CHAPTER 5

Wrist and Hand

EPIDEMIOLOGY OF WRIST AND HAND PAIN

WRIST AND HAND PAIN IN THE GENERAL POPULATION

Prevalence and common causes

•  3% to 26% (significant hand disability in ~13% elderly population, Rotterdam study) (1)

•  Most common (MC) causes of hand pain in elderly: osteoarthritis and rheumatoid arthritis

•  Age and Parkinson’s disease: significant contributors for hand disability in elderly

•  Often coexists with pain in other joints

WRIST AND HAND PAIN IN ATHLETES (2)

Prevalence of wrist and hand injury

•  9% to 25% of all athletic injuries

•  50% involve the fingers (3)

•  Sports with higher rates of injuries: football, gymnastics, wrestling, lacrosse, and basketball

Wrist and hand pain in different sports

•  Football: 15.8% incidence in national football league (hand sprains: 19%; fracture: 11%; wrist sprain: 10%; and dislocation: 9%)

•  Basketball: 10% to 23% for all hand injuries, fractures in two thirds of the total hand injuries (MC-type of hand injury), involvement of scaphoid in 38%, metacarpal in 30%, and phalange in 20%

      Sprain and dislocation of proximal interphalangeal (PIP) joint: MC

•  Golf: wrist involved in 20% of all golf-related injuries

      Tendinopathy: MC type of injury

      Hook of hamate: MC site for hand/wrist fracture in golf

•  Gymnastics: 46% to 80% prevalence in elite gymnasts

•  Boxing: MC musculoskeletal (MSK) injury site (up to 46%) in boxers

•  Skiing: Gamekeeper’s thumb (ulnar collateral ligament [UCL] tear of 1st metacarpophalangeal [MCP] joint)

Tendinopathy in sport

•  Seen in any sport/activity requiring a repetitive motion

      A tennis serve or volley, a basketball free throw, or “turning the wrists over” as in the completion of a golf or baseball swing: at risk for tendon inflammation, instability, or even rupture

  Extensor carpi ulnaris (ECU) (4) tendinopathy in elite tennis players

           –  Tenosynovitis or tendinitis more common than dislocation of the tendon, subluxation, and ECU rupture

      Racket sport: de Quervain’s tenosynovitis

      Recreational rock climbing: flexor pulley rupture (A2 and A3 pulley)

      Rowing and powder skiing: intersection syndrome often seen as it requires repetitive wrist dorsiflexion and radial deviation

WRIST AND HAND PAIN AT WORK (5)

Prevalence

•  ~22% complaints of wrist and hand pain over a year: 25% acute injury and 9% chronic pain

Carpal tunnel syndrome (CTS)

•  MC reason for worker’s compensation claims

•  More common in shellfish, fish, other meat-packing industries: 20/1,000 full-time employees

•  Risk factors (epidemiologic): repetitive motion, exertion, vibration (presence of multiple risk factors is a strong evidence for increased risk of wrist and hand pain at work)

Other injuries

•  Sprain or strains of the wrist and hand: highest reported cases in the upper extremity followed by CTS

      de Quervain’s tenosynovitis and trigger finger: commonly seen

•  Risk factors (epidemiologic): repetitive motion, exertion, range of motion (ROM), greater risk if multiple risk factors exist (6)

DIFFERENTIAL DIAGNOSIS

MSK CAUSES OF WRIST AND HAND PAIN BASED ON LOCATION (FLOWCHART 5.1)

Surface anatomy with surface landmark (7) (Figure 5.1)

•  Central versus ulnar (medial): midline of 4th digit

•  Central versus radial

      Dorsal landmark: Lister’s tubercle

      Ventral landmark: flexor carpi radialis (FCR) tendon

FIGURE 5.1

Surface anatomy of the hand and wrist (palmar aspect and dorsal aspect).

Source: Adapted from Ref. (7). Atzei A, Luchetti R. Clinical approach to the painful wrist arthroscopy. In: Geissler WB, ed. New York: Springer; 2005:185–195.

FLOWCHART 5.1

Differential diagnosis of wrist and hand pain.

