examination of the hand & wrist
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Examination of the Hand & Wrist
By
Dr.Abdullah H.A. Juma
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Medical Institutes
• The role of medical Institutes is to provide medical education tools in a multimedia form to upgrade the art of education & learning with the era of advanced technology.
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The objectives
• To improve the learning scale of basic study linked with observatory media.
• To apply the basic textbook knowledge in a clinically applied sense.
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Hand & Wrist
• The anatomy of the hand & wrist is important to understand the multi-functions of both when considering the normal and abnormal pathological conditions affecting both.The delicate structures entails the precision of work needed to carry out different modalities of activities in life.Hands & wrists are the path to every thing in life.
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The arches of the hand• The arches of the hand is a
vital component for the proper functions carried out by the anatomically related structures of bones,joints,capsules and tendons.
• If the hand is flat then it will be typically malfunctioning as stated in the Holy Koran :“ كباسط
وما فاه ليبلغ الماء الى كفيهببالغه ” هو
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The mobile & rigid segments
• The rigid segments are the middle ones and they are the 2nd & 3d metacarpal bones which provide stability for the efficiency of power grip.
• The mobile columns are the peripheral ones to accommodate different shapes and sizes of objects.
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The hand & wrist skeleton
• Formed of carpal bones in 2 rows proximally : scaphoid,lunate,pisiform& triquetrum.
distally : capitate,hamate,trapezium
& trapezoid. 5 metacarpal bones
articulate proximally to form part of the wrist joint and distally to form the hand .
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The dorsum of the hand
• The direction of the skin creases and elastic tissues are illustrated .
• The importance when a surgical incision is planned for to give a good looking scar.
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The anatomy of a finger
• The lateral structures of the index finger are illustrated.
• The vascular bundles , the nerves and the lymphatics run on the radial & ulnar compartments of each finger.
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The anatomy of a finger
• The side view of the anatomical structures are illustrated.
• The relation of the vascular branches & it’s distal network in the pulp space indicates it’s role in the blood supply.
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Fingers & hand proportions in the brain
• Fingers & hands are predominantly represented in comparison to the other parts of the body.
• A thumb has more topographical sites of pesentation.
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Wrist dissection
• Surgical dissection of the wrist reveals the superficial structures.
• Deeper structures are illustrated by retracting the overlying tendons.
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Sensory tools
• 2 points of sensory discrimination, pin prick and light touch sensations are the examination tools to assess the sensory changes affecting the dorsal & palmar surfaces of the hand and the wrist.
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The power of grip
• Gross grip is the action manifested when holding large objects in the palm of the hand and certain power is required to do the action.
• Delicate,fine grip requires little power but more precision.
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Test for ulnar nerve function
• Interosseous muscle is supplied by the ulnar nerve and is attached to the base of the proximal phalanx to move the finger side way.
• Affection of the ulnar nerve causes paralysis of those intrinsic small muscles of the hand.
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The dorsum of the hand
• The extensors of the fingers & wrist are illustrated as they pass behind the extensor retinuculum within their tendon sheaths.
• They form distally the extensor expansion.
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The collateral ligaments
• The lateral ligaments are shown.
• They stabilize the joints and allow safe flexion & extension and side way movements.
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The ligaments in relation to the tendon
• The tendon sheath & it’s related tendon are closely applied to the collateral ligaments.
• The flexor tendon gives a secure excursion enabled by the efficiency of those ligaments.
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Instability of the MC/P
• Rupture of the lateral ligaments & the volar plate cause marrked instability of the joint especially in the sagittal plane.
• This is seen more obviously when flexing the finger aided by the pull of the tendon.
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Metacarpal Head
• The CAM-like action of the MC head is seen clearly in flexion & extension.
• Those are different from the PIP & DIP joints.
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Testing the flexor tendons
• The flexor digitorum profundus runs distally.
• It is tested by stabilizing the proximal joints and allowing flexion of the DIP joint.
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The ROM of the thumb
• The C / MC joint of the thumb has more ROM in all directions.
• This is vitally important for it to perform the multi functional activities.
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Opposition movements
• Fingers are brought in apposition to the thumb to perform delicate functions of a fine grip.
• Hence thumb’s actions are considered >50% of the other fingers.
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The types of grip
• Delicate & fine grip requires the thumb , fingers and intrinsic small muscles of the hand to be in an optimal normal functions.
• Gross grip requires normal functioning of previous factors plus tendons.
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The inferior radio-ulnar joint
• The inferior R/U joint forms with the proximal row of the carpal bones the WRIST joint.
• The triangular cartilage is illustrated and is vulnerable to injury.
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Tendons of the wrist joint
• The attachment of extensor & flexor tendons of the wrist distally to the MC bones.
• They pass over the radius & carpal bones and their main functions are to move the wrist joint.
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The ROM at the wrist joint
• Dorsiflexion is compared with the other side in an indian style of prayer.
• The ROM is recorded in a measurable angle.
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ROM of the wrist together with the fingers movement
• Dorsiflexion og the wrist joint while flexing & extending the fingers.
• The power & excursion of the grip are both reduced in this position and increased in neutral position.
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ROM of the wrist in relation to the functions of the fingers
• The power of the grip is reduced in palmar-flexion.
• The best grip to get is when the wrist joint in a neutral position.
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ROM of the DIP joint
• Flexion of the distal interphalangeal joint is taking place by the flexor digitorum profundus.
• This is illustrated by stabilizing the proximal joints.
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ROM of the PIP joint
• Flexion of the proximal interphalangeal joint is taking place by the flexor digitorum sublimis( superficilis).
• Other fingers are held in extension to allow the pip joint to flex.
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Injury to the wrist area
• Injury to this area can cause a lot of damage especially the tendons and the neurovascular bundle.
• Careful examination is essential prior to take any action.
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Deep structures
• Deep structures are seen distally in the fingers such as : pulleys,volar plates,zones of the tendon sheaths.
• Proximally, the lumbrical muscles are seen with the carpal tunnel.
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The hand as a flag in a Titanic ship
• The hand leads the body ( the Ship ) in the ocean ( Life ).
• The strings to the body direct the ship to sail in the ocean. If any thing goes wrong then the hand is the cause to sink.
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Tendons around the finger
• The delicate arrangement of the tendons around the finger allow them to perform their sophisticated functions.
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Dissection of the dorsum of the finger
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Lateral dissection of the finger
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The action of flexors & extensors
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Clawing of the fingers
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Clawing of fingers & wasting of the 1st dorsal interosseous muscle
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Extension of the thumb
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1st dorsal interosseous muscle in action
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Swan neck deformity
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Testing DIP joint
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Finger flexion & extension
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Segments of the hand during action
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Different postures at function
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Grip ( prehension )
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Difference in the grip facility
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Demo of the 2 grips
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Delicate & fine & precise
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Factors precipitating in action
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A test
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Tests for Median nerve
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Pointing index finger test
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Flex. Dig. Profundus
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Wasting of the thenar eminence
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Detailed anatomy
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Deformity
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Sublaxation & instability
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Grip
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Topographic presentation
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Wasting dorsally
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Ulnar nerve testing
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Dorsum of the hand
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Deep structures
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Radiological involvement of deep layers
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MC heads & MC/P joints
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Volar & dorsal movements
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Combined actions
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The arches of the hand
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Anatomy of the finger
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Review of median nerve testing
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Different forces applied
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A hand in a Titanic ship
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Tendons required
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Review of further deep structures