problems. Okay, Dupuytren's contracture. This is essentially, think of in these flexor digitorum or profundus tendons, in our interossei tendons, or in our palmar fascia of the hand. especially, you're going to have nodules that can start to basically present over time adhesions, fibrosis in the tendons and palmar fascia of the hand. So you can see these tendons right here in this person's palm right here. Very fibrotic, thick, and therefore contracted in nature. These nodules and adhesions can become a major, major problem. It can lead to forced contracture of the MCP and PIP joints, as you can see here. So this person is not voluntarily in this position. It's just happening to them. And it's really, really common in the fourth and fifth digits. So in the ring finger and the pinky. Common sign you're going to see is this person is going to be unable to flatten their hand on, say, a tabletop or a countertop in that printed position because the finger is going to be so contracted into a flexed position. This is very much more common in our more geriatric population, so maybe a little less common in our athletic population. But for those of you that are going to be working in an outpatient or physician office setting, this may be more commonly seen there. This is another similar presentation. This is not duplicant contracture, but this is called trigger finger or stenosing tenovitis, which is most common in the index or middle fingers. And this is... a similar idea in the sense that you're going to have nodule formation in the tendons of those fingers, but not so much the palmar fascia. So here's a good picture of a potential nodule or fibrotic formation within the tendon itself. Why this becomes a problem and how this can get fingers stuck into a position is there's a lot of little retinaculums and sheaths over the MCP joint, PIP joint, DIP joint in order to create somewhat of a pulley system of the finger. This is called an A1. pulley system. These nodules or thickenings of the tendinous structures can get caught or stuck and basically get herky-jerky and have trouble gliding through those sheath little tunnels. And in that case, if it becomes stuck in one position, in a flexed position, then we call that a trigger finger because of all the flexion of that finger looks like, you know, obviously the position of a finger would be if it's pulling a trigger. So when these nodules become trapped into the pulley system... that essentially triggers trigger finger, no pun intended. But essentially, that's going to be very similar to Dupuytren's contracture, except this is more common in the pointer in middle fingers, whereas Dupuytren's is more common in the fourth and fifth fingers, and more commonly involves the fascia of the hand, as well as the tendons, versus trigger finger is specifically more into the tendons, stenosing into these fingers. Extra common or more common in our patients that have diabetes and rheumatoid arthritis. And essentially what we're going to see here is popping, maybe even some catching as these patients try to flex and extend their fingers. You're going to literally see like clunking of that finger or a locking in severe cases as they try to move their finger through those ranges of motions. In those severe cases too, you may even be able to palpate those nodules in the palm. palmar side of the hand as well. What are we going to do for treatment? We're going to refer these patients out. Oftentimes for non-surgical treatment, we're going to try that first, and this could involve rest, night splinting in order to put that finger back into a position of extension, NSAIDs of course, stretching, tendon gliding exercises, steroid injections into the tendon sheath. That's a very painful procedure. As you can see here in the picture, imagine just having that injection right into the tendon itself. And if none of that is going to help, then a surgical treatment is going to be necessary where they go in through the skin and they actually cut out the nodule itself and then therefore release that tendon. Okay, moving on to more finger injuries. This is going to be called a boutonniere deformity. This is going to be a common one that we see in a traumatic sense. The etiology or MOI here is going to be extreme flexion force or crushing blow. So think if someone has a blunt force trauma, say to the distal phalanx, that can do it. Middle to distal phalanx is basically a tear or rupture. of the central slip so that extensor hood that we talked about in the last lecture, that is going to be ruptured in a boutonniere deformity. So the extensor tendon mechanism is ruptured and then what we see here is the inability to extend through the pip joint, but because of all these tendons continuing to still run into the dip joint, you're going to see actually extension or hyperextension of the dip joint. So it's the combination of inability to extend through the PIP joint with involuntary extension and hyperextension of the dip joint. Okay, so how would we treat this? Is we would actually splint the PIP joint into a position of extension in order to allow for healing. That is what a splint could look like in this case. Another common injury that we can see in the metacarpal region would be a boxer's fracture. This is specifically a fracture to the fifth metacarpal bone of the hand. And it is most commonly fractured. It's called a boxer's fracture because it often happens when an athlete or a patient is punching a hard surface, such as, you know, boxing, maybe another person, or even maybe more common in our other non-boxing sports. It's when athletes become really frustrated, pissed off, and they actually punch the bench or they punch a wall, maybe due to poor performance during that game. And in the process, they can actually fracture. the distal metacarpal, distal fifth metacarpal right there. And that is very frustrating because obviously now that is very embarrassing for that athlete. They just broke their hand. No good. So what are we going to see? Obviously pain, tenderness, swelling over that fracture site on the fifth metacarpal, possible deformity, especially in this case, you can probably feel for lack of alignment in the fifth metacarpal. We're going to want to rice this person, refer for x-ray in order to confirm. You're going to want to splint that hand and finger, and often this can last up to four weeks. Surgery is possible, but it is not super common. That's really only going to be common in high amounts of displacement or nonunion, with high amounts of deformity, or in highly proximal cases. Moving on to dip and pip collateral sprains, okay? So maybe some of you guys have even had this. But dip and pip joints, they have their collateral ligaments, right, medial side and radial side of the fingers in order to maintain linear motion of the fingers. So fingers really like to flex and extend in the sagittal plane. Our phalanxes do not like to rotate too much or especially move into the dip joint and pip joint do not like to move into abduction or adduction. That's responsible at the MCP joint. So if we have... loading of the finger, say a jamming of the finger, with any sort of lateral compression or rotational aspect to that load, then you can start to see a sprain or full tear of these collateral ligaments, whether it's radial collateral ligament or on the other side would be the ulnar collateral ligament. What we would see here is obviously tentative palpation, pain and swelling over those ligaments themselves. We could also see pain and instability when we stress test. those ligaments through a varicervalgus stress test at the paper dip joint. And in an extreme case of a high-grade sprain or tear, where you have loss of integrity of that ligament, you can actually see a deformity or that finger becomes bent away from the side of injury, right? So if the injury is to this side of the finger, then it is going to be bent away because lack of integrity on this side. Splint these people up, rule out fracture. That's always nice, especially in the case of a dislocation or severe deformity. Rehab surgery is, in this case, is very unlikely in these injuries, but it is possible in the case of just slow healing, lack of improvement, and in the case of maybe a very severe fracture as well. Decourvain syndrome. This is a common one in the thumb. That is going to be where we are relating this injury to. So the outcropping of three that we went over in the anatomy video and in our lab palpation points, that is going to be the area of interest here. So again, those three tendons that form the outcropping of three are the extensor pollicis longus, That's going to be the one on the more dorsal or posterior aspect. And then also our extensor pollicis brevis and abductor pollicis longus. And again, these are the tendons that make that anatomical stuff box. Okay, so that's going to come up a lot. Just that being able to pop that finger up in order to palpate those tendons, not just for scaphoid palpation, which is in here, but also to assess the area for what we call de Quervain's syndrome. which really is inflammation of the synovial lining of these common sheaths. So tenosynovitis, tendonitis, or tendinosis of these tendons and their sheath. When we have that, that is going to be then called decorvain syndrome. And because we have this distal branch of the radial nerve coming into this area, inflammation