1. Hand and Wrist Anatomy 14 phalanges 5 metacarpals 8 carpal bones
2 sesamoid bones (thumb)
5 metacarpals
8 carpal bones
Distal Radius
Forms small ulnar notch to accept the ulnar head
Radial styloid process
Distal Ulna
Ulnar styloid process arises from medial surface
Ulnar head

2. Hand and Wrist Anatomy Carpals(flat bones aligned in 2 rows) Proximal
Scaphoid-most commonly fractures
Lunate-most commonly dislocated
Triquetrum
Pisiform-acts as sesmoid bone
Distal
Trapezium(aligns with 1st metacarpal)
Trapezoid(2nd metacarpal)
Capitate(3rd metacarpal)
Hamate(4th and 5th metacarpal)

3. Articulations Distal Radioulnar Formed by ulnar head and ulnar notch
Allows 1 degree freedom of movement
Pronation/supination
Radius glides around the ulna

4. Articulations Radiocarpal joint Reinforced by ligamentous thickening
Formed by distal radius articulating with scaphoid, lunate and triangular fibrocartilage disk(TFCC)
Ellipsoid joint (2 degrees freedom)
Flexion/extension
Radial/ulnar deviation

5. Articulations Intercarpal Joints
Palmar/dorsal/interosseous ligaments between each carpal
Very little gliding

6. Articulations Midcarpal Joints
Proximal/distal carpal row separated by a single joint cavity with small fibrous projections connecting the rows
Limited mobility in flex/ext, radial/ulnar deviation

7. Articulations Carpometacarpal Joint (CMC) MC1/trapezium MC2/trapezoid
MC3/capitate
MC4and 5/hamate (forms 1 articulation)

8. Articulations 1st CMC (thumb) Saddle joint 2 degrees of freedom(3)
Flexion/extension
Abduction/adduction
Accessory rotation
Allows for opposition

9. Articulations 2-4 CMC 5th CMC Plane/synovial joint 1 degree freedom
Flexion/extension
5th CMC
2 degree freedom
Abduction/adduction

10. Articulations Metacarpophalangeal Joint (MCP)
Two degrees freedom of movement
Flexion/extension
Abduction/adduction
Thumb can abduct at any point/fingers only when extended
Collateral ligaments
Varus/valgus force
When fingers are in flexion they tighten and limit abduction/adduction

11. Articulations Interphalangeal Joint One degree freedom of movement
Flexion/extension
Collateral ligaments

12. Muscular Anatomy Wrist Extensors (innervated by radial n.) Superficial
Extensor carpi radialis brevis/longus
Extensor carpi ulnaris
Extensor digitorium
brachioradialis
Deep compartment
Extensor pollicus longus/brevis
Abductor pollicus longus
Extensor indices
supinator
Secured by extensor retinaculum

13. Muscular Anatomy Wrist flexors (median n.) Superficial Deep
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Flexor digitorium superficialis
Pronator teres
Deep
Flexor digitorium profundus
Flexor pollicis longus
Pronator quadratus

14. Muscular Anatomy Palmar (intrinsic) Thenar Abductor pollicis brevis
Flexor pollicis brevis
Opponens Pollicis
Tendon FPL
Adductor pollicis

15. Muscular Anatomy Hypothenar Abductor digiti minimi
Opponens digiti minimi
Flexor digiti minimi brevis

16. Muscular Anatomy Central Lumbricales Palmar aponeurosis Interossei
Tendons FDS/FDP
Superficialis (PIP)
Profundus (DIP)
Lumbricales
Radial side profundus tendon(extensor hood)
Flex MP/ext PIP/DIP
Palmar aponeurosis
Interossei
4 palmar/4 dorsal

17. Carpal Tunnel Fibro-osseous structure Tunnel contains 10 structures
Floor is proximal carpal bones
Roof is transverse carpal ligament
Tunnel contains 10 structures
Median n., flexor pollicis longus tendon, 4 slips of flexor digitorium superficialis, flexor digitorium profundus
Compression results in paresthesia 2-4 fingers and decrease grip

18. Wrist and Hand Evaluation

19. History Location of pain Mechanism of injury
Relevant sounds/sensations
Duration of symptoms
Description of symptoms
Previous history
General medical health

20. Inspection General Posturing of hand Gross deformity Palmar Creases
Areas of lacerations or scars
Wrist
Continuity of distal radius and ulna
Continuity of carpals/metacarpals
Lunate dislocation
Alignment of MCP joint
Posture of wrist and hand
Ganglion cyst
Volkman’s Contracture
Finger Deformities

