Wrist and Hand Fractures

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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23 Wrist and Hand Fractures

Anatomy of the Wrist and Hand

image

Carpal Bones

image

Bones of Wrist and Hand

Carpal Bones: Lateral to Medial

• Proximal

image Scaphoid, lunate, triquetrum, pisiform

• Distal

image Trapezium, trapezoid, capitate, hamate

Metacarpals

• Numbered I/1 (thumb) to V/5 (digiti minimi)
• Parts: base, shaft, head
• Shafts triangular in cross section
• V/5 most commonly fractured metacarpal

Phalanges

• Proximal, middle, distal (3) in each finger
• Proximal, distal (2) in thumb
• Parts: base, shaft, tuberosity (in distal phalanges), head
• Distal phalanx 3 common fracture

Joints of Wrist and Hand

• Radiocarpal (RC) joint

image Synovial joint between distal radius and articular disc (concave) and scaphoid, lunate, and triquetrum (convex)
image Allows movement around 2 axes: flexion/extension, adduction/abduction (ulnar and radial deviation, respectively)

• Carpal joints

image Synovial joints between carpals
image Share common joint cavity
image Limited movement contributes to positioning of hand, grasp

• Carpometacarpal (CM) joints

image Synovial, between distal row of carpal bones and 5 metacarpal bases
image Saddle joint between trapezium and thumb metatarsal more mobile than others: flex/extend, abduct/adduct, rotate, circumduct
image CM joints II-V

image Synovial arthrodial/gliding
image Range of movement increases medially: metacarpal 5 greatest.

image Joint capsules reinforced by palmar and dorsal ligaments and medial and lateral collateral ligaments

• Metacarpophalangeal (MCP) joints

image Synovial condylar
image Between metacarpal heads and proximal phalanges
image Joint capsules reinforced by palmar ligaments and medial and lateral collateral ligaments

• Interphalangeal joints

image Synovial hinge
image Supported by palmar and medial, lateral collateral ligaments

Ligaments of Wrist and Hand

• Supporting wrist (RC) joint: palmar radiocarpal, palmar ulnocarpal, dorsal radiocarpal ligaments
• Flexor retinaculum (transverse carpal ligament) runs proximally between scaphoid (tubercle) and triquetrum and distally between trapezium (tubercle) and hamate (hook) and forms carpal tunnel.
• Multiple small ligaments run between adjoining carpal bones on their palmar and dorsal surfaces, reinforcing carpal joints.
• Deep transverse metacarpal ligaments: palmar bands interconnecting MCP palmar ligaments
image

Transverse Section of Wrist Demonstrating Carpal Tunnel

image

Bursae, Spaces, and Tendon Sheaths of Hand

Wrist and Hand Compartments

• Carpal tunnel

image Space between flexor retinaculum and carpal bones
image Contains flexors digitorum superficialis and profundus tendons, sheaths, and median nerve

• Forearm spaces around flexor digitorum tendons communicate with hand spaces and are pathways for forearm–hand compartment syndrome.
• Mid-palmar space: between flexor digitorum tendons and metacarpals/interosseous muscles
• Thenar space: between flexor pollicis tendon and adductor pollicis
• Hypothenar compartment: defined by hypothenar muscle fascia (abductor, flexor brevis, opponens digiti minimi)
• Interosseous compartment: defined by interosseous muscle fascia and metacarpals
• Ulnar bursa: common flexor tendon sheath runs from distal forearm through palm and into fifth digital tendon sheath (or more digits)
• Radial bursa: tendon sheath around flexor pollicis longus travels into thumb
• Dorsal antebrachial spaces communicate with dorsal hand and digit spaces, between extensor tendons and dorsal interossei.

Vessels and Nerves

image

Wrist and Hand: Vessels and Nerves

Arterial Supply

• Distal ulnar (medial) and radial (lateral) arteries contribute to anastomotic vascular arches in the palmar spaces.
• Anastomoses between arches and other distal antebrachial branches of ulnar and radial arteries

Superficial Palmar Arch

• Terminal branch of ulnar artery and superficial branch of radial artery
• Branches

image Common palmar digital arteries (3)
image Bifurcate and form proper palmar digital arteries II-V
image Proper palmar digital artery V, medial side

Deep Palmar Arch

• Terminal branch of radial artery and deep branch of ulnar artery
• Branches

image Princeps pollicis

image Radialis indicis
image Proper digital artery of thumb

image Palmar metacarpal arteries (3)

Venous Drainage

• Networks of superficial and deep veins interconnect.
• Deep veins run with major arterial branches of palmar arches and ulnar and radial arteries.
• Superficial veins drain into venous network on dorsum of hand.
• Cephalic vein originates from lateral side of dorsal venous network and passes into lateral forearm via anatomical snuffbox.
• Basilic vein originates from medial side of the dorsal venous network and passes into dorsomedial forearm.

