Transcript Wrist and Hand

Hand
19 Bones
19 Articulations
29 Muscles
Bones of the Hands
Arches of the Hand
Transverse
carpal arch
 Transverse
metacarpal
arch
 Longitudina
l arch

Mobility of 4th and 5th CMC
Joints
Creases of
the Hand
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Distal digital
crease
Middle digital
crease
Proximal digital
crease
Distal palmar
crease
Proximal palmar
crease
Thenar crease
Distal wrist crease
Proximal wrist
crease
Volar or
Palmar
Plates


Volar or Palmar
Plates are dense
thick discs of
fibrocartilage which
help to strengthen
joint and prevent
hyperextension
Note the fibrous
digital sheath in
top picture (annual
pulley)
Motions at the MP Joints

Flexion and Extension
◦ Axis - Lateral
◦ Plane - Sagittal

Abduction and Adduction
◦ Axis - Anterior/Posterior
◦ Plane – Frontal
Motions at the PIP and DIP
Joints

Flexion and Extension
◦ Axis - Lateral
◦ Plane - Sagittal
Extrinsics

Muscles originating
outside the hand
◦ Flexor Digitorium
Superficialis
◦ Flexor Digitiorium
Profundus
◦ Flexor Pollicus Longus
◦ Extensor Digitorum
◦ Extensor Indicis
Proprius
◦ Extensor Digiti Minimi
◦ Extensor Pollicus
Longus
◦ Extensor Pollicus
Brevis
◦ Abductor Pollicus
Longus
Intrinsics
Four Lumbricals
Three Palmar
Interossei
 Four Dorsal
Interossei
 Thenar muscles


◦ Opponens Pollicus
◦ Abductor Pollicus
Brevis
◦ Adductor Pollicus
◦ Flexor Pollicus Brevis
Intrinsics

Hypothenar muscles
◦ Opponens Digiti Minimi
◦ Abductor Digiti Minimi
◦ Flexor Digiti Minimi Brevis

Palmaris Brevis
Flexor Tendons
Flexor Digitorum
Superficialis
Test for Tendon Integrity

Therapist holds all
fingers except one
being tested in
extension. This
isolates the Flexor
Digitorum
Superficialis. If
client can flex at PIP
joint then FDS
tendon is intact.
Flexor Digitorum
Profundus
Test for Tendon Integrity

Therapist extends
all joints of
client’s finger
except the DIP.
Therapist asks
client to flex the
DIP. If client
can, FDP is intact
Annular Pulleys


Hold flexor
tendons relatively
close to joint
(functional
insertions)
Rupture results in
bowstringing with
less ROM and
Over the proximal phalanx the extensor
Extensor
tendon (fromAssembly
extensor digitorum) divides
into a central band and two lateral bands
 The central band inserts at the base of the
middle phalanx
 The two lateral bands rejoin over the
middle phalanx and insert at the base of
the distal phalanx

Extensor Mechanism
Extensor Mechanism
MCP 70
degree
s
 PIP/DI
P
extensi

Extensor Mechanism
Closed pack position
Closing Hand
Opening Hand
Relationship of AB & Adduction to
Flexion and Extension at MP Joints
When MP joints
are extended –
the collateral
ligaments are
slack and allow
for AB and
Adduction of
Fingers
 When MP joints
are flexed – the
collateral
ligaments are
taut (tight) and

Position for Long Term
Immobilization

Metacarpalphalan
geal joints in 60
to 70 degrees of
flexion

PIP and DIP joints
extended
Thumb Movements at CMC
Joint

Thumb Flexion/Extension (Radial
Adduction/Abduction)
◦ Axis - Anterior/Posterior
◦ Plane – Frontal

Thumb Palmar Adduction/Abduction
◦ Axis – Lateral
◦ Plane - Sagittal
Thumb Movements
Thumb
Movements at
CMC Joint

Flexion/Extension
◦ (Radial AB/Adduction)

AB/Adduction
◦ (Palmar
AB/Adduction)

Opposition/Repositio
n
Functional Position of Hand
Wrist is in 20 to
30 degrees of
extension and
slight ulnar
deviation
 Fingers in 45
degrees of MCP,
15 degrees of PIP
and DIP flexion
 Thumb is in 45
degrees of
abduction

Intrinsic
Plus
Flexion of
MP to 90
degrees
and
extension at
PIP and DIP
- or Roof
Top Position
 Interossei
and
lumbricals
at their
shortest
 Common in

