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Chapter 9 Wrist and Handimage

The wrist is a flexible osseo-ligamentous complex forming a connective link between the forearm and the hand. Multidirectional mobility results from the numerous multiarticular carpal bones which, along with the radio-ulnar joints, allow the hand to be positioned functionally at any angle. Stability is derived from the complex array of ligaments often injured when falling on an outstretched hand.

The hand, while being the most active and intricate joint complex in the body, is the least protected. Constructed as a series of complex, delicately balanced joints, it offers manipulating ability, dexterity and precision. This highly sensitive structure, used to hold, catch and manipulate, is particularly vulnerable to trauma when subjected to repetitive stresses or impact of falls.

Providing adequate support while maintaining functional movement is the prime consideration when taping the hand and or wrist.

image

Palm of the left hand The surface markings of various structures within the wrist and hand are indicated. Not all of them are palpable, e.g. the superficial and deep palmar arches (7, 8), but their relative positions are important.

• The curved lines proximal to the base of the fingers indicate the ends of the head of the metacarpophalangeal joints.

• The creases on the fingers indicate the level of the interphalangeal joints.

• The middle crease at the wrist indicates the level of the wrist joint.

• The radial artery at the wrist (23) is the most common site for feeling the pulse. The vessel is on the radial side of the tendon of flexor carpi radialis (18) and can be compressed against the lower end of the radius.

• The median nerve at the wrist (25) lies on the ulnar side of the tendon of flexor carpi radialis (18).

• The ulnar nerve and artery at the wrist (22, 23) are on the radial side of the tendon of flexor carpi ulnaris (16) and the pisiform bone (21). The artery is on the radial side of the nerve and its pulsation can be felt, though less easily than that of the radial artery (23).

• Abductor pollicis brevis (12) and flexor pollicis brevis (13), together with the underlying opponens pollicis, are the muscles which form the thenar eminence – the ‘bulge’ at the base of the thumb. Abductor digiti minimi (9) and flexor digiti minimi brevis (10), together with the underlying opponens digiti minimi, form the muscles of the hypothenar eminence, the less prominent bulge on the ulnar side of the palm where palmaris brevis (11) lies subcutaneously.

CREASES

1. Longitudinal

2. Proximal transverse

3. Distal transverse

4. Distal wrist

5. Middle wrist

6. Proximal wrist

ARCHES

7. Superficial palmar

8. Deep palmar

MUSCLES

9. Abductor digiti minimi

10. Flexor digiti minimi

11. Palmaris brevis

12. Abductor pollicis

13. Flexor pollicis brevis

14. Thenar eminence

15. Adductor pollicis

TENDONS

16. Flexor carpi ulnaris

17. Palmaris longus brevis

18. Flexor carpi radialis

BREVIS BONES

19. Head of metacarpal

20. Hook of hamate

21. Pisiform

ARTERIES

22. Ulnar

23. Radial

NERVES

24. Ulnar

25. Median

image

Anterior aspect of the wrist and hand: superficial tendons. 1 Flexor carpi ulnaris. 2 Pisohamate ligament. 3 Pisometacarpal ligament. 4 Palmaris longus. 5 Palmar aponeurosis. 6 Flexor carpi radialis. 7 Radial artery.

SURFACE ANATOMY

image image

Dorsum of the left hand The fingers are extended at the metacarpophalangeal joints, causing the extensor tendons of the fingers (1, 2 and 3) to stand out, and partially flexed at the interphalangeal joints. The thumb is extended at the carpometacarpal joint and partially flexed at the metacarpophalangeal and interphalangeal joints. The lines proximal to the bases of the fingers indicate the ends of the heads of the metacarpophalangeal joints. The anatomical snuffbox (9) is the hollow between the tendons of abductor pollicis longus (7) and extensor pollicis brevis (6) laterally and extensor pollicis longus medially (5).

