MINETTE RICO FERNANDEZ, PTRP

WRIST and HAND

Wrist and Hand

The hand and the wrist are the most active and the most intricate parts of the upper extremity. (Magee, David; Orthopedic Physical Assessment 4th Ed)

Vulnerable to injury and does not respond well to serious trauma. (Magee, David; Orthopedic Physical Assessment 4th Ed)

In addition to being an expressive organ of communication, the hand has a protective role and acts as both a motor and a sensory organ, providing information such as temperature, thickness, texture, depth, and shape as well as the motion of an object. (Magee, David; Orthopedic

Physical Assessment 4th Ed)

Topic contents:

BonesJointsMusclesCommon Hand ConditionsAssessment / Special TestsMini Quiz

Bones of the Wrist and Hand

Styloid process of ulna & radius

8 carpal bonesProximal row: scaphoid, lunate,

triquetrum, pisiform

Distal row: trapezium, trapezoid, capitate, hamate

5 metacarpals

14 phalanges

The Carpals

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The Carpal Bones

Navicular/ Scaphoid - most frequently fractured carpal bone

Lunate – most frequently dislocated carpal bone

Pisiform – smallest; lies on diff plane; last to ossify

Capitate – largest carpal bone, center of wrist, first to ossify

Hamate – with hook like process

How do you remember that the trapezium comes before the trapezoid?

TRAPEZIUM

Greater Multangular (TrapeZOOM)

The trapeziUM supports the thUMb

TRAPEZOID

Lesser Multangular

The trapezoid’s on the inZOID

Joints of the Wrist and Hand

Carpus/Wrist complex• Distal Radioulnar Joint(magee)• Radiocarpal joints (norkin)• Midcarpal joints• Intercarpal Joint• Carpometacarpal jts• Intermetacarpal jts.

Fingers & thumb• Metacarpophalangeal • Interphalangeal

Joints of the Wrist and Hand

Distal Radioulnar Joint• uniaxial pivot• one degree of freedom.• RP – 10 degrees supination• CP – 5 degrees supination• CPP – pain at extremes of rotation

Radiocarpal Joint• biaxial ellipsoid joint (2 degrees Freedom of Movement)• Scaphoid and lunate articulates with radius• Lunate and triquetrum articulates with triangular cartilaginous disc

(triangular fibrocartilage complex- TFCC)• RP – neutral with slight ulnar deviation• CP – extension• CPP – flexion and extension equally limited

Joints of the Wrist and HandMidcarpal Joint

• Articulation between proximal and distal carpal rows• Compound sellar joint; Two degrees of freedom• RP – neutral or slight flexion with ulnar deviation• CP – extension with ulnar deviation• CPP – flexion and extension equally limited

Intercarpal Joints• The joints between individual bones of proximal

carpal row and joints between individual bones of distal carpal row.

• RP – neutral or slight flexion• CP – extension• CPP – no capsular pattern

Joints of the Wrist and Hand

Carpometacarpal Joints (CMC)• 1st CMC – sellar with 3 degrees freedom of movement• 2nd-5th – plane joints (allow only gliding movements; 2nd

and 3rd relatively immobile) RP – Thumb, midway between abduction and adduction, and

midway between flexion and extension Fingers, midway between flexion and extension

CP – Thumb, full opposition; Fingers, full flexion CPP – Thumb, abduction, then extension

Fingers, equal limitation in all directions

Joints of the Wrist and Hand

Intermetacarpal Joints• have only a small amount of gliding movement between

them and do not include the thumb articulation. They are bound together by palmar, dorsal, and interosseous ligaments

Metacarpal Joints• Condyloid joints with 2 degrees of freedom• RP - slight flexion• CP – full opposition ; fingers full flexion• CPP – flexion then extension

Joints of the Wrist and Hand

Interphalangeal Joints• Uniaxial hinge joint with 1 degree of freedom• RP - slight flexion• CP – full extension• CPP – flexion then extension