Nerves

Median Nerve

• Enters palmar space via carpal tunnel
• Intermingled with deep and superficial flexor digitorum tendons
• Recurrent branch

image Arises in carpal tunnel
image Supplies thenar muscles

• Common palmar digital nerves

image Innervate lumbricals 1 and 2
image Branch into proper palmar digital nerves that run along sides of digits 1-3 and lateral aspect of digit 4

Ulnar Nerve

• Enters palmar space by passing lateral to pisiform bone (Guyon’s canal) and around hook of hamate
• Deep branch accompanies deep branch of ulnar artery, penetrates and supplies hypothenar muscles, and arches across palm to supply interossei, 2 medial lumbricals, adductor pollicis, and articular branches to wrist.
• Superficial branch

image Gives rise to common palmar digital nerve: innervates lumbricals 3 and 4
image Branches into proper palmar digital nerves that run along sides of digit 5, medial aspect of digit 4

Radial Nerve

• Superficial branch only part to run distally onto hand
• Enters via anatomical snuffbox
• Sensory to lateral thenar eminence and dorsum of hand to middle of digits 1-3

Clinical Correlates

Compartment Syndrome

• Distal radius, ulnar, or carpal fractures and related tissue and vascular trauma can lead to increased compartment pressure(s), swelling, pain, and paresthesias.
• Carpal tunnel syndrome

image Median nerve compressed with superficial and deep flexor tendons
image Flexor retinaculum release procedure may be indicated.

• Posttraumatic or reperfusional trauma can cause swollen hand from pressure in subcompartments (e.g., interossei, adductor pollicis).
image

Fracture of the Scaphoid

Scaphoid Fractures

• Most common carpal fracture
• Typically caused by a fall on an outstretched hand, with weight on thenar eminence
• Fracture of the waist (mid 1/3) most common
• Pain and swelling in anatomical snuffbox is often seen.
• Adequate healing depends on blood supply from palmar carpal branch of radial artery.
image

Finger Injuries

image

Proximal Interphalangeal Joint Dislocations

Metacarpal and Phalangeal Fractures

• Phalangeal and metacarpal fractures are common.
• Border digits are most commonly involved.
• Mechanisms include bending and torsion (common in sports).
• Crushing injuries often are associated with complex soft tissue injuries.
• 30%-50% open, more than half of these work related

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23 Wrist and Hand Fractures

Anatomy of the Wrist and Hand

image

Carpal Bones

image

Bones of Wrist and Hand

Carpal Bones: Lateral to Medial

• Proximal

image Scaphoid, lunate, triquetrum, pisiform

• Distal

image Trapezium, trapezoid, capitate, hamate

Metacarpals

• Numbered I/1 (thumb) to V/5 (digiti minimi)
• Parts: base, shaft, head
• Shafts triangular in cross section
• V/5 most commonly fractured metacarpal

Phalanges

• Proximal, middle, distal (3) in each finger
• Proximal, distal (2) in thumb
• Parts: base, shaft, tuberosity (in distal phalanges), head
• Distal phalanx 3 common fracture

Joints of Wrist and Hand

• Radiocarpal (RC) joint

image Synovial joint between distal radius and articular disc (concave) and scaphoid, lunate, and triquetrum (convex)
image Allows movement around 2 axes: flexion/extension, adduction/abduction (ulnar and radial deviation, respectively)

• Carpal joints

image Synovial joints between carpals
image Share common joint cavity
image Limited movement contributes to positioning of hand, grasp

• Carpometacarpal (CM) joints

image Synovial, between distal row of carpal bones and 5 metacarpal bases
image Saddle joint between trapezium and thumb metatarsal more mobile than others: flex/extend, abduct/adduct, rotate, circumduct
image CM joints II-V

image Synovial arthrodial/gliding
image Range of movement increases medially: metacarpal 5 greatest.

image Joint capsules reinforced by palmar and dorsal ligaments and medial and lateral collateral ligaments

• Metacarpophalangeal (MCP) joints

image Synovial condylar
image Between metacarpal heads and proximal phalanges
image Joint capsules reinforced by palmar ligaments and medial and lateral collateral ligaments

• Interphalangeal joints

image Synovial hinge
image Supported by palmar and medial, lateral collateral ligaments

Ligaments of Wrist and Hand

• Supporting wrist (RC) joint: palmar radiocarpal, palmar ulnocarpal, dorsal radiocarpal ligaments
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