HandHand19 Bones

19 Articulations29 Muscles

Bones of the HandsBones of the Hands

Arches of the HandArches of the Hand

Transverse carpal arch

Transverse metacarpal arch

Longitudinal arch

Mobility of 4Mobility of 4thth and 5 and 5thth CMC CMC JointsJoints

Creases of Creases of the Handthe Hand

Distal digital crease

Middle digital crease

Proximal digital crease

Distal palmar crease

Proximal palmar crease

Thenar creaseDistal wrist creaseProximal wrist

crease

Volar or Volar or Palmar Palmar PlatesPlates

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 JointsMotions 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 Motions at the PIP and DIP JointsJoints

Flexion and Extension◦Axis - Lateral◦Plane - Sagittal

ExtrinsicsExtrinsicsMuscles 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

IntrinsicsIntrinsicsFour LumbricalsThree Palmar

InterosseiFour Dorsal

InterosseiThenar muscles

◦Opponens Pollicus◦Abductor Pollicus

Brevis◦Adductor Pollicus◦Flexor Pollicus Brevis

IntrinsicsIntrinsics

Hypothenar muscles◦Opponens Digiti Minimi◦Abductor Digiti Minimi◦Flexor Digiti Minimi Brevis

Palmaris Brevis

Flexor TendonsFlexor Tendons

Flexor Digitorum Flexor Digitorum SuperficialisSuperficialisTest for Tendon IntegrityTest 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 Flexor Digitorum ProfundusProfundusTest for Tendon IntegrityTest 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 PulleysAnnular Pulleys

Hold flexor tendons relatively close to joint (functional insertions)

Rupture results in bowstringing with less ROM and strength

Trigger finger

Extensor AssemblyExtensor AssemblyOver the proximal phalanx the extensor

tendon (from 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 MechanismExtensor Mechanism

Extensor MechanismExtensor Mechanism

Extensor MechanismExtensor MechanismClosed pack positionClosed pack position

MCP 70 degrees

PIP/DIP extension

Closing HandClosing Hand

Opening HandOpening Hand

Relationship of AB & Adduction to Relationship of AB & Adduction to Flexion and Extension at MP JointsFlexion 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 prevent AB and ADduction

Position for Long Term Position for Long Term ImmobilizationImmobilization

Metacarpalphalangeal joints in 60 to 70 degrees of flexion

PIP and DIP joints extended

Thumb Movements at CMC Thumb Movements at CMC JointJoint

Thumb Flexion/Extension (Radial Adduction/Abduction) ◦Axis - Anterior/Posterior ◦Plane – Frontal

Thumb Palmar Adduction/Abduction◦Axis – Lateral◦Plane - Sagittal

Thumb MovementsThumb Movements

Thumb Thumb Movements at Movements at CMC JointCMC Joint

Flexion/Extension◦(Radial AB/Adduction)

AB/Adduction◦(Palmar AB/Adduction)

Opposition/Reposition

Functional Position of HandFunctional 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 Intrinsic PlusPlus

Flexion of MP to 90 degrees and extension at PIP and DIP - or Roof Top Position

Interossei and lumbricals at their shortest

Common in patients with R.A.

Intrinsic Intrinsic MinusMinus

Hyperextension of the MP joints and flexion of the PIP joints or “Clawhand”

Paralysis of interossei and lumbrical muscles

Intrinsic and extrinsicIntrinsic and extrinsicplus handplus hand

Intrinsic=(Lumbricals and interosseus =table top)

Extrinsic=ED, FDS, FDP) = Hook

Intrinsic Plus and MinusIntrinsic Plus and Minus

Types of PrehensionTypes of Prehension

Power grip◦Spherical◦Cylindrical

Precision gripPower (key)

pinch◦Lateral pinch

Precision pinchHook grip

MatchMatch

Power grip◦Spherical◦Cylindrical

Precision gripPower (key) pinch

◦Lateral pinchPrecision pinchHook grip

Common hand disorders

Problems of the HandProblems of the Hand

Intrinsic TightnessNerve injuries

◦ Ulnar Nerve Injury◦ Median Nerve Injury

Carpal Tunnel Syndrome◦ Radial Nerve Injury

Tendon injuries◦ Mallet Finger◦ Swan Neck Deformity◦ Boutonniere Deformity◦ Zig Zag Deformities◦ DeQuervain’s Disease

Fascia◦ Dupuytren’s

Contracture

Bunnell-Lister Test for Bunnell-Lister Test for Intrinsic TightnessIntrinsic TightnessMCP 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 Bunnell-Lister Test for Intrinsic Tightness: Step 1Intrinsic 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 Bunnell-Lister Test for Intrinsic Tightness: Step 2Intrinsic 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 Bunnell-Lister Test for Intrinsic Tightness: Step 3Intrinsic 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 – Musculotaneous nerve (C5, C6 – Continuation of the lateral cord)Continuation of the lateral cord)Points of entrapmentPoints of entrapment

1.) Coracoid process (may be injured during surgery)

2.) Coracobrachialis muscle

3.) Distal lateral arm as it goes through investing fascia

4.) Lateral Forearm – Vulnerable to blunt trauma

Tenodesis- C6Tenodesis- C6

http://video.google.com/videosearch?sourceid=navclient&rlz=1T4ADBF_enUS296US296&q=tenodesis&um=1&ie=UTF-8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0