CRPS, complex regional pain syndrome.

Source: Adapted from Ref. (7). Atzei A, Luchetti R. Clinical approach to the painful wrist arthroscopy. In: Geissler WB, ed. New York: Springer; 2005:185–195.

APL, abductor pollicis longus; CMC, carpometacarpal; Dz, disease; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; Ext., extensor; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; Jt., joint; Lig, ligament; MC, most common; MCP, metacarpophalangeal; N, nerve; OA, osteoarthritis; CTS, carpal tunnel syndrome.

NEUROPATHIC CAUSES OF WRIST AND HAND PAIN

•  Entrapment neuropathy (local): CTS (MC, volar radial aspect), ulnar neuropathy at elbow (2nd MC, ulnar side), or wrist or superficial radial neuropathy (dorsoradial)

      Cervical radiculopathy (C6: 1st–2nd finger, C7: 3rd finger vs C8: ulnar side, 4th–5th fingers without splitting of sensation in 4th digit)

•  Multifocal: mononeuropathy multiplex, hereditarily neuropathy liable to pressure palsy (similar to the common entrapment neuropathy site), and brachial amyotrophy

•  Diffuse: diabetic peripheral neuropathy (usually involving distal lower extremities first), sensory neuropathy, or inflammatory polyneuropathy (chronic inflammatory demyelinating polyneuropathy [CIDP] or others)

•  Concomitant diffuse neuropathy with entrapment syndrome: amyloidosis, diabetic, and so on

Neurological symptoms

CIDP, chronic inflammatory demyelinating polyneuropathy; CTS, carpal tunnel syndrome; Dx, diagnosis; M, muscle; MC, most common.

DIFFERENTIAL DIAGNOSIS OF FINGER/WRIST DROP

CVA, cerebrovascular accident; Dx, diagnosis; MSK, musculoskeletal; N, nerve; RA, rheumatoid arthritis.

SNAPPING (9)

Ulnar side snapping

•  ECU subluxation (MC): patient can demonstrate and palpate, reproducible with ulnar deviation and supination

      Sub-sheath tear, common in tennis and baseball players (batting)

•  Triangular fibrocartilage complex (TFCC) lesion: often difficult to localize

Dorsal-middle snapping

•  Midcarpal instability: radiotriquetral ligament insufficiency recurrent snapping of the triquetrum

      During ulnar (more than radial) deviation of the wrist, palmar sag of the proximal row with a typical triquetral catch-up clunk generated, confirming the instability

•  Boxer’s knuckle

      Extensor tendon dislocated ulnarly from disruption of the extensor hood by direct trauma

      Inflammatory joint disease or direct trauma

      Nontraumatic snaps at 5th digit, junctura tendinum (a fascial or tendinous band, linking adjacent extensor tendons) against MCP joint (intact dorsal hood)

ANATOMY

BONE, JOINT, AND LIGAMENT

The proximal carpal row

•  Scaphoid, lunate, triquetrum, and pisiform

•  Scaphoid

      A stabilizer of the midcarpal joint, acting as a bridge between the proximal and distal carpal rows (against hand/wrist dorsiflexion)

      Ulnar deviation: scaphoid more longitudinal position (dorsiflexion): lengthen

      Radial deviation: scaphoid palmar flexion

•  Intercalated: no tendon insert, movement by mechanical forces from surrounding articulation

•  With axial loading, scaphoid: flexion (distal pole; palmar flexion) and lunate/triquetrum (extension)

•  Flexion/extension; scaphoid: greatest motion versus lunate: least motion

The distal carpal row

•  Trapezium, trapezoid, capitate, and hamate

•  Negligible motion in-between, functional single unit bound by stout intercarpal ligaments

Radius: sigmoid notch (articulating with ulna) with variation of morphology

Ulnar: ulnar head covered by articular cartilage, not directly contacting with carpal bones (through TFCC complex)

Joints

Distal radioulnar (RU) joint

•  Pivot joint between head of the ulnar and ulnar (sigmoid) notch of the distal radius

•  Joint cavity between the fibrous cartilage (disc of TFCC) and the ulnar and radius