TENDONS

1. Extensor digiti minimi

2. Extensor digitorum

3. Extensor indicis

4. Extensor carpi radialis longus

5. Extensor pollicis longus

6. Extensor pollicis brevis

7. Abductor pollicis longus

MUSCLES

8. First dorsal interosseus

BONES

9. Anatomical snuffbox over scaphoid

10. Styloid process of radius

11. Head of ulna

VEINS

12. Cephalic

RETINACULUM

13. Extensor retinaculum

image

Thenar and hypothenar eminences. 1 Abductor pollicis brevis. 2 Flexor pollicis brevis. 3 Opponens pollicis. 4 Adductor pollicis oblique head. 5 Adductor pollicis transverse head. 6 Abductor digiti minimi. 7 Flexor digiti minimi. 8 Opponens digiti minimi. 9 Flexor retinaculum. 10 Palmar aponeurosis. 11 Flexor fibrous sheaths

image

Anatomical snuffbox: tendons. 1 Abductor pollicis longus. 2 Extensor pollicis brevis. 3 Extensor pollicis longus. 4 Extensor carpi radialis longus. 5 Extensor carpi radialis brevis.

image

Dorsal aspect of the wrist and hand: tendons. 1 Extensor carpi ulnaris. 2 Extensor digitorum. 3 Extensor indicis. 4 Extensor digiti minimi. 5 Extensor carpi radialis brevis. 6 Extensor carpi radialis longus. 7 Extensor retinaculum. 8 Extensor digital expansion.

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ANATOMICAL AREA: WRIST AND HAND

WRIST HYPEREXTENSION SPRAIN TAPING

Purpose

• reinforces the collateral ligaments of the wrist and the anterior joint structures

• restricts extension and limits the last degrees of radial and ulnar deviation

• permits functional use of the hand

Indications for use

• palmar radio-carpal ligaments sprains (hyperextension)

• for dorsal radio-carpal ligament (hyperflexion): apply the check-reins dorsally and add restraining Xs to the dorsal aspect, thus limiting end-range of flexion

• for radial collateral ligament sprain: reinforce the lateral X and add lateral palmar X to prevent ulnar deviation

• for ulnar collateral ligament sprain: reinforce the medial X and add medial palmar X to prevent radial deviation

• diffuse pain in the wrist due to repeated compression or ‘jamming’ the wrist

• wrist pain post immobilization

MATERIALS

Razor

Skin toughener spray/adhesive spray

Underwrap

3.8 cm (11/2 in) non-elastic tape

imageNOTES:

• Ensure that the proper diagnosis has been made to rule out fractures, particularly if the injury was caused by an outstretched hand (the scaphoid bone is the most commonly fractured).

• Clarify the mechanism of injury, whether it was hyperflexion or hyperextension that occurred.

• The use of skin toughener or quick-drying adhesive spray is essential for good adherence of taping, especially in rainy or hot conditions when hands, wrists and forearms can become quite damp.

• Wrap the circumferential strips with minimal tension, to avoid neurological or vascular compromise.

• Monitor circulatory status and sensation prior to, during and after taping.

For additional details regarding an injury example see T.E.S.T.S. chart, p. 199.

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Positioning

Sitting, with the wrist in a neutral position held in slight extension (approximately 20 °).

imageTIP:

The elbow can be supported on a table for added stability (not shown).

Procedure

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1. Make sure the area to be taped is clean and relatively hair free; shave if necessary.

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

image

3. Apply underwrap to forearm.

4. Apply two circumferential anchors of 3.8 cm non-elastic tape around the mid forearm at the musculo-tendinous junction, following the natural contours of the forearm.

image

5. Apply a circumferential anchor of non-elastic tape around the distal metacarpals (palm of hand).

imageTIP:

Ensure that these anchors do not unduly restrict the splaying of the metacarpals.

image

6. Hold the wrist in the neutral position and apply a check-rein from the anterior aspect of the distal anchor to the proximal, with strong tension, passing across the anterior joint line.

imageNOTE:

A second check-rein can be added, overlapping the first by a half for added strength and/or for wide wrists (not illustrated).

image

7. Start the medial X from the palmar aspect of the distal anchor to the posteromedial aspect of the proximal anchor.

8. Finish this X with a strip from the dorsal aspect of the distal anchor to the proximal anchor anteriorly with firm tension.

imageNOTE:

The X formed by these two strips should cross on the anteromedial joint line.

image

9. Begin lateral X with a strip from the dorsal aspect of the distal anchor, pulling with tension to the anterior aspect of the proximal anchor.