around it and under this extensor retinaculum can lead to compression and therefore injury to the radial nerve there, superficial branch. And so you can start to see potentially, not always, but potentially sensory deficits into the dorsal aspect of the hand. So dorsal aspect, top of the hand, into the thumb, pointer finger especially, but potentially into the rest of the hand as well. Common findings here, positive Finkelstein's test, we're going to see that in lab. Sharp pain at the outcropping of three. McCandle, Lieutenant... mechanical tendinopathy irritability, right? So think about that. Like what do we see with our common tendonitis is pain with warming it up. And then it kind of like wears off as the area gets warm and pain maybe after activity as well. If it's tendinosis, that's more of a degeneration kind of thing. And you're not going to be responding to NSAIDs. If there is kind of more of a degeneration, maybe you're going to have more of a crepitus situation is there as things get um, poor lubrication, start to get crunchy. If the radial nerve is involved, you can test this through a radial nerve tension test or a Tenell's test to that site. We're going to want to give this person edseds to reduce their inflammation. Cortisone injection or oral corticosteroids can help reduce that inflammation. And then later on, we're going to rehab for range of motion, especially accentuating the tendon and nerve gliding. We're going to want to splint these folks in severe cases where it is... limiting their activities of daily life. And last thing I want to point out is in this picture, you can actually see a little bit of swelling over the outcropping of three tendon area, redness as well. Okay. Mallet finger. This is one of our last pathologies into the fingers. Mallet finger is specifically a rupture of the extensor tendon at the dip joint. So this is not of the central hood or the, um, the central slip or the extensor hood. This is specifically to the distal interphalangeal joint extensor tendon. So the extensor digitorum tendon at the dip joint. This is often going to be due to an injury of axial compression to the finger with a little bit of flexor load. Okay, if that is fractured, then we're going to have this presentation here where you have the inability to extend through that distal phalanx, right? You could also have a fracture with that. That is very common. So we do just because we realize, oh, yeah, okay, this is a torn tendon does not mean there's no fracture. We want to refer these folks out for an x-ray in order to rule out a concomitant fracture in order to make sure that we're treating this person as a whole. Treatment for this is going to be a splint. We call that a stack splint where we're putting that distal phalanx into a position of extension. Swan neck deformity. This is another one you guys need to be familiar with. So we have boutonniere deformity, we have swan neck deformity, we have mallet finger, jersey finger. There's a lot of these deformities you need to be familiar with their presentation in order to catch it just on the eye test. And these will come up on your BOC, I promise you. So swan neck deformity is this sort of presentation. And some people are actually born with very hypermobile finger joints and they can actually go into these positions without injury. But in our athletic populations, we're concerned about it if it's an acute injury. So what would the injury be? It's a volar plate rupture. So that would be on the palmar aspect of the pip joint here. If that is ruptured, then you can have a presentation of going into hyperextension of the pip joint, and then which would put flexion into the dip joint due to the tendons being stretched out across the pip joint that are then pulling them down into the dip joint. How does this happen? Basically, again, I said you can essentially be born with it. or maybe hyperextension of that pip joint or fingers altogether can lead to volar plate rupture at that pip joint. Beautiful. Moving on to what we call handlebar. palsy. That's our layman's term for what is otherwise known as Guyon's canal syndrome. And you thought there was only a carpal tunnel syndrome in the hand. You were wrong. There's a Guyon's canal syndrome as well. The Guyon's canal lives next door to the carpal tunnel. All right. So you have Guyon's canal, carpal tunnel, their neighbors, their friendly neighbors, and they are not always involved on the same injuries, very rarely. So Guyon's canal syndrome is where we have ulnar nerve compression. through the guy on canal. So it's a different nerve. It's a different canal. This is more laterally or sorry, excuse me, medially located on the hand. And really that canal is formed between the hook of the hamate and the PC form here. Okay. So you can see this flexor retinaculum continues to go over here and that ulnar nerve, especially the superficial sensory branch and the deep motor branch running through this canal, supplying the fourth and fifth digits with sensation. and it is also supplying the hypothenar eminence and much of the palm with its motor function. So when we have a guidance canal injury, how do we have it? It's compression to that site. This is most commonly going to happen in the case of bikers or maybe golfers, where we have compression through that canal area. So on the handlebar, this is why it's called handlebars palsy. This can also happen potentially with a golf club, baseball bats, tennis rackets as well. if it's constantly being compressed into that canal. In the case of compression of the ulnar nerve in that canal, you're going to see, just like any nerve injury, deficits of the nerve function distal to the site of compression. Okay, I'll say that again, because this is super common in any area of the body. Any nerve injury, you can see the effects of deficits of that nerve's function distal to the site of compression. Okay, so motor and sensory function of the ulnar nerve distal to this canal are... Like we said, it's innervating the fourth and fifth digits with its sensation. So you could have parasesers there, numbness, tingling, burning. Or you can have weakness, that's the motor function, into the hand, especially with gripping. And that is going to be from the deep motor branch of that ulnar nerve. Okay, last slide, guys. We made it. Wrist ganglion cyst. Okay, so ganglion cyst you can have in multiple joints of the body. Probably going to be the most common in the wrist. You can also see them in the knee, in the popliteal fossa. but we're also most commonly, like I said, going to see them in the wrist. And that's usually going to be on the dorsal aspect of the wrist. And in some cases, you can actually see this as a protrusion of a fluid-filled sac or a herniated joint capsule sac that comes up so far that you can feel it and sometimes even see it in that joint line of the wrist. Why does it happen? That's a good question, you guys. It can happen after trauma, maybe a wrist sprain or strain. It can happen just with overuse of the area, but it can happen to some people and not to others. The etiology is somewhat unclear for ganglion cysts in general, and the findings are going to be pretty consistent, right? So basically, you're going to feel this palpable nodule fluid-filled sac in that area. It's going to be painful. And it could even restrict range of motion since it's taking up joint space. So I think this person is maybe going to have a hard time moving into full extension range of motion because it lives in the way. It's obstructing the motion. So how do we manage it? Well, if it's pretty good size, a physician can aspirate it. So put a needle in there and drain the fluid out. And then we can put a padding over the top of it in order to reduce any further aggravation. You can potentially use ultrasound to reduce the size. of it, but this is going to be more of a conservative treatment that takes slower effect. Surgical removal is the most effective way if it's severely symptomatic, but obviously this is the most intense way to go about it. So that's a hard sell for a lot of patients. And then you also have the Bible Blast technique, which is basically take a large firm object, smack it in order to pop it or reduce, relocate that ganglion cyst back into the joint surface where it came from. This is obviously very painful and is not a surefire way to do it. So we don't often actually see this method in the clinic. So ganglion cyst, usually the best case scenario is to actually refer this patient out in order to therefore be aspirated from a physician or potentially recommended for what conservative treatments you can be doing. Okay, you guys made it. We did it. That is all of our pathologies that we're going to be covering in this class to the wrist, hand, and fingers. Congratulations. We've completed the upper extremity. It's a lot of stuff, I know, but you did it. And this is one of the hardest things you're going to learn in the AT program is just going through the whole upper extremity evaluation process. So if you need to rewatch any portions of this lecture in order to just review certain pathologies, feel free. I highly recommend. or just reviewing through the PowerPoint itself, just to differentiate between any confusing or closely related pathologies is also very helpful. Otherwise, I'll see you guys in lab. Thanks for listening and have a good day.