•  Movement: rotation and translation

•  Joint capsule: indefinite, fibrous strand anteriorly, posteriorly fused with the disc below, and form a pouch called recessus sacciformis

•  Stabilizer

      Dynamic stabilizer: ECU, flexor carpi ulnaris (FCU), and pronator quadratus

      Static stabilizer: TFCC, interosseous membrane, dorsal/volar RU ligament, UCL, and the joint capsule

Radiocarpal (RC) joint (wrist) (10)

•  Ellipsoid joint by the radius, the articular disc (TFCC), proximal row of carpal bones except the pisiform

•  Capsule, localized strong bands

      The palmar RC ligament and thinner dorsal RC ligament

      The radial collateral ligament

•  Synovial membrane

      Communicate with intercarpal and pisotriquetral joint

      Does not cover the articular disc communicate with distal radioulnar joint (DRUJ; recessus sacciformis) only when the disc is perforated

Midcarpal (intercarpal) joint

•  Ellipsoidal joint between the carpal bones (except pisiform); capitate and hamate by concave socket formed by scaphoid, lunate, and triquetrum

•  Plane joint between the trapezium and trapezoid with the scaphoid

•  Two degrees of freedom

•  FCU extension (pisometacarpal ligament): connect the pisiform to the base of the 5th MC

Trapezio–1st carpometacarpal (CMC) joint

•  Biconcave–convex–reciprocal saddle joint

      Unstable joint with loosely arranged capsule

  16 ligaments with deep anterior oblique ligament (beak), dorsal radial ligaments as primary stabilizer

      Three planes 6 degrees of freedom and 90° rotated

  Flexion/extension (convex of the trapezium), parallel to the palm

  Abduction/adduction (concave direction), perpendicular to the palm

  Rotation (oblique)

           –  Opposition: flexion and abduction versus reposition: extension and adduction

Other four CMC joints

•  Plane (gliding) joint: some gliding motion; more on the 5th (2nd CMC joint: minimal or none)

MCP joint

•  Ellipsoidal (condyloid) joint; flexion/extension, adduction/abduction, circumduction

•  Fibrous capsule strengthened by the CL, palmar ligament

•  Deep transverse metacarpal ligament (connected palmar ligaments of the medial four MCP joints)

IP Joint: hinge (ginglymus) joint

Ligaments of Wrist (11)

Extrinsic ligaments: from the radius or ulnar to carpal bones

•  Dorsal ligament

      Dorsal RC ligament: from ulnar and radius, Lister’s tubercle to triquetrum and lunate

      Important secondary stabilizer of the scapholunate joint

•  Volar ligament: stabilizing the wrist, greater stability than dorsal ligaments

      Radioscaphocapitate (secondary stabilizer for scapholunate joint) and long radiolunate ligament

      The space of Poirier between radiolunate and radioscaphocapitate ligament at the midcarpal joints (interval between the capitate and lunate; poor ligament support perilunate dislocation/instability)

      Short radiolunate ligament and radioscaphoid ligament

Intrinsic ligaments

•  Scapholunate interosseous ligament: rotational stability of the scapholunate joint (dorsal interosseous ligament: thickest, strongest; primary stabilizer), centrally fibrocartilaginous structure (delta shape)

      Injured with excessive wrist extension with ulnar deviation (MC in fall) tear: more commonly at scaphoid attachment

•  Lunotriquetral: thickest and strongest part: volarly, C shape

      Tear: less common (dorsiflexed wrist in forearm pronated or radial deviation with extreme dorsiflexion); traumatic or degenerative

•  Carpal instability: not usually from intrinsic ligament alone; usually from both intrinsic and extrinsic ligament injuries

Triangular fibrocartilage complex (Figure 5.2)

•  The central fibrocartilage disc (the meniscal homolog), the dorsal and volar RU ligaments, the ulnolunate and ulnotriquetral ligaments, and the ECU tendon sheath

      TFCC disc: anchored to the articular cartilage of the ulnar side of the distal radius, attached to the ulnar styloid through fibrous bands