Intrinsic
Minus
Hyperextension
of the MP joints
and flexion of
the PIP joints
or “Clawhand”
 Paralysis of
interossei and
lumbrical
muscles
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

Intrinsic=(Lumb
ricals and
interosseus
=table top)
Extrinsic=ED,
FDS, FDP) =
Hook
Intrinsic and extrinsic
plus hand
Intrinsic Plus and Minus

Power grip
◦ Spherical
◦ Cylindrical


Precision grip
Power (key)
pinch
◦ Lateral pinch


Precision pinch
Hook grip
Types of Prehension

Power grip
◦ Spherical
◦ Cylindrical


Precision grip
Power (key) pinch
◦ Lateral pinch


Precision pinch
Hook grip
Match
Common
hand disorders
Intrinsic Tightness
 Nerve injuries
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
Tendon injuries
◦
◦
◦
◦
◦
◦ Ulnar Nerve Injury
◦ Median Nerve Injury
 Carpal Tunnel Syndrome
◦ Radial Nerve Injury

Mallet Finger
Swan Neck Deformity
Boutonniere Deformity
Zig Zag Deformities
DeQuervain’s Disease
Fascia
◦ Dupuytren’s
Contracture
Problems of the Hand
Bunnell-Lister Test for
Intrinsic Tightness
MCP joint held in slight extension while
examiner moves the PIP joint into
flexion – if can’t be flexed, intrinsic or
joint capsule tightness
 Place MCP joint in a few degrees of
flexion to relax intrinsics – if joint can
now flex, then it was intrinsic tightness
 If when MCP joint placed in flexion still
can’t flex PIP – then it is a joint capsule
tightness or contracture.

Bunnell-Lister Test for
Intrinsic Tightness: Step 1

MCP joint held in slight extension will therapist
moves the PIP joint into flexion – if can’t be
flexed, intrinsic or joint capsule tightness
Bunnell-Lister Test for
Intrinsic Tightness: Step 2

Place MCP joint in a few degrees of flexion to
relax intrinsics – if joint can now flex, then it
was intrinsic tightness
Bunnell-Lister Test for
Intrinsic Tightness: Step 3

If when MCP joint placed in flexion still can’t
flex PIP – then it is a joint capsule tightness or
contracture
Musculotaneous nerve (C5, C6 –
Continuation of the lateral cord)
Points of entrapment

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
1.) Coracoid
process (may be
injured during
surgery)
2.)
Coracobrachialis
muscle
3.) Distal lateral
arm as it goes
through investing
fascia
4.) Lateral
Forearm –

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Tenodesis- C6
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Unable to oppose thumb
Unable to make a complete fist
Atrophy of thenar eminence
Weak wrist flexion
Weak pronation of the forearm
Median Nerve Injury
1.) Ligament of
struthers/supracondylar
process (medial ridge)
2.) Bicipital aponeurosis
3.) Between 2 heads of
pronator teres (Pronator
syndrome)
4.) Sublimis Bridge (FDS
borders)
5.) AIN (Anterior
interosseous nerve
branch)- may also be
entrapped by pronator
6.) Carpal Tunnel- between
flexor tendons and
transverse carpal ligament
7.) Metacarpal tunnel –
between metacarpal
Median Nerve = C5-C6,
Medial and Lateral cords
Muscles Innervated by the
Median Nerve
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Flexor Carpi Radialis
Palmaris Longus
Flexor Digitorum Superficialis
Radial Half of Flexor Digitorum
Profundus
Two Radial Lumbricals
Flexor Pollicus Longus
Superficial portion of Flexor Pollicus
Brevis
Opponens Pollicus
Abductor Pollicus Brevis (may have
ulnar innervation)
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome –
Tinel’s Sign

Tinel’s Sign
– When
therapist
taps over
the carpal
tunnel, the
client will
feel
parasthesias
or tingling
distally
Phalen’s Test

Therapist flexes
client’s wrists
manually and
holds together
for one minute.
Positive test
elicits tingling in
thumb, index
finger, and
middle and
lateral half of
the ring finger
and is indicative
of Carpal Tunnel
Ape Hand Deformity