10. Finish this X with a strip from the palmar aspect of the distal anchor to the lateral aspect of the proximal anchor.

imageNOTE:

The X formed by these two strips should cross on the anterolateral joint line.

image

11. Re-anchor these supporting Xs both distally and proximally.

imageNOTE:

For added stability, posterior Xs can be added at this time, holding the wrist in 20 ° or less of extension (not illustrated).

image

12. Close up the hand portion of the taping by overlapping the distal anchor by half the width of the next circumferential strip of non-elastic tape.

13. Continue closing up by overlapping with light circumferential strips.

image

14. Test the degree of restriction: extension should be limited enough to cause no pain on passive extension at the wrist.

imageNOTE:

Check finger colour and sensation for signs of compromised circulation.

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ANATOMICAL AREA: WRIST AND HAND

INJURY: WRIST HYPEREXTENSION SPRAIN

TERMINOLOGY

• partial or complete tearing of anterior wrist capsule

• partial or complete tearing of radial and/or ulnar collateral ligaments

ETIOLOGY

• fall on outstretched hand

• forced hyperextension during a tackle with an opponent

• overloaded weight lifting

SYMPTOMS

• pain over anterior joint capsule and ligaments

• decreased range of motion

• swelling

• active movement testing: pain on end-range extension

• passive movement testing:

a. pain on extension
b. pain possible on end-range flexion resulting from compression of injured tissues

• resistance testing (neutral position): no significant pain with moderate resistance; pain possible on flexion if flexors also involved

• stress testing: varying degrees of pain and laxity

imageNOTE:

If wrist is unstable when testing ligaments, X-rays must be taken to rule out the possibility of fracture.

TREATMENT

Early

• R.I.C.E.S.

• initially: elastic tensor compression and sling support with careful attention to circulation for the first 48 hours

• therapeutic modalities, contrast baths

Later

• continued therapy including:

a. therapeutic modalities
b. flexibility exercises
c. strengthening (isometric initially)

• total rehabilitation programme for mobility, flexibility, strengthening and dexterity

• taping for gradual return to pain-free functional activities

imageNOTE:

Sprains that do not respond well to treatment should be reassessed by a hand specialist. Pain and clicking on the ulnar side may imply damage to the triangular fibro-cartilage (meniscus). Persistent pain on the radial side may indicate a necrosis or missed fracture of the scaphoid.

SEQUELAE

• tenosynovitis

• weakness

• chronic sprain

• instability

• degenerative joint changes

• stubborn cases may suggest an associated meniscal tear and require some form of splinting for dynamic activity

R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support.

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ANATOMICAL AREA: WRIST AND HAND

THUMB SPRAIN TAPING

Purpose

• supports the collateral ligaments of the first metacarpophalangeal joint (MCPJ)

• prevents the last degrees of extension, limits abduction

• allows some flexion

• does not compromise wrist and hand function

Indications for use

• MCPJ sprain (ulnar ligament)

• carpo-metacarpal joint (CMCJ) sprain (ulnar aspect); reinforce the diagonal anchor

• ‘skier’s thumb’, ‘gamekeeper’s thumb’

• post-immobilization tenderness

• after surgery of 3rd-degree repair

MATERIALS

Razor

Skin toughener spray/adhesive spray

Underwrap

3.8 cm (11/2 in) non-elastic tape

2.5 cm (1 in) non-elastic tape

imageNOTES:

• If 3rd-degree sprain is suspected, a hand surgeon should be seen as early as possible.

• X-rays will rule out the possibility of an avulsion fracture.

• Thoroughly inspect the hand for cuts, abrasions and any other possible sources of infection.

• Watch carefully for signs of restricted circulation, particularly during the first 48 hours post injury when swelling tends to be greatest.

• Restricted circulation, apart from causing discomfort, can be particularly dangerous in below freezing weather (increased risk of frostbite).

• Hand and thumb size will dictate the width of tape required.

For additional details regarding an injury example see T.E.S.T.S. chart, p. 206.

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Positioning

Sitting with the thumb and hand held in a neutral, functional position.