      ECU: dorsally, dorsal/ventral RU ligament

•  Stabilizer of the DRUJ and a cushion for the ulnar carpus

      Separate the RC from the DRUJ

      Limit pronation/supination/axial migration

      Continuous gliding surface for the RC joint to the ulnocarpal (UC) joint

      Articular surface of the sigmoid notch of radius to the ulnar styloid/UC ligament

•  Clinical implications: cause of ulnar-sided wrist pain, instability, and painful decrease in ROM ± snapping

Ligaments of Fingers

Volar plate: thickening of joint capsule volar side of MCP joint and PIP joints (Figure 5.3)

•  Thumb: sesamoid bone (two in thumb MP joint, one at thumb interphalangeal [IP] joint, one at 2nd and 5th MP joints)

      Radial sesamoid; more subject to degenerative and arthritic changes

•  Tight in MCP extension; prevent hyperextension injury

Collateral ligament

•  MCP CL: radial and UCL

      Accessory: fan shape, more volar, tight in extension, valgus, varus stress with extension

      Proper ligament: cord like, more dorsal, tight in 30° flexion, check with 30° flexion

      Injury of UCL in 1st MCP: Gamekeeper’s thumb

•  Short in flexed IP joint due to oblique direction (keep IP joint straight [in splinting] to prevent contracture), crucial for opposing pinch stability

Retinacular ligament (Figure 5.4)

•  Oblique and transverse band

      Retain and position common extensor mechanism (lateral band to the dorsal tip of distal phalanx) during PIP and distal interphalangeal (DIP) joint flexion similar to sagittal band function

•  Clinical implication of retinacular ligament dysfunction (Figure 5.5)

      Attenuation of transverse band leads to dorsal translation of lateral bands and a resulting Swan neck deformity (PIP hyperextension and DIP joint flexion)

      Contracture (with attenuation of triangular ligament) of retinacular ligament leads to volar translation of lateral bands, resulting in Boutonnière deformity (DIP joint hyperextension and PIP joint flexion; Figure 5.5)

FIGURE 5.2

Triangular fibrous cartilage complex.

FIGURE 5.3

Pulley system (digital flexor pulley of the finger).

FIGURE 5.4

Collateral ligament and transverse retinacular ligament

Source: Adapted from Ref. (12). Ishizuki M, Sugihara T, Wakabayashi Y, et al. Stener-like lesions of collateral ligament ruptures of the metacarpophalangeal joint of the finger. J Orthop Sci. 2009;14(2):150–154.

FIGURE 5.5

Common finger deformities. (A) Boutonnière deformity. (B) Swan neck deformity. (C) Mallet finger.

FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis.

Digital cutaneous ligament

•  Stabilize the digital neurovascular bundle with finger flexion and extension

•  Grayson’s ligament: volar to digital nerve; involved in Dupuytren’s disease

NERVE

Cutaneous Sensation (13,14)

Median nerve

•  Lateral 3.5 fingers (MC pattern, not in everyone) and palmar aspect

•  Thenar eminence innervated by palmar cutaneous nerve (branch proximal to carpal tunnel, go over (not inside) the carpal tunnel; spared in typical CTS)

Ulnar nerve

•  Medial 1.5 fingers

•  Hypothenar eminence and dorsal ulnar aspect (palmar cutaneous of hypothenar and dorsal ulnar cutaneous [DUC] nerve) branching proximal to the wrist spared in ulnar nerve at the wrist (Guyon’s canal) lesion

•  No splitting of abnormal sensation in 4th digit: can be secondary to variation of ulnar nerve distribution, plexus (lower trunk) or C8 lesion rather than typical ulnar nerve lesion (spared in radial aspect)

Superficial radial nerve

•  Adjacent to the radial artery at the mid forearm

•  Passes beneath musculotendinous junction of the brachioradialis and the tendon of extensor carpi radialis longus (ECRL; common entrapment site with pronation; Wartenberg syndrome) emerges 8–9 cm above the radial styloid (possible entrapment by fascial bands) (15)

•  Cross (volar to dorsal, superficial to) the 1st dorsal compartment (abductor pollicis longus [APL], extensor pollicis brevis [EPB]) close to the cephalic vein at the wrist (16)

Joint Innervation (Figure 5.6)

Small branch of the superficial radial nerve

•  1st interosseous space dorsally

FIGURE 5.6

Nerve innervation of the wrist. The radiocarpal, intercarpal, and carpometacarpal joints are innervated by anterior interosseous nerve (AIN), posterior interosseous nerve (PIN), and ulnar (dorsal and deep branches) nerves.

br., branch; N, nerve; PIN, posterior interosseous nerve.