21. Inspection Hand Alignment of knuckles Alignment of fingernails
Depressed(metacarpal fracture)
Alignment of fingernails
Spiral fracture
Boutonniere deformity
Flex PIP, ext MP/DIP
Mallet finger
Inability to extend distal phalanx
Avulsion of extensor tendon flexion DIP
Jersey Finger
Ruptured FDP-inability to flex DIP

22. Palpation Anteromedial Ulnar head Ulnar styloid process
UCL-(styloid, triquetrum and pisiform)
Pisiform
Triquetrum
Hamate
Wrist flexor group
Flexor Carpi Ulnaris
Flexor Digitorium Profundus
Palmaris Longus
Flexor carpi radialis
Carpal Tunnel

23. Palpation Posterolateral Radial shaft
Distal radius and styloid process
Radial collateral ligament
Scaphoid(Anatomical snuff box)
Extensor Carpi Radialis Longus
Extensor Digitorium
Extensor Carpi Ulnaris
Thumb extensors (EPL, EPB)

24. Palpation Bony Carpals Metacarpals Phalages Ulna Radius
scaphoid
Metacarpals
Phalages
Ulna
Radius
Lister’s Tubercle

25. Palpation Hand Collateral ligaments of MCP(1-5) Phalanges
Collateral ligaments of IP joints
Thenar compartment
Thenar webspace
Central compartment
Hypothenar eminence

26. Wrist AROM (2 degrees)
PROM
RROM
Ligamentous/Capsular Testing
Neurologic Testing
Special Tests

27. Wrist Goniometry Flexion and Extension Patient Fulcrum Stationary Arm
Forearm pronated with hand off edge of table
Fulcrum
Over lateral joint line of wrist
Stationary Arm
Centered midline of ulnar shaft
Movement Arm
Centered on midline of 5th metacarpal

28. Radial and Ulnar Deviation
Patient
Forearm is pronated with hand resting on table
Fulcrum
Aligned with the center of distal radioulnar joint just proximal to capitate
Stationary Arm
Centered over midline of forearm
Movement Arm
Centered over 3rd metacarpal

29. Wrist AROM 2 degrees Sagittal plane Frontal plane (in neutral)
Flexion (80-90)
Extension (75-85)
Fingers relaxed to ensure maximum ROM
Frontal plane (in neutral)
Radial (20)
Ulnar deviation (35)

30. PROM Flexion: firm end point Extension: firm end point
Radial deviation: hard (scaphoid/styloid)
Ulnar deviation: firm end point

31. RROM
Flexion/extension
Radial/ulnar deviation

32. Finger A/P/RROM MCP joint
Flexion/extension MCP ( )
Flexion hard end feel
Extension firm
Abduction/adduction MCP (20-25)
Abduction firm
Flexion/extension IP
Test each finger individually

33. Wrist Special Tests Valgus and Varus Test Patient Examiner Procedure
Sitting with elbow flexed to 90 deg, forearm pronated
Examiner
One hand grips distal forearm other grasps hand across metacarpals
Procedure
UCL : Valgus stress is applied (radially deviated wrist)
RCL: Varus stress is applied (ulnarly deviate wrist
Positive Test
Pain or laxity
Implications

34. Wrist Special Tests Wrist Glide Patient Examiner Procedure
Sitting, elbow flexed to 90 deg, forearm pronated
Examiner
One hand grasps distal radius, other grasps proximal carpal row
Procedure
Shear force is applied to wrist by gliding distal segment in a radial and ulnar direction and then in a volar and dorsal direction
Positive Test
Pain or significant change in glide
Implications

35. Wrist Special Tests Ligamentous/capsular testing for fingers
Valgus/Varus
Full extension IP
MCP-thumb
Ulnar colateral (valgus)
RCL of little finger

36. Wrist Special Tests Murphy’s sign Patient makes a fist
If the head of the third metacarpal is level with the 2nd and 4th metacarpal, sign is positive for lunate dislocation

37. Wrist Special Tests Finkelstein’s test Patient Procedure Positive test
Seated or standing
Procedure
Tucks thumb under fingers by making a fist
Ulnarly deviate wrist
Positive test
Increased pain over radial styloid process and length of extensor pollicis brevis and abductor pollicis longus
Implication
deQuervian’s syndrome

38. Wrist Special Tests Neurologic Testing Special tests
Drop wrist syndrome
Inability to extend wrist (radial n.)
Tinel’s sign

39. Wrist Special Tests Phalen’s Test Patient Procedure Positive Test
Standing or seated
Procedure
Examiner applies overpressure during passive wrist flexion and holds for 1 minute
Positive Test
Tingling in distribution of median n.
Implications
Median Nerve Compression

40. Wrist Special Tests
Vascular Occlusion
Allen’s test