Usually it's going to be the radius because that's the more weight-bearing bone of the distal forearm and when we foosh and that's the MOI here when we go into a fooshing mechanism. most of the shock absorption in the forces is going to go through the primarily weight-bearing bone, which is the radius. And what makes this specifically called a dinner fork or Colley's fracture, dinner fork being the layman's term here, is the shape or presentation of the fracture that we're going to see as the radius becomes displaced in the posterior direction, because this is usually a non-union fracture.

So this presentation specifically makes a radial fracture a Colley's fracture. And because it is a non-union fracture and there's little to no chance for those bones to heal without them being in proper alignment, our typical care for this would be to splint and refer. And many times these folks are going to need to be reduced by a physician in the ER and or internally fixated in a surgery. You can also have ulnar involvement. up to 50-60% of the time, and it could, if that's the case, if there is ulnar involvement, then the TFCC could be involved as well.

But typically speaking, when we think collies fracture, genitoforque fracture, we're looking at mostly the radius. In addition to a typical collies fracture presentation, which is MOI again from a FUSH, which would be this picture here, or sorry, this one here on the left, then the opposite of that would be if we FUSH, but instead of the hand being in an extended position, if we fall, which is less common, but fall with our hand in a flexed position, you can have a similar distal radial fracture, but the displacement or dislocation of the hand and, you know, distal chunk of radius there, it's going to go the other direction. So this would be called a Smith's fracture or a reverse Collius fracture. And then your deformity that you would see on inspection would be in the opposite direction.

So it'd be a reverse dinner fork fracture. Okay, another thing that can happen when we foosh and fracture the distal radius is going to be a compression fracture, right? So the radius is going to be compressing into the proximal carpal row, right? We can see that space between the distal radius and the proximal carpal row is very limited because this is our main source of stability in the wrist. This open space over here in the ulna means that there's less weight-bearing capacity going through the ulna.

And the TFCC is going to live largely in this gap space. So when we fall and foosh, we have our scaphoid here, which you can see is fractured right where my mouse is. And there's also a little fracture here in the distal radius. This would be essentially a buckle fracture or compression fracture of the distal radius and the scaphoid, right?

So scaphoid fracture we'll get to soon here in this PowerPoint is going to have the same MOI. Fooshing with an extended hand. Same MOI as a distal radius fracture.

And so all this to say is that you can possibly have both, especially in the case of a younger population in our children, because you can start to have the compression or buckle fracture presentation in the radius and also have that fracture in the scaphoid. OK, moving on from our distal radio fractures into carpal tunnel syndrome. So we went over the anatomy in pretty good depth in our previous lecture. But now we're going to apply it into the pathophysiology.

So again, we have these nine tendons running through this carpal tunnel, four from the superficialis, four from the profundus, and one from the flexor pollicis longus. All of those nine tendons are running through this small, narrow carpal tunnel. And if those become inflamed, enlarged, fibrotic, or just in a compressed wrist flexed position for long periods of time, This is usually over chronic amounts of time.

So think slow buildup of symptom presentation. Then that median nerve that lives in there can become affected. It has less space to live and thrive.

And so it can become compressed. When that happens, the median nerve distal to that site is going to become affected. And so you can have nerve symptoms distal to that in the form of sensory symptoms or motor symptoms.

Okay, so... There's our pinching site. That's the carpal tunnel. Again, it's not up here in the wrist.

It's right here. on the proximal row of the carpals. So the most often symptoms that you're going to feel, or your patients are going to feel, hopefully it's not you, is going to be sensory deficits. So this would be in the specific median nerve innervation of the palm and fingers. So not just the entire palm, but specific to where the median nerve travels.

So digits one through four, mainly one through three, but on the... Okay. In terms of motor function, We are going to commonly see this manifest itself in weakness with gripping.

So most of the motor function of the median nerve into the hand supplies the thanar eminence, so the muscles controlling the thumb. And so you're going to have a weak pinch grip because of that thumb weakness. So you're going to have sensory loss, and you're also going to have weakened musculature in that thanar eminence.

And if this is a chronic presentation, which it usually is, and it lasts for a long time, that weakness and lack of neurological supply to the muscles can start to actually lead to atrophy of that muscle group. That can be a very significant finding when you're examining these patients, is that that muscle group is actually withered away. This is very common and often exacerbated in our patients with rheumatoid arthritis and diabetes. And we do have some special tests for this. There's a few.

Phalen's test, we'll go over that in lab, is typically going to be a positive test when we see a patient with carpal tunnel syndrome. Also, Durkin's, aka carpal compression test, is going to be positive as well. That's typically one of our most sensitive and specific tests.

And then lastly, Tenell's test, when we apply that tapping over the carpal tunnel itself, that can be a positive as well. What are we going to do about it? Of course, we're going to ice activity modification in order to remove our patients from the... aggravating activities, but a night splint is going to be very common, and we can also have our patients wear that during aggravating activities.

The reason why we want to wear it at night is because a lot of people sleep at night curled up on their sides or on their back with their wrists in positions of prolonged flexion, and those prolonged flexion positions place a lot of compression on that carpal tunnel, therefore aggravating a lot of people's carpal tunnel, and we're going to have a lot of night symptoms as a result. If your patient is one of those people, has a lot of night symptoms, then a splint at night will be helpful. Also, things that can help is oral steroids or in a non-conservative manner, having a corticosteroid injection. Things that we can do for rehab, which we'll get to in 6010, which will be carpal bone mobilizations, tendon and nerve gliding in order to mobilize those structures through the carpal tunnel, as well as grip strengthening exercises.

And if conservative treatment fails, then a lot of times... there will be an aspiration so you're going to relieve some of the swelling or edema from the carpal tunnel or worst case scenario a fasciotomy or a surgical release of that retinaculum flexor retinaculum that sits over top of the carpal tunnel in order to remove the pressure that way so this is what that would look like there's our carpal tunnel it's been released this would be an open release because the skin is open so they're just cutting that flexor retinaculum in order to release the pressure Nowadays, what's going to be a little bit more common is going to be an arthroscopic release. Either way, you're getting the same job done, but you're just doing it arthroscopically, so you have less scarring and less trauma to the skin and the superficial fascia.

Both successful at a fairly high rate, 70 to 90 percent, and is very good in relieving those sensory effects from carpal tunnel syndrome. And those motor effects are still going to need to be worked back over time. You're not just going to relieve atrophy overnight.

You have to regain the strength. So when would you want to refer a patient for this kind of surgery? If their presentation has been lasting for longer than 10 months.

So we're talking about a really long time, very, very chronic, continual numbness or any of those other sensory symptoms that we might feel. And if you start to see the atrophy, in the thenar eminence muscles themselves. So not just weakness, but actual atrophy of those muscles. Another thing would be symptoms occur within 30 seconds of the Phelan's test, which again, we'll go over that in lab, or if our patients are above 50 years of age because they have a less of aptitude to quickly heal and recover. Here is what some of our scars could look like in our patients from a, this would be more of a open arthroscopic sorry, an open release, excuse me, on the right here versus arthroscopic release.

Okay, so both are options. And when we have these patients, not only are we going to be treating the carpal tunnel surgery, but we're going to want to be treating the incision site as well. And sorry, before I move on, check out this left hand. Look at that thanar eminence. This is a really good example, you guys, of that atrophy of the thumb musculature compared to this right hand.

So this would be more of a shorter timeline presentation, you would guess, or predominantly a sensory presentation where this left hand is going to be a very obviously this person would have had a lot of weakness on the pinch grip and just gripping in general because of the thanar eminence atrophy. OK, moving on to the TFCC. So when we have a triangular fibrocartilage complex injury, that is an injury to any or all parts of the TFCC.

So that could be to the articular disc. It could be to the onocarpal ligament. It could be to the dorsal or volar radial ulnar ligaments. Or it could be to part of the ECU sheath, so the extensor carpi ulnaris. Important to note here, similar to the scaphoid, this area is a very low blood supply.

Only about 15 to 20 percent, and this is of the periphery of the TCZ, has blood supply really at all. And largely this is due to being in a joint space. So it undergoes large amounts of compression.