Italicized terms indicate major contributors.

Posterior interosseous nerve

•  Within 1 cm proximal to Lister’s tubercle, terminal branch passing deep to the level of the interosseous membrane where it courses before innervating the dorsal wrist capsule

•  The terminal branch of the PIN

      The main articular branch to the dorsal aspect of the wrist capsule

      PIN with AIN: innervates three-fourths of the wrist joint capsule

      Location of the nerve block

  Located in the radial deep aspect of the fourth dorsal compartment (extensor indicis [EI], extensor digitorum communis [EDC])

  1.2-cm ulnar to Lister’s tubercle and superficial to the periosteum of the radius (17)

      Resection of this terminal branch anywhere along its length provides denervation to the main portion of the dorsal aspect of the wrist capsule

Lateral antebrachial cutaneous nerve

•  Innervates radial side of the RC and 1st CMC joint consistently (13)

•  Accompanied by radial artery

Ulnar nerve main trunk

•  Articular branch to the pisotriquetral joint in ~50%

•  Deep branch: 2nd to 4th palmar CMC joints, palmar distal and midcarpal joints

Anterior interosseous nerve

•  Provide partial innervation to the palmar RC joint

•  In the distal forearm, the AIN runs along the volar surface of the interosseous membrane

FIGURE 5.7

Wrist compartment (dorsal and ventral compartment).

N, nerve.

MUSCLE

Wrist extensor compartment (Figure 5.7)

•  From radial to ulnar; first to sixth dorsal compartments

•  PIN except ECRL (radial nerve)

•  ECRL/B: C6–7, EDC: C6–8, otherwise: C7–8

•  Long extensor (extrinsic); extend MCP, intrinsic (lumbricals, interosseous) extend PIP and DIP

•  Extrinsic: finger abduction (as net effect)

•  Expansion hood: to extend PIP and DIP joints

      Central slip: extend PIP, insert to the base of the middle finger

      Lateral band: extend DIP, insert to distal phalanx, lumbricals, EI, interosseous insert on lateral band

Muscle and tendon of hands and fingers

NO MAN’S LAND

•  Zone II: distal palmar crease to the middle crease in the finger (zone I is distal to zone II): A1 pulley to insertion of the flexor digitorum superficialis, unpredictable surgical outcome for tendon repair at this level

•  Flexor profundus and sublimis are tightly enclosed within the tenosynovium and inflammatory disease of palm between the distal palmar crease and the crease of the PIP

•  Stiffness is common after the surgery

BIOMECHANICS

FOREARM MOVEMENT AND RU JOINT (11,18)

Ulnar variance: ulnar length (distal end) compared to the radius; varies individually, positive (ulnar longer than radial): pose more loading to UC articulation

In forearm pronation, the distal ulna translates dorsally and distally, whereas in supination, the ulna translates volarly and proximally

•  Forearm pronation and ulnar deviation; most pressure to ulnar-carpal/TFCC structures used in TFCC provocation test

Axial wrist force: through radius (80%–85%) more than ulnar (15%–20%)

•  ~50% through scaphoid (scaphotrapezial: 30%, scaphocapitate: 19%), ~30% through the lunocapitate, and ~20% through triquetrohamate joint

•  Clinical implication: radial and scaphoid injury more common

ROM OF WRIST AND HAND

•  Most activities of daily living (ADL) requires 54° of flexion, 60° of extension, 40° of ulnar deviation, and 17° of radial deviation

•  40° of wrist flexion/extension and radial/ulnar deviation for most of hand placement and ROM

