The wrist is one of the most complex anatomical structures and features eight bones that are collectively known as the carpus or carpal bones. The carpus is comprised of the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate.
Moving distally, we will have the metacarpals and phalangeals, as well as the distal radius and ulna.
Wrist and hand pain is reported to have a point prevalence of about 13% with women being almost twice as often affected as men across all age groups (Picavet et al. 2003).
The Dutch GP Association reports on the course of wrist and hand pain (NHG 2010). The course of wrist and hand pain appears to be unfavorable as only 25% of patients recover after three months and 40% after one year. Prosser et al. (2012) report that patients who received arthroscopy for nonspecific wrist pain had a 50% chance to have moderate levels of pain and low levels of disability one-year post-surgery.
Prognostic factors (Artus et al. 2017, NHG 2010, Prosser et al. 2012)
The following prognostic factors are specifically described for the wrist and hand:
- old age
- female gender
- long duration (>3 months)
- somatisation (+ fracture = increased risk for CRPS)
- less control over pain and function
- baseline Patient-Reported Wrist and Hand Examination (PRWHE)
Furthermore, you should not forget the prognostic factors for general MSK complaints by Artus et al.:
- widespread pain
- high functional disability
- high pain intensity
- presence of previous pain episodes
There are several specific pathologies that count as red flags. These are:
Common fractures are those of the scaphoid, distal ulna, and distal radius.
Distal radius fractures are:
- Smith fractures: distal head of the radius fractures with volar angulation of the fragment(s)
- Colles fractures: Most common after FOOSH (fall on an outstretched hand) trauma. Impact of the scaphoid on the distal radius leads to fracture and dorsal angulation of the radial fragment(s)
Karaca et al (2016) developed the Karadeniz Wrist Rule to screen for fractures of the wrist. Check the video below to learn how to do them.
“Gamekeeper’s thumb/ski pole thumb” (Opposition trauma)
Usually due to a fall: when skiing, the thumb may be injured in a fall, caught in the ski pole loop. “Gamekeeper’s thumb” refers to an old task that Scottish gamekeepers had to do, which led to repetitive strain on the ulnar collateral ligament (UCL) of the thumb. In severe cases, the UCL displaces proximal and superficial to the adductor aponeurosis. This is called a Stener Lesion (Christensen et al. 2016)
Signs & Symptoms include:
- Ecchymosis of the thumb MCP
- Weakness of pinch grasp
Scapholunate (SL) ligament lesion
Signs & symptoms include:
- Clicking and pain on the dorsoradial aspect of the wrist
- Clear wrist trauma in history
- Diminished grip strength & reduced ROM
Vascularization issues / Decalcification
- SNAC: Scaphoid Non-Union Advanced Collapse (due to non-healed scaphoid fracture)
- SLAC: Scaphoid-Lunated Advanced Collapse (due to ruptured SL-ligament)
Signs and symptoms include:
- Wrist pain
- Dorsoradial swelling
- Limited ROM
- Tenderness of the radiocarpal and mid-carpal joint
Let’s start with active range of motion:
Standard values for the range of motion in different directions are as follows:
AROM assessment is then typically followed by Passive Range of Motion Assessment (PROM) that you can watch with a click on the following video:
During PROM assessment, it’s important to compare the range of motion as well as the end-feel of the affected with the unaffected side.
Specific Pathologies in the Wrist & Hand
There are several pathologies that are commonly seen in the wrist & hand. For more information, click on the respective pathology (content will be added in the near future):
- Carpal Tunnel Syndrome
- De Quervain’s Disease
- Triangular Fibrocartilage Complex (TFCC) Lesions
- Intercarpal Instability
- Impaired Blood Flow & Vascularization
Artus, Majid et al. “Generic Prognostic Factors for Musculoskeletal Pain in Primary Care: A Systematic Review.” BMJ Open 7.1 (2017): e012901. PMC. Web. 6 Sept. 2018.
Cevik, Arif Alper, et al. “Evaluation of physical findings in acute wrist trauma in the emergency department.” Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES 9.4 (2003): 257-261.