And if we think about most of our cartilaginous structures or ligamentous structures, they just don't get a lot of blood flow. So if we have an injury to this area, that's important to note because it's going to be a slow healer. So we're going to typically have to take a little bit more cautious approaches.

and be a little bit more aggressive in terms of splinting and all that stuff. The TFCC is a major stabilizer of not only the carpal ulnar joint, but of the distal radial ulnar joint. And we'll get into that more on our next injury here.

But this basically prevents displacement or dislocation of the ulna within the pronated position. Okay, so one test that we can see here as being a positive in the case of a TFCC injury is when the hand is in a pronated position, and... the ulna may rise posteriorly or up, and then you could have a positive piano key test in order to press that distal styloid back down.

Okay, so what's our MOI specifically? Oftentimes we're going to have a foosh injury if it's done in an acute sense, and that foosh is going to be typically in a funky position. It might be in a rotated position, like a hyperpronated position. It might be in a position of ulnar deviation. Or if it's a chronic presentation, which is also common, then our patients are going to be repetitively forced into positions of ulnar deviation, pronation, and extension.

So think a lot of tennis players that are doing backhand, forehand, backhand, forehand, they get a lot of ulnar deviation. This could potentially happen in our golfers as well. They have a lot of ulnar deviation as they come down in their swing to strike the ball.

So a lot of those sports that do a lot of repetitive motions with ulnar deviation. this can happen. Signs and symptoms, well, they're going to have a lot of pain, tenderness, palpation over the TFCC. We've gone over that in lab of where to palpate that, but they're also going to have limited motion going into those problematic directions.

So ulnar deviation could be affected, extension, that should be EXT, sorry, not ECT. Protation and supination range of motion can also be decreased and limited as a result of the pain, swelling, and apprehension going into those areas. Other special tests that we can see as being positives here is this TFCC compression test, which is shown in the picture here at the bottom right of the screen.

In this test, we're applying an axial load and with ulnar deviation. So you can imagine what that's doing to this TFCC. So the axial load is already compressing it, and if that's not enough, then we are applying an ulnar deviation, which is further compressing the area, which it's not going to like. Another test is going to be the supination lift test, and we'll go over that in lab coming up.

treatment, oftentimes we're going to want to splint for this in order to allow for proper healing due to that poor blood flow, especially if there is any instability noted. And in cases of high instability or low progress with healing, then there is a likelihood of surgical stabilization. Okay, so moving on, and this could be often involved with a TFCC injury or it could be separate, is a distal radial ulnar diastasis. So I think this is going to be very similar, you guys, to... a high ankle sprain, right?

So the wrist joint itself is very similar to the ankle joint in that you have a cruris, so that distal radial ulnar joint looks very similar, concavity, two bones coming together, similar to the distal tibiofibular joint, and then it sits on top of a sac of carpals or tarsals in order to make up the wrist or ankle joint. So similarly in a high ankle sprain, where that can go into the anterior tibiofibular ligament, we can have sprains to this upper wrist area into the distal radial ulnar ligaments. We have a dorsal and a palmar one. And then if bad enough, that can actually radiate and become more of a separation.

or a diastasis as we call it, up into the radial ulnar syndesmosis, right? We have a syndesmosis here just like we do in the lower leg. So not only can this distal ligament be sprained, but if severe enough also so can the syndesmosis. And since the TFCC is a primary stabilizer of this distal radial ulnar joint, oftentimes the TFCC can be involved here. So what are we going to find?

So tenderness to palpation, on the dorsum of the hand, pain with active pronation, supination, compression, right? If you apply an axial load to that hand, that will cause a lot of pain in the distal radial ulnar joint, and maybe even extending up into the syndesmotic region of the wrist itself, or of the forearm. You're going to also probably see a lot of pain and laxity if we do a distal radial ulnar joint play assessment, and that is because there's a high likelihood of, here's our dorsal radial ulnar ligament, that could be compromised, or our palmar radial ulnar ligament, that can be compromised as well. Okay, moving on. So another injury that we can have from a FUSH mechanism, this would be just moving down more into the carpal area rather than of the distal radius and ulna TFCC area, is one, and this is a really common one, maybe the most common one in terms of fractures that we're going to see with a FUSH, is a scaphoid fracture.

Depending on the source that you look, this could be either the most commonly fractured bone in the body or the second most commonly fractured bone in the body. So this is one that you need to be very familiar with for obvious reasons. You're going to see it a lot. And it's going to hide because it's a small bone.

And similar to a lot of other small bones and tarsal bones and bones that live in joint spaces like this, there's a low blood supply. So this is very important to identify early on. Okay, so... When we have a FUSH injury, let's get into a little bit more of that MOI.

The scaphoid is going to be compressed majorly between the distal radius and the distal row of carpals. So there's a high amount of compression between those bones, which can lead to the cracking and the fracturing. Because of the poor blood supply to the scaphoid, it is often a low or poor healing rate to this bone. So that is why it's important to identify it early, refer our patients out for an x-ray so that they may be properly splinted or even casted in order to allow for proper healing. If our patients are not splinted and casted appropriately, then healing will be stunted or non-existent because of overuse and therefore continued lack of activity modification in the area is going to slow down the healing or prevent it altogether.

Oftentimes, this immobilization is going to be required, and it is going to last up to six weeks, just like we would see with most fractures. And then we're going to want to strengthen it, apply any protective tape or bracing to it in order to continue to provide it support after that casting. Okay, one thing I want to point out here is a particular palpation. So we've gone over this in lab, but again, can't hurt to review because this is a very common fracture site. The scaphoid is going to live.

on this lateral aspect of the wrist joint inside the anatomical snuff box. So if you're at home right now and not driving, please don't be driving and do this, but go ahead and just abduct your thumb out to the side and you will see your anatomical snuff box become prominent as those tendons raise up. Now stick your other thumb within that anatomical snuff box right here and only deviate the wrist and you will feel a bone. It's probably going to be a little bit tender just on the norm. Okay, that bone that kind of pops up into your palpating thumb as you ulnarly deviate is your scaphoid.

As you radially deviate, you'll kind of feel it like almost like slip away into the abyss. That's your scaphoid. That's the easiest way you're going to palpate this bone. Okay, so this is what it's going to look like right here. So there's your outcropping of three.

So on a cadaveric dissection, there's your scaphoid. It's very deep in there at the base of the thumb, right? So right proximal to the trapezium. In the case of surgical fixation, right, if splinting is not enough or if you have a displaced fracture of the scaphoid, then oftentimes you're going to need to have your patient get a screw or like a basically plate, not so much because it's a really small area. But a little screw is going to be inserted into that scaphoid in order to restore alignment, which is going to be what we see here.

So this picture on the left is going to be pretty much a live surgery picture. And then on the right, this is after. four months of healing. And so you can see that union has been accomplished very nicely.

So these patients are always going to go for follow-up x-rays in order to ensure that that union is happening. And it's also happening with proper alignment, which is what the screw is for. Again, this is not going to happen in our patients unless we refer.

So we have to make sure we catch these. Moving on from scaphoid fractures to the next carpal bone over in the proximal row, that would be your lunate, right? Scaphoid, lunate.

tricletrum pisiform, that's our proximal row. One common injury we can see here, and this is also, you guessed it, going to be from a FUSH mechanism, is going to be what we call a lunate instability injury, or oftentimes a lunate dislocation. It could be a subluxation, it could be a sprain, and in worst case scenario, or in a severe case, it's going to be a lunate dislocation.

