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: Bones Joints Muscles Common Hand Conditions Assessment / Special Tests Mini Quiz

Bones of the Wrist and Hand Styloid process of ulna & radius 8 carpal bones Proximal row: scaphoid, lunate, triquetrum, pisiform Distal row: trapezium, trapezoid, capitate, hamate 5 metacarpals 14 phalanges

The Carpals Some Lawyers Tender Proposals That They Cannot Handle

The Carpal Bones 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? 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 Hand Midcarpal 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

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 contracture Swan-neck deformity Boutonniere deformity Mallet finger Jersey finger Ulnar drift Trigger finger Claw fingers Ape hand deformity Bishop’s hand Wrist drop deformity De 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 Deformity Result of contracture of the intrinsic muscles Often seen after trauma or in patients with RA Flexion of the MCP & DIP joints & extension of the PIP joint

Common Wrist and Hand Conditions Boutonniere Deformity Result of the rupture of the central tendinous slip of the extensor hood Most common after trauma or in RA Extension of the MCP & DIP joints & flexion of the PIP joint

Common Wrist and Hand Conditions Mallet Finger Result 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 Finger Caused by rupture of the flexor digitorum profundus tendon Common among football players Occurs most often in the ring finger Inability 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 RA Ulnar deviation of the digits

Common Wrist and Hand Conditions Claw Fingers Intrinsic minus hand Loss of intrinsic muscle action & the overaction of the extrinsic muscles on the proximal phalanx of the fingers Combined median & ulnar nerve palsy MCP joints are hyperextended & the PIP & DIP joints are flexed

Common Wrist and Hand Conditions Ape Hand Deformity Median nerve palsy Wasting of the thenar eminence of the hand Inability to oppose or flex the thumb

Common Wrist and Hand Conditions Bishop’s Hand or Benediction Hand Deformity Ulnar nerve palsy Wasting of the hypothenar muscles of the hand, the interossei muscles, & the two lumbrical muscles Flexion of the 4th & 5th fingers

Common Wrist and Hand Conditions Wrist Drop Deformity Radial nerve palsy Paralysis of the extensor muscles of the wrist

Common Wrist and Hand Conditions De Quervain’s Syndrome Seen 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

Special tests for tendon and muscle pathology Wrist and Hand Special tests for tendon and muscle pathology

SPECIAL TEST FOR WRIST AND HAND FINKELSTEIN -- PASSIVE PROCEDURE - 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

SWEATER FINGER / JERSEY TEST PROCEDURE - THE Pt WILL FLEXED ALL THE MCP JOINTS POSITIVE - IF THE DIP WILL NOT FLEX INDICATION - FDP RUPTURE

Bunnel-Littler Test Tests for … Position Stimulus (+) Response 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.

Tests for neurologic dysfunction 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.

PHALEN’S PROCEDURE - 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

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 TEST PROCEDURE - 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 TEST PROCEDURE - 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.

Proximal Row of carpal bones all except: 1.Scaphoid 2.Lunate 3.Trapezium 4.Triquetral A patient reported with a history of fall on an outstretched hand, complains of pain in the anatomical snuffbox and clinically no deformities visible.The diagnosis is: 1.Colles fracture 2.Lunate dislocation 3. Barton’s fracture 4.Scaphoid fracture The most common nerve involvement is dislocation of lunate is Median nerve Anterior interosseus Posterior interosseous Bennet’s fracture is fracture dislocation of base of metacarpal: 1.4th 2. 3rd 3.2nd 4.1st

A 30 year old man involved in a fight, injured his middle finger and noticed slight flexion of DIP joint. X rays were normal . The most appropriate management at this stage is: Ignore Splint the finger in hyperextension Surgical repair of the flexor tendon Buddy strapping In hand surgery which area is called no mans land: Proximal phalanx Distal phalanx Wrist Between distal phalanx crease and proximal phalanx. True regarding mallet finger is: Avulsion of tendon at the base of the middle phalanx Avulsion of extensor tendon at the base of the distal phalanx Fracture of distal phalanx Fracture of proximal phalanx Froment sign is positive in: 1.Ulnar nerve injury 2. Radial nerve injury 3. Median nerve injury 4. Erbs palsy