Median Nerve InjuryMedian Nerve Injury

Unable to oppose thumbUnable to make a complete fistAtrophy of thenar eminenceWeak wrist flexionWeak pronation of the forearm

Median Nerve = C5-C6, Median Nerve = C5-C6, Medial and Lateral cordsMedial and Lateral cords

1.) Ligament of struthers/supracondylar process (medial ridge)

2.) Bicipital aponeurosis3.) 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 ligaments and MCP’s

Muscles Innervated by the Muscles Innervated by the Median NerveMedian Nerve

Flexor Carpi Radialis Palmaris LongusFlexor Digitorum SuperficialisRadial Half of Flexor Digitorum

Profundus Two Radial LumbricalsFlexor Pollicus Longus Superficial portion of Flexor Pollicus

BrevisOpponens Pollicus Abductor Pollicus Brevis (may have

ulnar innervation)

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Carpal Tunnel Syndrome – Carpal Tunnel Syndrome – Tinel’s SignTinel’s Sign

Tinel’s Sign – When therapist taps over the carpal tunnel, the client will feel parasthesias or tingling distally

Phalen’s TestPhalen’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 Syndrome.

Ape Hand DeformityApe Hand Deformity

Median Nerve Injury Median Nerve Injury (ape or pope)(ape or pope)

Low injury = Thumb, index, middle. Loss of 2 lateral lumbricals ◦Index and middle have noticeable claw,

◦Thumb is rotated and flexed and in same plane as 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)

Hand is virtually useless

Ulnar nerve- points of Ulnar nerve- points of entrapmententrapment

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, from chronic compression (bike rider)

Ulnar nerve injuryUlnar nerve injury

More severe deformity with low injury

High injury also loose FDP so fingers are less flexed

Muscles innervated by the Muscles innervated by the Ulnar nerveUlnar nerve

Flexor carpi ulnarisMedial 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 minimiFlexor policis brevis

(also has median innervation)

Ulnar Nerve InjuryUlnar Nerve Injury

Flexion Deformity of the 4th and 5th fingers (due to paralysis of the lumbricals)

Atrophy of hypothenar eminence

Atrophy of interrosseiAtrophy of thumb web

spaceDifficulty holding a paper

between thumb and index finger

“Claw Hand”

Froment’s SignFroment’s Sign

Therapist has client hold paper with a lateral pinch

Cubital Tunnel SyndromeCubital Tunnel Syndrome

Surgery consists of a.) "decompression",

(removal of the roof or one wall of the tunnel

ORb.) "transposition"

which moves the ulna nerve out of the cubital tunnel to another place.

Radial Nerve- Points of Radial Nerve- Points of entrapmententrapment

Spiral Groove – with fracture, (Saturday night palsy- when compressed between bone and hard surface)

Lateral intermuscular septum

Radial TunnelSuperficial branch-

(posterior interosseous nerve) – vulnerable to external forces, and as it branches through fascia

Muscles Innervated by the Muscles Innervated by the Radial NerveRadial Nerve Extensor Carpi Radialis LongusExtensor Carpi Radialis BrevisExtensor Carpi UlnarisExtensor DigitorumExtensor Indicis PropriusExtensor Pollicus LongusExtensor Pollicus BrevisAbductor Pollicus Longus

Radial Nerve Injury = Wrist Radial Nerve Injury = Wrist drop or Saturday night drop or Saturday night palsypalsy

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 Tunnel SyndromeRadial Tunnel Syndrome

Radial Nerve InjuryRadial Nerve Injury

Wrist dropLack of MP extensionLack of thumb IP extensionLack of thumb abductionGrip affected due to lack of wrist

extension

Wrist Drop (Radial Nerve Wrist Drop (Radial Nerve Injury)Injury)

Mallet FingerMallet Finger

Tear of the extensor tendon from the attachment on the distal phalanx

Swan Neck DeformitySwan Neck DeformityMCP joint

subluxes volarly and PIP extends as intrinsics contract.

Is a result of contracture of the intrinsics

Boutonniere DeformityBoutonniere 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) and flexes PIP.

Zig Zag Deformities of the Zig Zag Deformities of the FingersFingers

Zig Zag Deformity of the Zig Zag Deformity of the ThumbThumb

DeQuervain’s DiseaseDeQuervain’s Disease

Tenosynovitis of thumb “tendons at the radial styloid process◦ abductor pollicus longus ◦extensor pollicus brevis

Maybe a swelling in the area, tenderness

Anatomical Snuff BoxAnatomical Snuff Box

Abductor pollicus longus

Extensor pollicus brevis

Extensor pollicus brevis

Finkelstein Finkelstein TestTest

Client makes a fist with thumb “inside” the fist. Therapist stabilizes forearm and ulnarly deviates wrist. Positive sign is pain over the abductor pollicus and extensor pollicus brevis.

Palmar AponeurosisPalmar Aponeurosis

Fascia in the palm of hand

Dupuytren’s ContractureDupuytren’s Contracture

Fibrous contracture of the palmar fascia