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Anatomy and Function

Figures 5.1, 5.2, and 5.3 illustrate the surface anatomy of the proximal wrist. The wrist is composed of the distal radius and ulna, which articulate with each other to form the radioulnar joint. The distal radius also articulates with the scaphoid and lunate bones [1]. The distal ulna articulates with the triangular fibrocartilage complex (TFCC), which functions much like the meniscus of the knee. The TFCC also has ligamentous attachments to the lunate, capitate, and triquetrum [1]. The distal wrist is composed of the eight carpal bones arranged in two rows. The proximal carpals (scaphoid, lunate, triquetrum, and pisiform) are closely approximated to the radius, while the distal carpals (trapezium, trapezoid, capitate, and hamate) are closely associated with the metacarpal bones. When the wrist deviates radially or dorsiflexes, the scaphoid flexes palmarly, which puts it in a precarious position to be injured when a patient falls, particularly when the patient falls on an outstretched hand [2]. Figure 5.4 shows the basic anatomy of the wrist.

Fig. 5.1
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Surface anatomy of the hand – palmar aspect

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Fig. 5.2
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Surface anatomy of the hand – dorsal aspect

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Fig. 5.3
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Surface anatomy of the wrist– lateral view

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Fig. 5.4
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Skeletal anatomy of the wrist – palmar aspect

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Each of the digits has two neurovascular bundles, one on the radial side and the other on the ulnar side, which contain an artery, vein, and nerve [3]. The extensor tendons, which originate on the lateral dorsal forearm, insert on the dorsal hand. The flexor tendons from the medial forearm insert on the palm of the wrist and hand [4]. The superficial flexor tendon on each phalynx inserts at the base of the middle phalynx, while the deep flexor tendon inserts on the base of the distal phalynx. Figure 5.5 and Table 5.1 demonstrate the extensor and flexor tendons of the fingers.

Fig. 5.5
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Flexor and extensor tendons

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Table 5.1 Flexor and extensor tendons
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The metacarpal–phalangeal (MCP) joint of the thumb differs from the usual “ball and socket” joints of the other digits. Instead, it is a “saddle” joint, which allows for the pincer grip. This joint is largely supported by soft tissue and is therefore easily injured.

Red Flags

Several hand and wrist conditions should be urgently investigated or referred due to potential serious sequelae.

Compound fracture. Any compound fracture should be urgently referred to a specialist. Active or profuse bleeding should be controlled with pressure; no attempts at exploration should be made.

“Fight bite.” A fight bite occurs when the fist strikes a tooth of another person, usually over the knuckles of the ring or little fingers. This type of injury carries high risk of penetration of tendon or even bone, and even a very small mark on the skin may overlie a more serious injury. These injuries are at high risk for infection and should be referred for surgical exploration.

Burns. Severe burns, especially on the palmar side of the hand or wrist, carry risk of underlying tendon injury and should be referred for management.

Injury from high-pressure tools. Air and paint guns can cause high-pressure injury to underlying structures with only a small entry point in the skin and should be referred.

Tendon lacerations. Wounds involving tendon laceration should not be explored in the office; bleeding should be controlled and the patient immediately referred to the appropriate specialist.

“No man’s land” lacerations. Lacerations in the area between the PIP joint and the proximal palm are likely to injure the numerous nerves, tendons, and arteries in this area and should be referred for evaluation.

General Approach to the Patient with Hand Pain

Hand complaints are very common. Many are overuse-type injuries and can be managed conservatively. The challenge of the primary care provider is identifying those with pathology that requires intervention to prevent harmful sequelae.

History should include location and duration of symptoms, inquiry about any trauma or mechanism of injury, and, in the case of overuse injuries, questioning about occupation and/or daily activities. Inquiry should be made regarding the presence of any neurologic or radicular symptoms, which may be referred from the neck or arm.