And similarly to how the scaphoid is compressed on a FUSH from the distal radius, Well, that distal radius can also compress the lunate, which, for whatever reason, instead of often fracturing it, usually it displaces it in a volar direction or in a palmar direction. So when that moves anteriorly or in a palmar direction, we can lose our integrity of that joint. It can possibly even compress the median nerve, which is running through that carpal tunnel right over top or volarly.

to that lunate, and in that case, with lunate dislocation, you may start to see sensory changes in the first and second fingers as a result. Not always, of course, but if you do start to see that, then think, okay, maybe there's a lunate dislocation that's protruding forward and shrinking the space in the carpal tunnel. This x-ray picture here is a really good one.

This red bone here is the lunate yellow highlighted around the radius, and then the blue would be indicating more of the distal carpal row. Okay, so this is a normal presentation in an x-ray. This is a healthy hand, no fracture or dislocation. And in this picture on the right, you have a dislocated lunate that has literally popped out forward.

Okay, and it's not going to be so obvious. You're not going to see an obvious deformity when you're just looking at the, you know, proximal palm and wrist. But on x-ray, on this side view, or frontal plane view, coronal view, it will be very obvious.

And also you're going to see it. specific presentation called Murphy's sign when you look at this patient's fists or a knuckle alignment from this view. So this person has a lunate dislocation on their left hand and you can tell because this third knuckle, so the knuckle of your middle finger, this MCP here becomes sunken or depressed. So it becomes in line with the second and the fourth MCP or knuckles.

And if you see here on the healthy side, this is not normal. The third MCP should be a little bit raised or sitting in a dorsal position to the rest. It should be the most tall knuckle. But in the case of a lunate instability or dislocation, that anterior falling or displacement of the lunate is going to drag down the metacarpal with it because they're all connected. And so you're going to have a falling of that third metacarpal.

Yeah, third metacarpal, excuse me. And that's called a Murphy's sign. Okay.

Other things that the patient might report is they're going to have pain, instability with things like gripping, with pushups. Just getting into that extended position is going to be very difficult and painful because that was their MOI. Does that make sense?

And they might even report a feeling of instability during some of these activities. Here's another picture of how the bones can displace in different ways. So there's your hyperextension mechanism and then your lunate can come down. forward. Oftentimes for treatment, we are going to want to immobilize this.

If it is fully dislocated, they need to be reduced first. This can often be done by a physician or a chiropractor, assuming that we've referred out or sorry, ruled out a fracture, right? We don't want to reduce anything before ruling out a fracture.

But once they've been reduced, or if it's a low grade sprain and no reduction is necessary, then a splint is going to be very helpful in order to let that. ligament area heal with proper alignment. If it's a full tear, you may need to refer out for surgical intervention in order to repair that ligament. Okay, and then another test that we can do in order to identify this would be called the Blotman test. So the Blotman test we were going to go over in lab, and you can do this basically as a joint play assessment between any intercarpal joint.

This is not specific to the lunate. You can do it even between a distal radius and ulna. But when we apply it to this pathology, then we are going to do it on the lunate, and oftentimes the carpal that sits next to it, which would be the triquetrum.

If we do the Blotment test to the lunotricretial joint, then it is called the lunotricretial Blotment test. Okay, so that makes sense. And all it is, is we're doing a shear force, so we're basically shearing the lunate in relation to the tricretium or the other way around.

So the tricretium in relation to the lunate in an anterior to posterior direction. If you have excessive movement relative to the contralateral side, then that would indicate... instability or even a dislocation of that lunate. Okay, moving on to the next carpal.

Okay, so now we're going into more of the distal row of the carpals when we talk about the hamate. The most common injury to the hamate that we're going to see in our athletes is going to be a hook of the hamate fracture. Okay, so the hamate is going to be able to be palpated from both the dorsal side of the hand and the palmar side, but we are going to palpate the hook of the hamate from the palmar side of the hand.

So that lives. at the base of the hypothenar eminence. Okay, so we've palpated this one in lab already. I want you to palpate that on yourself. This is a really good one to be familiar with.

Scaphoid, hook of hammy, and the lunate, those are going to be the three most commonly injured carpal bones that you're going to see in your athletes. So you need to be very good at palpating them in order to identify injury to those areas. How do we potentially injure our hook of the hammy? Usually it's with a fracture. And that is either it could potentially be from a foosh where you land with a lot of weight on your hypothenar eminence specifically.

And that hook of the hammock could just become compressed and fractured. But probably more commonly, it's going to be due to trauma having to do with the sporting motion. So this is going to be really common in our swinging, bat sports, racket sports, club sports.

Right. So baseball, tennis and golf. So how that's going to look is oftentimes the knob. of either the golf club, the baseball bat, or the tennis racket can compress either acutely in a high load or chronically, repetitively over time, it can be, if it's placed right over that hook of the handmate, that chronic repetitive compression can actually lead to a fracture.

And so if you think about golfers that are constantly doing ulnar deviation, right, then they're... adding compression onto that ulnar side of their hand. Tennis players, same thing. When we're doing backhands especially, and in baseball players, that bottom hand on the bat can sit right on that knob, and a funky pitch where, say, maybe they foul a ball off the end of the bat adds a lot of vibration into the bat. A lot of force is going to go down into the base of the hand, and that force can be transmitted specifically to that hook of the hammy, and over the course of time, you can start to have a fracture develop there.

Okay, so these patients are going to present with a lot of tenderness to palpation over that hook of the handmaid, as you could probably guess. And they're also going to have significant amount of wrist pain and weakness. What do we do in this case? Well, of course, we're going to need to refer out because we need to have an x-ray in order to rule this in. We're going to splint these folks.

And in the case of a displaced fracture or a non-union fracture, then there's going to be a surgery required here. Down the road, after they've recovered from their fracture or surgery and they're easing back into their sports, they are going to potentially be a little bit sensitive to the knob of that club or bat resting on that area again. And so oftentimes, a donut pad can be helpful to place over that hook of the hammy in order to offload or just spread out the compressive forces around the hook of the hammy, rather than having them be centered into the hook of the hammy.

This can be very helpful, but keep in mind... these athletes are very fine-tuned and touch-oriented, and they might not like the feel of having a padding there, right? They might feel like that's actually going to worsen their performance at their sport, and so you might have to look into other things, maybe a more padded glove, especially in the case of tennis, or sorry, in the case of golf or baseball. And in the case of baseball specifically, we're going down a little bit of a niche rabbit hole here, but changing or...

offering to change their bat type from a typical round bat knob into what we call an axe handle bat, which is more of an axe handle shape. And so the portion that articulates with the palm is going to be more of a flat surface rather than having a knob squishing right into the hand. But again, the player may or may not actually like this kind of bat, so all we can do is suggest these things, and then hopefully they take us up on it because we know the benefit of those things. Okay, so here's a nice MRI hookahaminate fracture right here, where you can see at the base of that hook, good fracture there.

That's from a golfer. Okay, we're going to move into finger pathologies here. So we hit a lot of wrists, then we did a lot of carpals, now we're going to end on finger pathologies.

So hang with me here. This is the last section of this, and then we are actually done with the upper extremity overall, guys. We did shoulder, elbow, wrist, hand, and now into fingers. We're almost there. A lot of finger stuff, though.

First thing we're going to talk about is called gamekeeper's thumb. This can also be called skier's thumb. That's another one.

But gamekeeper's thumb, so think about goalies. That's going to be common here. The etiology or the MOI is going to be forced thumb abduction or hyperabduction. So a valgus force, essentially, you can think of to the thumb.