Christensen, Thomas, et al. “Long-term outcomes of primary repair of chronic thumb ulnar collateral ligament injuries.” Hand 11.3 (2016): 303-309.
Herziening, Eerste. “NHG-Standaard Hand-en polsklachten.” Huisarts en wetenschap 1.2010 (2010): 22-39.
Karaca, Yunus, et al. “A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules.” The American journal of emergency medicine 34.11 (2016): 2074-2078.
Picavet, H. S. J., and J. S. A. G. Schouten. “Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study.” Pain 102.1-2 (2003): 167-178.
Prosser, Rosemary, et al. “Prognosis and prognostic factors for patients with persistent wrist pain who proceed to wrist arthroscopy.” Journal of Hand Therapy 25.3 (2012): 264-270.
Shah, C. M., & Stern, P. J. (2013). Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis. Current reviews in musculoskeletal medicine, 6(1), 9-17.
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What customers have to say about this online course
- Lucinda de Vries20/02/23Orthopedic Physiotherapy of the Upper and Lower Extremities ORTHOPEDIC PHYSIOTHERAPY OF THE UPPER AND LOWER EXTREMITIES
Super interessante en leuke cursus. Ook zeker voor afgestudeerde fysiotherapeuten om hun kennis weer op te halen/bij te spijkeren. Ondanks dat ik al 5 jaar werkzaam ben als fysiotherapeut was deze cursus zeker een uitdaging en op veel punten echt heel moeilijk en leerzaam.
Het enige vervelende (waar weinig aan gedaan kan worden). de vertalingen eng-nl zijn soms heel onduidelijk.
Al met al zeer genoten tijdens het volgen van deze cursus en er zullen er zeker meerdere volgen.Aurelio Basile09/12/22Orthopedic Physiotherapy of the Spine ORTHOPEDIC PHYSIOTERAPY OF THE SPINE
Fantastic course! simple to follow and extremely helpful in assessing and treating spinal related issues. Furthermore, it is possible to immediately apply the knowledge acquired in the clinic. A must for us physiotherapists.Aurelio Basile09/12/22Orthopedic Physiotherapy of the Upper and Lower Extremities ORTHOPEDIC PHYSIOTERAPY OF THE UPPER AND LOWER EXTREMITIES
Great course! It allows you to make objective assessments with order and clarity. As a result, it is possible to set up effective and efficient treatments.
I also found the sections on the epidemiology and course of the diseases very useful, in order to educate patients and obtain greater compliance with the treatment. Super recommended!!
- DUNCAN10/01/21Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
Great course, lots of information, the instruction videos are really helpful.DOUWE WILLAERT28/12/20Orthopedic Physiotherapy of the Upper and Lower Extremities i would recommend this course to everyone.
if i may give one suggestion that is maybe hard to implement. but i sometimes struggle with explaining things in patient language. so maybe add some frequent asked questions / mechanisms from patients and how to explain it simple or with a metaphore ?
Thanks again for all your work putted in to this course <3JEROEN VAN ZANTEN20/10/20Orthopedic Physiotherapy of the Upper and Lower Extremities I LOVE IT
This course really helps the starting physio. It gives you more convidence. The first year out of school i was really not convident and after this ( relative cheap) course, it got better! Thanks a lot physiotutors! I also got motivation to start studying manual therapy, as i know now, that there is way more to learn.
- WOUTER13/09/20Orthopedic Physiotherapy of the Upper and Lower Extremities FUN AND EASY TO IMPLEMENT IN THE CLINICAL PRACTISE
Took my time to learn and enjoy form this course!
Would definitely recommend this to other physiotherapist who work in the first-line care.ANTONIUS SMOOK22/08/20Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
They go, from the basic assessment to the lower and upper limb, step by step with scientific reasoning. It’s a very usefull course to improve your clinical reasoning in practice.JASMIN KONJIC07/07/20Orthopedic Physiotherapy of the Upper and Lower Extremities REALLY REALLY GREAT!
