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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
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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)
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Articulations Distal Radioulnar Formed by ulnar head and ulnar notch
Allows 1 degree freedom of movement Pronation/supination Radius glides around the ulna
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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
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Articulations Intercarpal Joints
Palmar/dorsal/interosseous ligaments between each carpal Very little gliding
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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
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Articulations Carpometacarpal Joint (CMC) MC1/trapezium MC2/trapezoid
MC3/capitate MC4and 5/hamate (forms 1 articulation)
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Articulations 1st CMC (thumb) Saddle joint 2 degrees of freedom(3)
Flexion/extension Abduction/adduction Accessory rotation Allows for opposition
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Articulations 2-4 CMC 5th CMC Plane/synovial joint 1 degree freedom
Flexion/extension 5th CMC 2 degree freedom Abduction/adduction
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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
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Articulations Interphalangeal Joint One degree freedom of movement
Flexion/extension Collateral ligaments
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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
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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
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Muscular Anatomy Palmar (intrinsic) Thenar Abductor pollicis brevis
Flexor pollicis brevis Opponens Pollicis Tendon FPL Adductor pollicis
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Muscular Anatomy Hypothenar Abductor digiti minimi
Opponens digiti minimi Flexor digiti minimi brevis
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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
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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
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Wrist and Hand Evaluation
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History Location of pain Mechanism of injury
Relevant sounds/sensations Duration of symptoms Description of symptoms Previous history General medical health
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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
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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
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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
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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)
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Palpation Bony Carpals Metacarpals Phalages Ulna Radius
scaphoid Metacarpals Phalages Ulna Radius Lister’s Tubercle
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Palpation Hand Collateral ligaments of MCP(1-5) Phalanges
Collateral ligaments of IP joints Thenar compartment Thenar webspace Central compartment Hypothenar eminence
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Wrist AROM (2 degrees) PROM RROM Ligamentous/Capsular Testing Neurologic Testing Special Tests
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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
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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
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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)
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PROM Flexion: firm end point Extension: firm end point
Radial deviation: hard (scaphoid/styloid) Ulnar deviation: firm end point
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RROM Flexion/extension Radial/ulnar deviation
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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
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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
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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
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Wrist Special Tests Ligamentous/capsular testing for fingers
Valgus/Varus Full extension IP MCP-thumb Ulnar colateral (valgus) RCL of little finger
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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
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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
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Wrist Special Tests Neurologic Testing Special tests
Drop wrist syndrome Inability to extend wrist (radial n.) Tinel’s sign
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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
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Wrist Special Tests Vascular Occlusion Allen’s test
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