So it is a sprain or tear of the onocollateral ligament of the thumb, right? So right through there. And then this is what our patients are going to look like maybe after.

due to that instability, they're going to have a ton of abduction through that first MCP joint. Okay. So that ulnar collateral ligament of the first MCP joint.

This is often common in our gamekeepers or our goalies, because think when they try to maybe catch a ball, it's coming at them with a high amount of velocity. If they miss it a little bit and it just bends their thumb back rather than hitting the palm of their hand nicely, then that could tweak their thumb back into this position. and sprain or tear that ligament.

It can also happen in your skiers because if you fall on, say, a ski pole, then the thumb can become hyper abducted on the ski pole as you see here in the picture. So this can happen in multiple ways, but those are the common ones. And often we're going to see certain signs and symptoms.

So of course, pain, tendon distal palpation over that ligament, over that medial aspect of the first MCP. and a lot of pain with abduction, especially passive abduction of the thumb. That's not going to feel good because it's going to put a lot of tensile stress on that ligament and aspect of the joint. Other things that we're going to see is inability to snap your fingers.

So snap your fingers right now, and just notice what kind of force, hold the snap position. Before you let the finger snap, hold that position, that pinch grip position. What kind of force is going through that first MCP of your thumb? it's a valgus force, right?

So if you have pain and inability to snap the fingers, that can be indicative of an injury to this area. And of course, we can apply a valgus stress test even to that ligament itself. So if we do that and we notice pain and laxity relative to the contralateral thumb, that can be indicative of a UCL injury to the thumb.

What are we going to do? Just like any ligament injury, in a mild case, right? So a low grade sprain, maybe a grade one, we're going to treat symptomatically.

We're going to rice. We're going to work on range of motion, blah, blah, blah. In a moderate case, so we have some laxity and some damage to the ligament, we are going to immobilize. So think tape, splint.

You can maybe even cast this thumb. In a severe case, a full tear, oftentimes a surgery may be required to fix it. Or if not, you could potentially work it back, but this person will forever have this laxity presentation. the thumb.

Okay, moving on to a Bennett's fracture. So this is a fracture specifically to the trapezium, so the bone, the carpal bone, distal carpal bone that sits at the base of the thumb or the base of that first CMC, but it's not just isolated to the trapezium. Oftentimes a Bennett's fracture can extend into the articular surface of the first CMC. So this could be a fracture going between the first CMC, so the proximal metacarpal of the thumb, and the trapezium itself.

This will oftentimes be due to an axial load, so either a foosh or potentially jamming the thumb very hard, or think maybe a baseball catcher that is often catching high velocity pitches and maybe catches one, he or she catches one, at the at the base of the thumb over and over and over. that high velocity pitch can start to degrade and weaken and fracture that area of the thumb. Oftentimes, this fracture, because it involves articular surface and can extend across the joint line, oftentimes this type of fracture will require an ORIF, which stands for open reduction internal fixation. It could also require arthroscopic fixation. But what we mean by that, reduction fixation.

Reduction meaning... If the bones are malunion or displaced, those need to be reduced and realigned. And open fixation means that they're going to be maintained in alignment via a pin or a screw. Okay, so this is going to be really common in a Bennett's fracture injury to see a reduction of that fracture and a screw or pin in order to maintain alignment. So again, very important to refer these patients out for an x-ray because then they start that domino.

trickle effect of, okay, now we're seeing a physician, we have the x-ray, now they go, oh man, you have a Benis fracture, we need to start the line of you know, basically lining up a surgery in this case. Moving on to finger dislocations slash fractures. How is that going to happen? Usually it's going to be with a crushing blow. It's going to be an axial blow, right?

So think maybe rebounding a basketball with a straight finger or potentially trying to catch a ball with a straight finger and that ball or potentially another opponent's body part. It's a blow to the tip of the finger. Okay, in that case, you can have a...

maldirection, right? So this would be, in this picture, is a dislocation of the distal phalanx of the second digit, excuse me. And oftentimes this longitudinal force not only acts as a compression force, but with a rotation force as well.

So that's how we can have a fracture as well. Distal phalanx is going to be the most commonly affected because that is where this blow is going to be starting from. But middle phalanx, not so much.

Proximal phalanx can be affected as well, especially in the presence of a twisting or rotational force that is applied to the finger. Okay, so what are these patients going to feel? They're going to feel a pop.

They're going to be tender to palpation over the affected phalanx. You may see some swelling. In the case of a dislocation, you will see a deformity into the direction of dislocation. And you can apply some of your fracture tests to these folks in order to rule out fracture, such as your percussion tests, compression tests, tuning fork.

And we'll go down the line there. Now, just keep in mind, these tests themselves are not highly accurate clinical tests. So they can be helpful.

You do not want to rely on them. And just because you have some negatives here, don't assume that you have no fracture. It's still helpful, especially in the case of dislocation, to refer our patients out to have an x-ray because that can be very common with a dislocation.

And we can have a lot of false negatives with these tests. So complications of finger fractures. So oftentimes in the case of a twisting or rotational fracture, then there may need to be a fixation of that bony fracture. So if there's a deformity into the metacarpal proximal phalanx, then surgery may be required because phalanxes and fingers in general do not tolerate twisting or rotational forces very well at all. And so they can become fractured very easily and you may need a plate in order to do so.

So spiral fractures can occur here. Angulated fractures can occur. And if they're bad enough, they can become non-union.

Okay. So in those cases, our patients would often need a surgery. And this, I just want to point out that you guys should be extra sensitive with referring our younger or youth athletes out for x-rays. Really in any case of suspected fracture.

but especially in the hand and fingers because the likelihood is so high for them to have growth plate involvement. And that's really important to catch early on. So that's going to need to be treated differently than an adult with a fracture that is not to the growth plate.

OK, moving on to what we in layman's terms know as Jersey finger. So Jersey finger. or profundus finger or sweater sign, there's a few names for it. Jersey finger is gonna be the most common thing we talk about.

It's really, that's layman's terms, right? So what is it really? It's a rupture of the flexor digitorum profundus tendon.

Profundus tendon, we can see here at the bottom, is the deep one, right? It's gonna go all the way down and flex and take action and flexion of the dip joint of your finger. So the distal interphalangeal phalanx joint. As opposed to the flexor digitorum superficialis, which acts and flexes at the pip joint. Okay, so when we have a flexor digitorum profundus rupture, that is often going to be from an excessive eccentric load to that dip joint itself.

That often happens. Imagine if a football player or really any athlete is trying to make a tackle or grab onto another player, grab onto that jersey, and you say maybe you get your finger caught in there as that. player is breaking away or running away, the eccentric load, or even as you're trying to pull down that player, the eccentric load on the finger is going to be very, very high, right?

You're pulling down an entire player or that jersey on that person is breaking away from you. So that eccentric load can be excessive and too high on the tendon itself. And so that tendon can rip and rupture at some point.

Either it could be distally into the finger, it could be proximally in the finger, or it could happen in the palm itself. In any case, we are going to see a similar presentation where these patients are unable to make a fist, and when they try to make a fist, the involved finger cannot flex, especially being said at that dip joint, right? So you can see here in this bottom picture, there's decent flexion here of the pip joint, but there is zero flexion at the dip joint.

So that's how you know that the profundus tendon specifically has been involved and ruptured here. Okay, so in these cases, we want to splint and refer. Surgery is going to be somewhat common in these cases. But in any case, this is not our decision.