Everything is extremely well-researched and carefully structured! My only complaint, or actually just a hope for their future courses is that more things should to be structured as bullet points. It can sometimes hard to remember facts from a big block of text. Other than that, amazing. Thanks for your great work guys, it’s been a big help!
- AVIV27/05/20Orthopedic Physiotherapy of the Upper and Lower Extremities Great course, very nice and clean, full attention to details, great job boys!
AvivThomas20/03/20Orthopedic Physiotherapy of the Upper and Lower Extremities STARKES KONZEPT!
Starkes Konzept wissenschaftlich untermauert für die Haupt-Diagnosen der Extremitäten. Sehr übersichtliches Design. Gute Möglichkeit das Lernen einzuteilen. Fortbildung der Zukunft. Nur zu empfehlen. Freue mich auf die nächsten Kurse!Marc07/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities LEERZAAM
Goede opbouw en uitleg per onderdeel.
- JUDITH06/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities My compliments for this online course! I’m feeling all up to date now! I can see why it is highly accredited with the KNGF. Other than expected I quite enjoyed taking the course! Good structure ,good balance between text en videos and content en quiz. For me the assessment assignments worked great to lock the knowledge in! Quizzes are sufficiantly challenging and force/ motivate to really study the contents, think about it and listen to the questions carefully!
Great video footage of tests and exercises! Great links to articles! All very useful for dailey practice (even in osteopathy ;)) and immediately applicable! Should contribute to communication with other health care specialists e.g. when it comes to clinical reasoning for requesting further medical examination e.g. immaging. I already recommended the course to several colleagues!
One point of attention: I got the feeling that the short quizzes at the end of each unit didn’t always mach the unit’s content or plainly state differently (e.g. Type of SLAP lesions).AARON03/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities PERFECT INFORMATION
Much of it was fresh rehearsal including some new insights! Would recommend.DIMITRY22/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities THE FUTURE OF PHYSIOTHERAPY
I think this course should be done by all physiotherapists! The evidence based principle should be adopted by every physiotherapist, this course is a great way to learn how to apply tests, but also background information, advice for patients and some rehabilitation. I believe this kind of course is the future of physiotherapy and is very suitable for everyone.
- Marijke13/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities BEDANKT!
Uitstekende manier van leren.LIEKE11/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities PERFECT
The course was very interesting Learned a lot!JORN08/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities ZEER LEERZAAM!
Zeer leerzame cursus, welke zeker de moeite en tijd waard is!
Gaat goed stapsgewijs dieper in op de stof.
Zorg er wel voor dat je engels up-to-date is.
- MATAN03/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
Super cursus!! Overzichtelijk en up to date.Willem01/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities EXCELLENT COURSE!
A course of the highest quality. It adresses a plethora of conditions both theoreticaly and practically. Everything is well laid out and substatiated with current research. Its fun to take and challenging. If you spend the nescessary time on this course youre sure to learn a lot.
Theres allways room for some pointers so
Andreas you should stop staring so aggresivly during the examinations, its scaring me. Just lay off the steroids for a while and youll mellow out soon enough, theyre other ways to get swole bro.
Kai youve been blasting me with research citations during the whole course. my head is about to explode. Youve been luring me to the dark side of science but i know this knowledge has been paid for in missed sleep and coffee. The bags under your eyes attest to this.
Just joking, you guys are heroes to everyone enrolled in the physiotherapy eduction and therapists alike. ill be buying all of your courses as will the rest of my team.HYEOK17/11/19Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE FOR NOT ONLY FIRST YEAR PHYSIOS BUT ALSO EXPERIENCED PHYSIOS.
I’ve been working in this field for 10 years and still learn from many resources such as books, youtube channels, essays and so on. And this course is awesome because it’s time efficacy and broad perspective of information in each chapter from basic anatomy, pathophysiology, to treatment. After taking this course for 5 months, I able to give more clear, updated information about each patient’s conditions and course of the current problem.
I hope you guys make another course for the spine . I wil take it!