Procedure

image

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

image

2. Apply two circumferential strips of 3.8 cm non-elastic tape around the wrist using light tension.

image

3. Apply distal anchor.

a. Using 3.8 cm non-elastic tape, start from the posterior side of the proximal anchor, wrap around the wrist, pull up and across the dorsum of the hand.
image

b. Cross from posterior to anterior between the thumb and index finger.

c. Pinch the tape as it passes through the web of the space to avoid irritating the soft skin at this site.

imageTIP:

Be careful not to apply any pressure through the web space.

image

d. Continue diagonally across the palmar aspect of the hand and fix the strip medially on the proximal anchor.

image

4. Apply the thumb anchor lightly, placing the strip circumferentially around the proximal phalanx, following its contours using 2.5 cm non-elastic tape (use a narrower tape if necessary).

image

5. Apply an incomplete figure-of-eight strip of 1.2 cm non-elastic tape by pulling gently around the thumb, crossing the strips and pulling equally with both hands medially, adducting the thumb before adhering both ends of this strip to the anchor.

image

6. The anterior end is applied to the palmar anchor, and the posterior end is applied to the dorsal anchor with firm pressure.

imageTIP:

Be careful not to apply strong pressure circumferentially around the thumb during application of tape.

image

7a Apply another half figure of eight more proximally, overlapping by half the width of the tape on the thumb anchor.

image

7b Allow the strip ends to fan out slightly before they reach the anchor.

image

8. Continue repeating the half figure of eights, overlapping by half to three-quarters the width of the tape, moving proximally down the thumb.

image

9. Re-anchor the ends of the incomplete figure of eights with another diagonal anchor.

imageTIP:

Be careful not to apply strong pressure through the web space.

imageNOTE:

A figure-of-eight check-rein can be applied between the thumb and first finger to further restrict abduction (not illustrated).

image

10. Apply circumferential strips of 3.8 cm non-elastic tape around the wrist, covering the diagonal anchor and any remaining tape ends.

image

11. Check functional position of the hand and test the degree of restriction: extension and abduction must be limited enough that there is no pain on passive movements, especially extension and abduction.

imageNOTE:

Check thumb colour and sensation for signs of compromised circulation.

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ANATOMICAL AREA: WRIST AND HAND

INJURY: THUMB SPRAIN

TERMINOLOGY

• partial or complete tearing of ulnar collateral ligament: the first MCPJ; degree of severity 1st–3rd

• ‘game-keeper’s thumb’

• ‘skier’s thumb’

ETIOLOGY

• forced extension and/or abduction of the MCPJ

• a fall on an outstretched hand, common in skiing

SYMPTOMS

• tenderness over medial aspect of the MCPJ

• local swelling and/or discolouration

• active movement testing: pain on end-range extension

• passive movement testing: pain on extension plus abduction

• resistance testing (neutral position): no significant pain on moderate resistance

TREATMENT

Early

• R.I.C.E.S. for first 48 hours

• therapeutic modalities; contrast baths

• range of motion (ROM) exercises

• taping: for Thumb Sprain, see p. 200

imageNOTE:

Third-degree and severe 2nd-degree sprains require spica splinting, casting or surgery with at least 3 weeks of immobilization.

Later

• continued therapy including:

a. therapeutic modalities
b. joint mobilizations if stiff post immobilization
c. strengthening (isometric at first)

• gradual return to pain-free functional activities with taped support

• complete rehabilitation programme including range of motion, flexibility, strengthening and dexterity

SEQUELAE

• chronic instability with severe dysfunction

• weakness of grip

• tenosynovitis

• degenerative changes of MCPJ

R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support.

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ANATOMICAL AREA: WRIST AND HAND

FINGER SPRAIN TAPING

Purpose

• supports the palmar and collateral ligaments of the finger

• prevents full extension

• allows full flexion

Indications for use

• palmar ligament sprain (hyperextension) of the finger

• post-immobilization painful stiffness of the finger

• ‘jammed’ or ‘stubbed’ finger

• medial collateral ligament (MCL) sprain of the finger: reinforce medial X

• lateral collateral ligament (LCL) sprain of the finger: reinforce lateral X

MATERIALS

Razor

Skin toughener spray

1.2 cm (1/2 in) Non-elastic tape

imageNOTES:

• Never allow the athlete to continue playing (even when taped) if a serious injury is suspected.

• Ensure a correct diagnosis by a doctor or hand specialist. (Fractures and dislocations are often misdiagnosed and mistreated.)

• Localize the exact site of the injury – which aspect of which joint of which finger – and re-test for pain through range during and after the tape job is completed.