We want to refer out to let an orthopedic or hand surgeon make that call. The reason why maybe you're not going to see surgeries in every case is depending on the location of the tear will determine the successful rate or prediction rate of the surgery itself. There are certain areas that respond to surgery better because there are certain areas that are going to have a little bit more stiffness or problems.

with the recovery portion of things. So they're going to be notorious for extended healing times and have a lot of complications. So think tears in these red areas right here. That is going to be biggest problems.

Okay, Dupuytren's contracture. This is essentially, think of in these flexor digitorum or profundus tendons, in our interossei tendons, or in our palmar fascia of the hand. especially, you're going to have nodules that can start to basically present over time adhesions, fibrosis in the tendons and palmar fascia of the hand.

So you can see these tendons right here in this person's palm right here. Very fibrotic, thick, and therefore contracted in nature. These nodules and adhesions can become a major, major problem.

It can lead to forced contracture of the MCP and PIP joints, as you can see here. So this person is not voluntarily in this position. It's just happening to them.

And it's really, really common in the fourth and fifth digits. So in the ring finger and the pinky. Common sign you're going to see is this person is going to be unable to flatten their hand on, say, a tabletop or a countertop in that printed position because the finger is going to be so contracted into a flexed position. This is very much more common in our more geriatric population, so maybe a little less common in our athletic population.

But for those of you that are going to be working in an outpatient or physician office setting, this may be more commonly seen there. This is another similar presentation. This is not duplicant contracture, but this is called trigger finger or stenosing tenovitis, which is most common in the index or middle fingers.

And this is... a similar idea in the sense that you're going to have nodule formation in the tendons of those fingers, but not so much the palmar fascia. So here's a good picture of a potential nodule or fibrotic formation within the tendon itself.

Why this becomes a problem and how this can get fingers stuck into a position is there's a lot of little retinaculums and sheaths over the MCP joint, PIP joint, DIP joint in order to create somewhat of a pulley system of the finger. This is called an A1. pulley system.

These nodules or thickenings of the tendinous structures can get caught or stuck and basically get herky-jerky and have trouble gliding through those sheath little tunnels. And in that case, if it becomes stuck in one position, in a flexed position, then we call that a trigger finger because of all the flexion of that finger looks like, you know, obviously the position of a finger would be if it's pulling a trigger. So when these nodules become trapped into the pulley system... that essentially triggers trigger finger, no pun intended.

But essentially, that's going to be very similar to Dupuytren's contracture, except this is more common in the pointer in middle fingers, whereas Dupuytren's is more common in the fourth and fifth fingers, and more commonly involves the fascia of the hand, as well as the tendons, versus trigger finger is specifically more into the tendons, stenosing into these fingers. Extra common or more common in our patients that have diabetes and rheumatoid arthritis. And essentially what we're going to see here is popping, maybe even some catching as these patients try to flex and extend their fingers.

You're going to literally see like clunking of that finger or a locking in severe cases as they try to move their finger through those ranges of motions. In those severe cases too, you may even be able to palpate those nodules in the palm. palmar side of the hand as well. What are we going to do for treatment? We're going to refer these patients out.

Oftentimes for non-surgical treatment, we're going to try that first, and this could involve rest, night splinting in order to put that finger back into a position of extension, NSAIDs of course, stretching, tendon gliding exercises, steroid injections into the tendon sheath. That's a very painful procedure. As you can see here in the picture, imagine just having that injection right into the tendon itself. And if none of that is going to help, then a surgical treatment is going to be necessary where they go in through the skin and they actually cut out the nodule itself and then therefore release that tendon. Okay, moving on to more finger injuries.

This is going to be called a boutonniere deformity. This is going to be a common one that we see in a traumatic sense. The etiology or MOI here is going to be extreme flexion force or crushing blow.

So think if someone has a blunt force trauma, say to the distal phalanx, that can do it. Middle to distal phalanx is basically a tear or rupture. of the central slip so that extensor hood that we talked about in the last lecture, that is going to be ruptured in a boutonniere deformity.

So the extensor tendon mechanism is ruptured and then what we see here is the inability to extend through the pip joint, but because of all these tendons continuing to still run into the dip joint, you're going to see actually extension or hyperextension of the dip joint. So it's the combination of inability to extend through the PIP joint with involuntary extension and hyperextension of the dip joint. Okay, so how would we treat this?

Is we would actually splint the PIP joint into a position of extension in order to allow for healing. That is what a splint could look like in this case. Another common injury that we can see in the metacarpal region would be a boxer's fracture.

This is specifically a fracture to the fifth metacarpal bone of the hand. And it is most commonly fractured. It's called a boxer's fracture because it often happens when an athlete or a patient is punching a hard surface, such as, you know, boxing, maybe another person, or even maybe more common in our other non-boxing sports. It's when athletes become really frustrated, pissed off, and they actually punch the bench or they punch a wall, maybe due to poor performance during that game. And in the process, they can actually fracture.

the distal metacarpal, distal fifth metacarpal right there. And that is very frustrating because obviously now that is very embarrassing for that athlete. They just broke their hand. No good. So what are we going to see?

Obviously pain, tenderness, swelling over that fracture site on the fifth metacarpal, possible deformity, especially in this case, you can probably feel for lack of alignment in the fifth metacarpal. We're going to want to rice this person, refer for x-ray in order to confirm. You're going to want to splint that hand and finger, and often this can last up to four weeks.

Surgery is possible, but it is not super common. That's really only going to be common in high amounts of displacement or nonunion, with high amounts of deformity, or in highly proximal cases. Moving on to dip and pip collateral sprains, okay? So maybe some of you guys have even had this.

But dip and pip joints, they have their collateral ligaments, right, medial side and radial side of the fingers in order to maintain linear motion of the fingers. So fingers really like to flex and extend in the sagittal plane. Our phalanxes do not like to rotate too much or especially move into the dip joint and pip joint do not like to move into abduction or adduction.

That's responsible at the MCP joint. So if we have... loading of the finger, say a jamming of the finger, with any sort of lateral compression or rotational aspect to that load, then you can start to see a sprain or full tear of these collateral ligaments, whether it's radial collateral ligament or on the other side would be the ulnar collateral ligament. What we would see here is obviously tentative palpation, pain and swelling over those ligaments themselves. We could also see pain and instability when we stress test.

those ligaments through a varicervalgus stress test at the paper dip joint. And in an extreme case of a high-grade sprain or tear, where you have loss of integrity of that ligament, you can actually see a deformity or that finger becomes bent away from the side of injury, right? So if the injury is to this side of the finger, then it is going to be bent away because lack of integrity on this side.

Splint these people up, rule out fracture. That's always nice, especially in the case of a dislocation or severe deformity. Rehab surgery is, in this case, is very unlikely in these injuries, but it is possible in the case of just slow healing, lack of improvement, and in the case of maybe a very severe fracture as well.

Decourvain syndrome. This is a common one in the thumb. That is going to be where we are relating this injury to.

So the outcropping of three that we went over in the anatomy video and in our lab palpation points, that is going to be the area of interest here. So again, those three tendons that form the outcropping of three are the extensor pollicis longus, That's going to be the one on the more dorsal or posterior aspect. And then also our extensor pollicis brevis and abductor pollicis longus.

And again, these are the tendons that make that anatomical stuff box. Okay, so that's going to come up a lot. Just that being able to pop that finger up in order to palpate those tendons, not just for scaphoid palpation, which is in here, but also to assess the area for what we call de Quervain's syndrome. which really is inflammation of the synovial lining of these common sheaths. So tenosynovitis, tendonitis, or tendinosis of these tendons and their sheath.