Muscles of the Wrist and Hand

Wrist extensors• Brachioradialis• ECRL• ECRB• Extensor digitorum• Extensor carpi ulnaris

Wrist flexors• Palmaris longus• Flexor carpi radialis• Flexor carpi ulnaris• Flexor digitorum superficialis

Muscles of the Wrist and Hand

Ulnar abductors• Extensor carpi ulnaris• Flexor carpi ulnaris

Radial abductors• ECRL• Flexor carpi radialis• Abductor pollicis longus• Extensor pollicis brevis

Muscles of the Wrist and Hand

Extrinsic hand muscles• Extensor digitorum• Extensor indicis proprius• Extensor digiti minimi• Extensor pollicis longus• Extensor pollicis brevis• Abductor pollicis longus• Flexor digitorum superficialis• Flexor digitorum profundus• Flexor pollicis longus

Intrinsic hand muscles

• 4 lumbricals• 3 palmar interrosei• 4 dorsal interrosei Thenar muscles:

opponens pollicis, APB adductor pollicis, FPB

Hypothenar muscles: opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevis

• Palmar brevis

Common Wrist and Hand Conditions

Dupuytren’s contractureSwan-neck deformityBoutonniere deformityMallet fingerJersey fingerUlnar driftTrigger fingerClaw fingersApe hand deformityBishop’s handWrist drop deformityDe Quervain’s deformity

Common Wrist and Hand Conditions

Dupuytren’s Contracture Due to the contracture of the palmar fascia Common among men Usually seen in the 50- to 70- age group Fixed flexion deformity

of the MCP & PIP joints Usually seen in the ring

or little finger

Common Wrist and Hand Conditions

Swan-Neck DeformityResult of contracture of the intrinsic muscles Often seen after trauma or in patients with RAFlexion of the MCP & DIP joints & extension of the

PIP joint

Common Wrist and Hand Conditions

Boutonniere DeformityResult of the rupture of the central tendinous slip

of the extensor hoodMost common after trauma or in RAExtension of the MCP & DIP joints & flexion of the

PIP joint

Common Wrist and Hand Conditions

Mallet FingerResult of the rupture or avulsion of the extensor

tendon where it inserts in the distal phalanx of the finger

Distal phalanx rests in a flexed position

Common Wrist and Hand Conditions

Jersey FingerCaused by rupture of the flexor digitorum

profundus tendonCommon among football playersOccurs most often in the ring fingerInability to flex the affected DIP joint which

becomes apparent when the patient is asked to make a fist

Positive sweater finger sign

Common Wrist and Hand Conditions

Ulnar Drift

Due to weakening of the capsuloligamentous structures of the MCP joints & the accompanying bowstring effect if the extensor communis tendons

Commonly seen in patients with RAUlnar deviation of the digits

Common Wrist and Hand Conditions

Claw FingersIntrinsic minus handLoss of intrinsic muscle action & the overaction of

the extrinsic muscles on the proximal phalanx of the fingers

Combined median & ulnar nerve palsyMCP joints are hyperextended & the PIP & DIP

joints are flexed

Common Wrist and Hand Conditions

Ape Hand DeformityMedian nerve palsyWasting of the thenar eminence of the handInability to oppose or flex the thumb

Common Wrist and Hand Conditions

Bishop’s Hand or Benediction Hand Deformity

Ulnar nerve palsyWasting of the hypothenar muscles of the hand, the

interossei muscles, & the two lumbrical musclesFlexion of the 4th & 5th fingers

Common Wrist and Hand Conditions

Wrist Drop DeformityRadial nerve palsyParalysis of the extensor muscles of the

wrist

Common Wrist and Hand Conditions

De Quervain’s SyndromeSeen in patients who perform activities requiring

forceful gripping with radial deviation of the wrist, or repetitive use of the thumb