• Taping the injured finger to its neighbour (‘buddy taping’) further protects the injured ligaments while allowing function and movement.

• If the athlete needs to use the injured hand to handle a ball during a game, ‘buddy tape’ the fingers slightly apart to allow better control of the ball.

For additional details regarding an injury example see T.E.S.T.S. chart, p. 211.

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Positioning

Sitting with the elbow supported on a table and the finger(s) placed in a neutral, functional position (approximately 20 ° flexion).

Procedure

image

1. Make sure the area to be taped is clean and relatively hair free; shave if necessary.

2. Check skin for cuts, blisters or areas of irritation before spraying with skin toughener or spray adhesive.

imageTIP:

A cotton-tip applicator can be used to minimize the adherence of non-affected digits.

image

3. Gently apply two circumferential anchors of 1.2 cm non-elastic tape, one above and one below the injured joint.

imageTIP:

Be careful to avoid constriction.

image

4. Apply a vertical strip of 1.2 cm (1/2 in) white tape from the distal anchor to the proximal anchor on the centre of the volar (under) aspect of the finger, with strong tension, keeping the finger flexed about 20 °.

image

5. Apply a lateral X with two strips from the distal anchor to the proximal, with strong tension, forming the X on the lateral joint line.

image

6. Repeat the above on the medial aspect, with the X lying on the medial joint line.

7. Repeat the anchors as in Step 2, to cover the ends of the vertical strips.

image

8. Perform a simple ‘buddy-taping’ technique by taping the injured finger to its neighbour.

imageNOTE:

This step is useful for sports not needing full hand function (as in soccer, excluding goalkeeper), when the fingers can function as a unit.

image

9. Alternative method: apply a webbed ‘buddy-taping’ by keeping the injured digit slightly abducted (spread apart) while taping it to its neighbour.

imageNOTE:

This technique is useful for sports requiring full functional dexterity and use of individual fingers (as in basketball or volleyball). Note that more space is left between the fingers with this option.

image

10. Pinch the buddy tape strip between the fingers to allow some independent movement of the injured digit.

image

11. Check for functional dexterity and verify adequate limits of taping.

12. Test the degree of restriction: extension must be limited enough that there is no pain on stressing the injured ligament.

imageNOTE:

Finger colour and sensation must be checked for signs of compromised circulation.

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ANATOMICAL AREA: WRIST AND HAND

INJURY: FINGER SPRAIN

TERMINOLOGY

• partial or complete rupture of palmar ligament (anterior capsule), medial collateral (ulnar) ligament or lateral collateral (radial) ligaments: degree of severity, 1st–3rd

• ‘stoved’ finger

• ‘jammed’ finger

ETIOLOGY

• telescoping blow: direct compressive force on the tip of the finger (i.e. jamming it against a ball as in basketball, volleyball or rugby)

• torsional stresses

• sideways stress to a finger: may catch on clothing, equipment or terrain

• hyperextension of finger

• contusion of ligaments

SYMPTOMS

• pain over site of injury

• swelling and discolouration

• local tenderness

• active movement testing: pain on end-range extension and/or flexion (pinching the injured capsule)

• passive movement testing: pain on end-range extension and/or possibly on flexion

• resistance testing (neutral position): no significant pain on moderate resistance

• stress testing:

a. pain with or without laxity on lateral stress testing in 1st- and 2nd-degree sprains
b. instability with 3rd-degree sprains (often with less pain)

TREATMENT

Early

• R.I.C.E.S.

• initial taping: loose Buddy Taping, see p. 210

• therapeutic modalities; contrast baths

• range of motion exercises

NOTE:image

Third-degree and severe 2nd-degree sprains usually require splinting with at least 1 week of complete immobilization and 2 weeks of mobilization between treatments and range of motion (ROM) exercises, followed by 8 weeks of taped support.

Later

• continued therapy including:

a. therapeutic modalities
b. mobilizations
c. flexibility

• strengthening exercises for all hand musculature

• taping for gradual return to pain-free functional activities

• progressive exercises for range of motion, strength and dexterity

SEQUELAE

• persistent laxity (instability)

• chronic sprain reinjury

• deformity

• stiffness

• degenerative joint changes

R.I.C.E.S.: Rest, Ice, Compress, Elevate, Support.

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