When we have that, that is going to be then called decorvain syndrome. And because we have this distal branch of the radial nerve coming into this area, inflammation around it and under this extensor retinaculum can lead to compression and therefore injury to the radial nerve there, superficial branch. And so you can start to see potentially, not always, but potentially sensory deficits into the dorsal aspect of the hand.

So dorsal aspect, top of the hand, into the thumb, pointer finger especially, but potentially into the rest of the hand as well. Common findings here, positive Finkelstein's test, we're going to see that in lab. Sharp pain at the outcropping of three. McCandle, Lieutenant...

mechanical tendinopathy irritability, right? So think about that. Like what do we see with our common tendonitis is pain with warming it up. And then it kind of like wears off as the area gets warm and pain maybe after activity as well.

If it's tendinosis, that's more of a degeneration kind of thing. And you're not going to be responding to NSAIDs. If there is kind of more of a degeneration, maybe you're going to have more of a crepitus situation is there as things get um, poor lubrication, start to get crunchy.

If the radial nerve is involved, you can test this through a radial nerve tension test or a Tenell's test to that site. We're going to want to give this person edseds to reduce their inflammation. Cortisone injection or oral corticosteroids can help reduce that inflammation. And then later on, we're going to rehab for range of motion, especially accentuating the tendon and nerve gliding.

We're going to want to splint these folks in severe cases where it is... limiting their activities of daily life. And last thing I want to point out is in this picture, you can actually see a little bit of swelling over the outcropping of three tendon area, redness as well. Okay.

Mallet finger. This is one of our last pathologies into the fingers. Mallet finger is specifically a rupture of the extensor tendon at the dip joint. So this is not of the central hood or the, um, the central slip or the extensor hood.

This is specifically to the distal interphalangeal joint extensor tendon. So the extensor digitorum tendon at the dip joint. This is often going to be due to an injury of axial compression to the finger with a little bit of flexor load. Okay, if that is fractured, then we're going to have this presentation here where you have the inability to extend through that distal phalanx, right? You could also have a fracture with that.

That is very common. So we do just because we realize, oh, yeah, okay, this is a torn tendon does not mean there's no fracture. We want to refer these folks out for an x-ray in order to rule out a concomitant fracture in order to make sure that we're treating this person as a whole. Treatment for this is going to be a splint.

We call that a stack splint where we're putting that distal phalanx into a position of extension. Swan neck deformity. This is another one you guys need to be familiar with.

So we have boutonniere deformity, we have swan neck deformity, we have mallet finger, jersey finger. There's a lot of these deformities you need to be familiar with their presentation in order to catch it just on the eye test. And these will come up on your BOC, I promise you. So swan neck deformity is this sort of presentation.

And some people are actually born with very hypermobile finger joints and they can actually go into these positions without injury. But in our athletic populations, we're concerned about it if it's an acute injury. So what would the injury be?

It's a volar plate rupture. So that would be on the palmar aspect of the pip joint here. If that is ruptured, then you can have a presentation of going into hyperextension of the pip joint, and then which would put flexion into the dip joint due to the tendons being stretched out across the pip joint that are then pulling them down into the dip joint. How does this happen?

Basically, again, I said you can essentially be born with it. or maybe hyperextension of that pip joint or fingers altogether can lead to volar plate rupture at that pip joint. Beautiful.

Moving on to what we call handlebar. palsy. That's our layman's term for what is otherwise known as Guyon's canal syndrome.

And you thought there was only a carpal tunnel syndrome in the hand. You were wrong. There's a Guyon's canal syndrome as well. The Guyon's canal lives next door to the carpal tunnel.

All right. So you have Guyon's canal, carpal tunnel, their neighbors, their friendly neighbors, and they are not always involved on the same injuries, very rarely. So Guyon's canal syndrome is where we have ulnar nerve compression. through the guy on canal.

So it's a different nerve. It's a different canal. This is more laterally or sorry, excuse me, medially located on the hand.

And really that canal is formed between the hook of the hamate and the PC form here. Okay. So you can see this flexor retinaculum continues to go over here and that ulnar nerve, especially the superficial sensory branch and the deep motor branch running through this canal, supplying the fourth and fifth digits with sensation. and it is also supplying the hypothenar eminence and much of the palm with its motor function.

So when we have a guidance canal injury, how do we have it? It's compression to that site. This is most commonly going to happen in the case of bikers or maybe golfers, where we have compression through that canal area.

So on the handlebar, this is why it's called handlebars palsy. This can also happen potentially with a golf club, baseball bats, tennis rackets as well. if it's constantly being compressed into that canal. In the case of compression of the ulnar nerve in that canal, you're going to see, just like any nerve injury, deficits of the nerve function distal to the site of compression.

Okay, I'll say that again, because this is super common in any area of the body. Any nerve injury, you can see the effects of deficits of that nerve's function distal to the site of compression. Okay, so motor and sensory function of the ulnar nerve distal to this canal are...

Like we said, it's innervating the fourth and fifth digits with its sensation. So you could have parasesers there, numbness, tingling, burning. Or you can have weakness, that's the motor function, into the hand, especially with gripping.

And that is going to be from the deep motor branch of that ulnar nerve. Okay, last slide, guys. We made it. Wrist ganglion cyst. Okay, so ganglion cyst you can have in multiple joints of the body.

Probably going to be the most common in the wrist. You can also see them in the knee, in the popliteal fossa. but we're also most commonly, like I said, going to see them in the wrist.

And that's usually going to be on the dorsal aspect of the wrist. And in some cases, you can actually see this as a protrusion of a fluid-filled sac or a herniated joint capsule sac that comes up so far that you can feel it and sometimes even see it in that joint line of the wrist. Why does it happen? That's a good question, you guys.

It can happen after trauma, maybe a wrist sprain or strain. It can happen just with overuse of the area, but it can happen to some people and not to others. The etiology is somewhat unclear for ganglion cysts in general, and the findings are going to be pretty consistent, right?

So basically, you're going to feel this palpable nodule fluid-filled sac in that area. It's going to be painful. And it could even restrict range of motion since it's taking up joint space. So I think this person is maybe going to have a hard time moving into full extension range of motion because it lives in the way.

It's obstructing the motion. So how do we manage it? Well, if it's pretty good size, a physician can aspirate it. So put a needle in there and drain the fluid out. And then we can put a padding over the top of it in order to reduce any further aggravation.

You can potentially use ultrasound to reduce the size. of it, but this is going to be more of a conservative treatment that takes slower effect. Surgical removal is the most effective way if it's severely symptomatic, but obviously this is the most intense way to go about it. So that's a hard sell for a lot of patients. And then you also have the Bible Blast technique, which is basically take a large firm object, smack it in order to pop it or reduce, relocate that ganglion cyst back into the joint surface where it came from.

This is obviously very painful and is not a surefire way to do it. So we don't often actually see this method in the clinic. So ganglion cyst, usually the best case scenario is to actually refer this patient out in order to therefore be aspirated from a physician or potentially recommended for what conservative treatments you can be doing. Okay, you guys made it.

We did it. That is all of our pathologies that we're going to be covering in this class to the wrist, hand, and fingers. Congratulations.

We've completed the upper extremity. It's a lot of stuff, I know, but you did it. And this is one of the hardest things you're going to learn in the AT program is just going through the whole upper extremity evaluation process. So if you need to rewatch any portions of this lecture in order to just review certain pathologies, feel free.

I highly recommend. or just reviewing through the PowerPoint itself, just to differentiate between any confusing or closely related pathologies is also very helpful. Otherwise, I'll see you guys in lab. Thanks for listening and have a good day.

Transcript for:Traumatic Wrist and Hand Pathologies

Transcript for:
Traumatic Wrist and Hand Pathologies