The “primary” physical examination should be performed on all patients presenting with hand and wrist complaints [5]. Based on history findings as well as these primary examination findings, appropriate secondary examination can be performed.

Primary Hand Examination

Observe the hand in the “safe hand position” as pictured in Fig. 5.6.

Fig. 5.6
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Safe hand position

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  1. 1.

    Note any fingers that are abnormally flexed or extended. This may indicate tendon disruption.

  2. 2.

    Have the patient flex the fingers toward the palm. All of the fingers should be pointing toward the scaphoid bone. Overlapping or crossing of fingers may indicate a fracture with rotational deformity of the finger.

  3. 3.

    Look closely at the distal digits for skin color change or loss of sweating ability, which can involve the whole digit or only a portion of the finger. This finding indicates distal nerve injury.

  4. 4.

    Test capillary refill. In the distal finger, blanching that lasts more than 2 s may indicate microvascular compromise.

  5. 5.

    Test 2-point discrimination of the distal fingertip. The patient should be able to discriminate two points 5 or more millimeters apart. Failure indicates neurologic compromise.

  6. 6.

    Grasp the patient’s hand in a handshake. If the patient is able to grasp your hand without significant pain, (s)he is unlikely to have a wrist or hand pathology that requires urgent evaluation [5, 6].

Based on findings in the history and above primary examination, the examiner then performs the appropriate secondary examination focusing on the area(s) in question. See Table 5.2. Simple palpation for tenderness can oftentimes assist in obtaining a diagnosis.

Table 5.2 Secondary hand and wrist exam
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Common Clinical Presentations

Trauma

All patients with wrist and hand complaints who have a history of significant trauma should have X-ray evaluation done as part of their workup. Any fracture or bony anomaly seen on X-ray with the exception of the specific diagnoses listed on the flow sheet should be referred to a specialist for management. In the case of negative X-ray findings with negative clinical examination for worrisome pathology, most patients can be conservatively managed using the flow diagram found in the appendix.

Acute Nontraumatic Hand and Wrist Pain (<8 Weeks Duration)

Most patients who have no history of trauma but have pain that has been present for days to weeks will have overuse-type injuries. After doing appropriate secondary examination to rule out major pathology, the clinician can usually manage these conservatively; however, the clinician should consider X-ray if there is any suspicion of underlying bony pathology, as sometimes, traumatic incidents are forgotten by the patient.

These patients will generally fall into either an easily diagnosable condition, such as DeQuervain’s tenosynovitis (DQT), carpal tunnel syndrome (CTS), or will have nonspecific but benign hand or wrist complaints. The former two conditions can be managed appropriately in the primary care setting following the flow diagram. The latter can be managed via the RICE protocol (rest, ice, compression, elevation) and reevaluated. If pain persists after RICE therapy or appropriate treatment, X-ray should be performed, if not already done. If X-ray findings are negative, conservative management can be continued for a short time, but referral should be made if symptoms persist.

Chronic Nontraumatic Hand and Wrist Pain (>8 Weeks Duration)

Pain present for 8 or more weeks at first assessment should usually receive radiologic evaluation. Exceptions may be made for classically presenting CTS and DQT, which may be diagnosed clinically without the use of X-ray, as long as the provider carefully rules out other pathologies. Any positive findings on X-ray can then be appropriately managed, but those with chronic undiagnosed wrist and hand pain should be referred to a specialist for evaluation. Similarly, those with DQT and CTS who have continued symptoms after appropriate treatment should be referred.

The flow sheet which follows can help the provider in the appropriate evaluation and management of common hand and wrist complaints. It is by no means exhaustive but represents the most common pathologies encountered in the primary care setting. In general, the primary care provider should err on the side of caution when evaluating hand and wrist complaints, as misdiagnosis or lack of diagnosis and correct management can have potentially disastrous consequences.

Please refer to Fig. 5.7 for the Hand and Wrist Meaningful Use form.

Fig. 5.7
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The Hand and Wrist Meaningful Use Form

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