- Rik24/10/19Orthopedic Physiotherapy of the Upper and Lower Extremities This course showed me some new insights that I can use in my own practice.
The course is easy to follow in your own time.
I really enjoyed it!
Thanks guys!M.J. Post08/09/19Orthopedic Physiotherapy of the Upper and Lower Extremities As I said, great course. When you take this course, you’re being pushed into improving your assessment skillset.Vadym Grytsenko29/07/19GREAT ILLUSTRATION OF WHAT ONLINE EDUCATION SHOULD BE! The great course with absolutely new approache to study information online!
Content is extremely useful in daily physiotherapy routine and all the material is based upon scientific researches. I did rehearse the screening and assessment process.
Great illustration of what online education should be!
- Jerry06/06/19GREAT! It was an excellent course! Took me 33 hours and 26 minutes to complete. I liked the cases a lot and the statistics gave me a totally new point of view to assess different tests. This course will make me a better physiotherapist. Thank you!Francisco Javier31/05/19THE UNIVERSITY OF THE FUTURE Awesome Course!!!, honestly it´s the University of future, you will learn all the commmon pathologies of the body with just 1 click: epidemiology, prognostic factors, course, asessment and treatment, everything from a scientific point of view. Well structured, easy to read, fast navegation, high quality videos. You will be able to answer your patient how long the complaints will last base on the last evidence with proper numbers, giving a fair prognosis which will help you to keep them motivate to the therapy and be patients and constant. There is no a day when I dont use it in the practice to consult a specific test or the sensibility of this one. Even you get you acreditation points, a bunch of them actually in comparison with other courses that you will never use in your daily routine. 100% advisable!!!
Curso Magnifico!!!, honestamente, es la universidad del futuro, aprenderá todas las patologías comunes del cuerpo con un solo clic: epidemiología, factores pronósticos, curso, evaluación y tratamiento, todo desde un punto de vista científico. Bien estructurado, fácil de leer, navegación rápida, videos de alta calidad. Podrás responder a tu paciente cuánto tiempo durarán sus molestias basado en la última evidencia con los números adecuados, lo que les dará un pronóstico justo que los ayudará a mantenerlos motivados para la terapia y ser pacientes y constantes. No hay un día en el que no lo use en la práctica para consultar una test específico o la sensibilidad de este. Incluso se obtienen puntos de acreditación, un monton ellos en comparación con otros cursos que luego nunca usas en su rutina diaria. 100% recomendable!!Nathan28/05/19Orthopedic Physiotherapy of the Upper and Lower Extremities A great course for new grads! I have found this course to be very well put together. Firstly the formatting is very user friendly – it’s easy to work through but also very to easy to navigate to specific sections to use as a reference resource. As always with these guys the videos are very high quality. The attention to detail with academic references is also spot on. You can be assured that the info is evidence based. Overall, highly recommended.
- Stijn14/02/19GREAT COURSE I thinks this course is great, I find the framework it teaches you very useful in assessing my patients. I like how the different pathologies are very clearly explained from epidemiology to pathophysiology to diagnostics to treatment, all evidence based. The Physiotutors-style videos used to explain the subject matter are really useful for studying too. Finally, the assingments at the end of the chapters are a great way to test and practice your knowledge on the subject you just studied.Remy29/05/22Orthopedic Physiotherapy of the Upper and Lower Extremities Great course; gives you a good foundation to build upon. As for potential improvements; maybe include a bit more articles that are freely available for people that don’t have access to the scientific database.Rick10/01/22Orthopedic Physiotherapy of the Upper and Lower Extremities USEFUL AND CLEAR
The course consists of easily understandable bite sized lessons. This way it was easy to spend a little time every day to work on this course. All information is easily to find and it is not too much information to remember. It really helped me as a starting physio to get more structure and confidence in my intakes and testing procedures.
Sometimes there are some grammatical or spelling mistakes, but those don’t bother me. Sometimes it would have been nice to maybe have had a bit more information on treatments though.
All-in-all a great course that I would recommend, especially for starting physio’s!