•  Flexion ROM contributed by 60% at midcarpal and 40% at RC joints

•  Extension ROM contributed by 66% at RC and 33% at midcarpal joints

•  Radial deviation: ~90% from midcarpal joint

•  Ulnar deviation: 50% to 66% midcarpal and <50% RC joint

Maximal grip strength output at a self-selected optimal wrist position of 35° of extension and 7° of ulnar deviation

Coupled movement: radiodorsal and ulnopalmar motion of the midcarpal joint

Radial deviation: distal carpal row extend and supinate vs flex and pronate with ulnar deviation

PROXIMAL CARPAL MOVEMENTS

Scaphoid: palmar flex (distal flex volarly) vs triquetrum: tend to extend

Lunate: balanced by scapholunate and lunate-triquetral ligament

Lunate-capitate joint: highly mobile and unrestricted (no ligament other than capsule)

Dorsal intercalated segmental instability (DISI)

•  Lunate dorsally extended position (face dorsally)

•  Scapholunate dissociation and scaphoid fracture > scaphotrapezium-trapezoid OA

Volar intercalated segmental instability (VISI) (19)

•  Lunotriquetral ligament rupture

•  Seen in normal variant or with midcarpal instability

WRIST STABILITY

Lunate

•  Proximal row without direct tendon attachment

•  Movement affected by link to other carpal bones

Scaphoid

•  In the lateral mobile column with trapezium and trapezoid

•  Scaphoid position affected by resting forces and radial deviation (link), triquetrum position (opposite to the scaphoid)

BIOMECHANICS OF HAND (20)

•  Hand: ~90% of upper limb function

•  Thumb: 40% to 50%

•  Index digit (lateral, pulp-to-pulp (finger tip) pinch and power grip)

•  Middle finger: strongest

•  The little finger: power grip

Three biomechanical concepts

•  Concepts of link, column, and rows explain motion and role

•  Lateral (mobile column: scaphoid-trapezium/trapezoid)—center (flexion/extension: lunate-capitate)—medial column (rotation: triquetrum and distal rows)

•  Proximal (lunate) and distal rows: function as a unit, scaphoid connecting both rows

•  Three links of chain in radius, lunate, and capitate (center of rotation); intercalated ligament

Hand functions

•  Precision grip (21): MCP joints and the radial side and intrinsic muscle

      Flexion at distal interphalangeal joint (DIP) of the index and at interphalangeal joint (IPJ) of the thumb. The ends of the fingernails are brought together as in lifting a paper clip from a tabletop

•  Oppositional pinch: dynamometer

      The pulp of the index and thumb brought together with the DIP joints extended. The force to be generated through the thumb opposition, first dorsal interosseous muscle (DI) contraction, and second flexor digitorum profundus (FDP)

•  Key pinch

      The thumb adducted to the radial side of the middle phalanx of the index finger

      In ulnar neuropathy compensate key pinch by thumb and index finger flexion (median nerve innervated muscles)

•  Directional grip (chuck grip)

      The thumb, index, and long finger come together to surround a cylindrical object. When using this grip, a combined rotational and axial force is usually applied to the held object (ie, using a screwdriver)

•  Power grip

      Hook grip

      Cylindrical grip

      Sperical grip

•  Hook grip

      Finger flexion at the IP joints and extension at the MP joints

      The only type of functional grasp that does not require thumb function

•  Cylindrical grip: extrinsic muscles, less thumb

      The fingers are fully flexed while the thumb is flexed and opposed over the other digits, as in holding a baseball bat

      Force generated by applying the fingers into the palm

•  Span (spherical) grasp

      The DIP and PIP joints flex to ~30° and the thumb is abducted. Force is generated between the thumb and fingers, distinct to cylindrical grasp (only by fingers). Requires the thumb MP and IP stability

•  Simpler: thumb finger pinch or digitopalmar grasp

•  Forearm position: affects key and fingertip pinches but not the three-jaw chuck pinch

•  Measurement: dynamometer, pinch meter

      Normal pinch: 3 to 10 kg and grasp strength: 20 to 40 kg

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