Insidious onset of pain & tenderness over the dorsal radial aspect of the wrist

Positive Finkelstein’s test

Wrist and Hand

SPECIAL TESTS FOR TENDON AND MUSCLE PATHOLOGY

1.FINKELSTEIN -- PASSIVEPROCEDURE

- Pt MAKES A FIST WITH THUMB INSIDE THE FINGERS

- THE PT WILL STABILIZED THE FOREARM AND DEVIATES THE WRIST TOWARDS ULNAR SIDE

POSITIVE- PAIN OVER THE ABPL AND EPB

INDICATION - DE QUERVEINS / HOFFMAN’S DSE

COMMON- ROWERS

SPECIAL TEST FOR WRIST AND HAND

2. SWEATER FINGER / JERSEY TESTPROCEDURE

- THE Pt WILL FLEXED ALL THE MCP JOINTSPOSITIVE

- IF THE DIP WILL NOT FLEXINDICATION

- FDP RUPTURE

Bunnel-Littler Test

Tests for … Tightness or contracture in the joint capsule of the PIP joint.

Position Sitting with MCP joint held in extension.

Stimulus Move PIP joint into flexion.

(+) Response

PIP joint does not move into flexion. If MCP is flexed & PIP does move into more flexion, then intrinsic muscle tightness.

Wrist and Hand

TESTS FOR NEUROLOGIC DYSFUNCTION

Tinel’s Sign at the Wrist

Tests for … Median nerve.

Position Sitting with forearm supination.

Stimulus Tap over pt.’s volar carpal ligament with fingertip.

(+) Response

Pain or paresthesia distal to the wrist.

3. PHALEN’SPROCEDURE

- THE EXAMINER WILL FLEXED THE WRIST MAXIMALLY AND HOLD THE POSITION FOR 1 MIN

POSITIVE- PARESTHESIA / TINGLING SENSATION ON THUMB, INDEX, MIDDLE AND HALF OF THE RING FINGER

INDICATION - CARPAL TUNNEL SYNDROME - MEDIAN NERVE IMPINGEMENT

4. REVERSE PHALEN’S / PRAYERS TEST- SAME AS PHALEN’S TEST

CARPAL TUNNEL SYNDROME

ATROPHY OF THENAR- LONG TERM COMPRESSION

NO SENSORY LOSS+ PARESTHESIA PAIN AT NIGHT

PT MANAGEMENT REST AND AROMES

5. OK SIGN USE

- TEST THE INTEGRITY OF THE AIN - PQ, FPL AND FDP

PROCEDURE- ASK THE PATIENT TO MAKE AN OK SIGN

POSITIVE- IF PULP TO PULP /

INDICATION - AIN SYNDROME PATHOLOGY KILOH – NEVIN SYNDROME

NO SENSORY SYMPTOMS

6. FROMENT’S TESTPROCEDURE

- Pt GRASP THE PIECE OF PAPER BETWEEN THE THUMB AND INDEX THE PT WILL PULL THE PAPER

POSITIVE- FLXION OF THE DIP OF THUMB

INDICATION - ADDUCTOR POLLICIS AFFECTATION

7. WRINKLE / SHRIVEL TESTPROCEDURE

- Pt FINGER PLACE IN WARM WATER FOR 5 TO 20 MINS.

POSITIVE- NO WRINKLING OF PULP

INDICATIVE - DENERVATION

Allen Test for Radial & Ulnar Nerve Patency

Tests for … Patency of the radial & ulnar arteries

Position Sitting with forearm free to move, elbow bent with fingers pointing up toward the ceiling.

Stimulus Compress the radial & ulnar arteries at the wrist, one thumb on the ulnar artery & the other on the radial artery. Pt. should open & close fist quickly. PT then releases the pressure on the one artery & observes the filling pattern of the vessels in the palm. Do the same for the other artery.

(+) Response

Blanching remains in the palm after pressure is released from the artery. Can also be used to test individual fingers.

The End.

Thank You!