Low injury = Thumb,
index, middle. Loss of
2 lateral lumbricals
◦ Index and middle
have noticeable
claw,
◦ Thumb is rotated
Median
Nerve
and flexed
and in
same
as
(ape
orplane
pope)
fingers, looses
opposition (ape)
High injury = Only FCU
and ulnar half of FDP
are spared. Similar
claw but not as
pronounced because
don’t have the force of
the long flexors.
(pope)
Injury
1.) Arcade of Struthers (as
goes into posterior
compartment through
medial septum)
2.) Posterior to medial
epicondyle (on bony
floor)
3.) Cubital tunnel –
between FCU and medial
collateral ligament
(cubital tunnel
syndrome)
4.) Guyon’s canal – against
piso-hamate ligament,
Ulnar nerve- points of
entrapment
Ulnar nerve injury
More severe
deformity
with low
injury
High injury
also loose
FDP so
fingers are
less flexed


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
Flexor carpi ulnaris
Medial half of the
flexor digitorum
profundus
Medial two
lumbricals,
Interossei (4 dorsal
and 4 palmar)
Adductor pollicis




Abductor digiti
minimi
Opponnens digiti
minimi
Flexor digiti minimi
Flexor policis brevis
(also has median
innervation)
Muscles innervated by the
Ulnar nerve
Flexion Deformity of the
4th and 5th fingers (due
to paralysis of the
lumbricals)
 Atrophy of hypothenar
eminence
 Atrophy of interrossei
 Atrophy of thumb web
space
 Difficulty holding a paper
between
thumb and
Ulnar
Nerve
Injury
index finger
 “Claw Hand”

Froment’s Sign

Therapist has
client hold
paper with a
lateral pinch
Cubital Tunnel Syndrome
Surgery consists of
a.) "decompression",
(removal of the roof
or one wall of the
tunnel
OR
b.) "transposition"
which moves the
ulna nerve out of the
cubital tunnel to
another place.
Spiral Groove – with
fracture, (Saturday
night palsy- when
compressed between
bone and hard
surface)
 Lateral intermuscular
septum
 Radial Tunnel
 Superficial branchRadial Nerve(posterior Points of
interosseous nerve)
entrapment
– vulnerable to
external forces, and
as it branches

Muscles Innervated by the
Radial Nerve
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Extensor Carpi Radialis Longus
Extensor Carpi Radialis Brevis
Extensor Carpi Ulnaris
Extensor Digitorum
Extensor Indicis Proprius
Extensor Pollicus Longus
Extensor Pollicus Brevis
Abductor Pollicus Longus
In Axilla- loss of elbow
extensors and extensors of
the wrist and digits
resulting in wrist drop.
There is a sensory loss to a
narrow strip of skin on the
back of the forearm and on
the dorsum of the hand
and lateral three and one
half digits.


Spiral Groove The
branches to the triceps
are spared in this injury
so that extension of the
elbow is possible.
The long extensors of the
forearm are paralyzed
and this will result in a
"wrist drop". There is a
small loss of sensation
over the dorsal surface
of the hand and the
dorsla sufaces of the
roots of the lateral three
fingers.
Radial Nerve Injury = Wrist
drop or Saturday night
palsy
Radial Tunnel Syndrome





Wrist drop
Lack of MP extension
Lack of thumb IP extension
Lack of thumb abduction
Grip affected due to lack of wrist
extension
Radial Nerve Injury
Wrist Drop (Radial Nerve
Injury)
Mallet Finger

Tear of the extensor tendon from
the attachment on the distal
phalanx
Swan Neck Deformity
MCP joint
subluxes
volarly and
PIP extends
as intrinsics
contract.
 Is a result of
contracture
of the
intrinsics

Boutonniere Deformity
Deformity is a result of a rupture of the
central tendinous slip of the extensor
hood
 Central extensor slip and lateral bands
migrate volarly; extends MCP (and DIP)

Zig Zag Deformities of the
Fingers
Zig Zag Deformity of the
Thumb

Tenosynovitis of thumb “tendons at the
radial styloid process
◦ abductor pollicus longus
◦ extensor pollicus brevis

Maybe a swelling in the area, tenderness
DeQuervain’s Disease
Anatomical Snuff Box
Abductor
pollicus longus
 Extensor
pollicus brevis
 Extensor
pollicus brevis

Finkelstein
Test

Client makes
a fist with
thumb
“inside” the
fist.
Therapist
stabilizes
forearm and
ulnarly
deviates
wrist.
Positive sign
is pain over
the abductor
Palmar Aponeurosis

Fascia in
the palm
of hand
Dupuytren’s Contracture

Fibrous
contracture
of the palmar
fascia