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19 Bones 19 Articulations 29 Muscles

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1 19 Bones 19 Articulations 29 Muscles
Hand 19 Bones 19 Articulations 29 Muscles

2 Bones of the Hands

3 Arches of the Hand Transverse carpal arch Transverse metacarpal arch
Longitudina l arch Need arches for functional hand If develop flat hand will not have a functional hand

4 Mobility of 4th and 5th CMC Joints
Articulations at the 4th and 5th CMC joints allow the “cupping” of the hand Mobility of 4th and 5th CMC Joints

5 Creases of the Hand Distal digital crease Middle digital crease
Proximal digital crease Distal palmar crease Proximal palmar crease Thenar crease Distal wrist crease Proximal wrist crease

6 Volar or Palmar Plates 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)

7 Motions at the MP Joints
Flexion and Extension Axis - Lateral Plane - Sagittal Abduction and Adduction Axis - Anterior/Posterior Plane – Frontal

8 Motions at the PIP and DIP Joints
Flexion and Extension Axis - Lateral Plane - Sagittal

9 Extrinsics Muscles 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 Extensor Digitorum - Radial Extensor Indicis Proprius - Radial Extensor Digiti Minimi - Radial Extensor Pollicus Longus - Radial Extensor Pollicus Brevis - Radial Abductor Pollicus Longus - Radial Flexor Digitorium Superficialis - Median Flexor Digitiorium Profundus - Median/on radial side;; Ulnar/Ulnar side Flexor Pollicus Longus - Median

10 Intrinsics Four Lumbricals Three Palmar Interossei
Four Dorsal Interossei Thenar muscles Opponens Pollicus Abductor Pollicus Brevis Adductor Pollicus Flexor Pollicus Brevis Four Lumbricals Radial two – Median; Ulnar two - Ulnar Three Palmar Interossei - Ulnar Four Dorsal Interossei - Ulnar Thenar muscles Opponens Pollicus - Median Abductor Pollicus Brevis - Median Adductor Pollicus - Ulnar Flexor Pollicus Brevis – Superficial (median); Deep (Ulnar)

11 Intrinsics Hypothenar muscles Palmaris Brevis Opponens Digiti Minimi
Abductor Digiti Minimi Flexor Digiti Minimi Brevis Palmaris Brevis All Ulnar Nerve Hypothenar muscles Opponens Digiti Minimi Abductor Digiti Minimi Flexor Digiti Minimi Brevis Palmaris Brevis

12 Flexor Tendons

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14 Flexor Digitorum Superficialis Test 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.

15 Flexor Digitorum Profundus Test 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

16 Annular Pulleys Hold flexor tendons relatively close to joint (functional insertions) Rupture results in bowstringing with less ROM and strength Trigger finger Have 5 Annular Pulleys A2 (on Proximal phalanx) and A4 (on middle phalanx) are major pulleys (attach to shafts of phalanges) A1, A3, A5 attach to palmar/volar plates of respective joints Also have 3 Cruciate pulleys (between A2 and A3; A3 and A4; A4 and A5) thinner fibers

17 Extensor Assembly Over 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

18 Extensor assembly is made up of a tendinous system composed of thee distal tendons of attachment of the extensor muscles, lumbricals, interossei, and thenar and hypothenar muscles. Purpose of the assembly is to extend the digits in different positions of finger flexion. Over 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 Mechanism

19 Extensor Mechanism Over 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

20 Extensor Mechanism Closed pack position
MCP 70 degree s PIP/DI P extensi on Hood slides forward here over proximal phalanx. During flexion the lateral bands move volarly. Extensor Mechanism Closed pack position

21 Closing Hand Early – FDP and FDS and interossei muscles actively flex the joints Late – lumbricals still inactive, assembly (hood) moves over proximal phalanx

22 Opening Hand Early – extensor digitorum is extending at MCP joint
Middle – Intrinsics (lumbricals and interossei) assist extension at the PIP and DIP joints Late – Assembly (Hood) slides back over MCP joint

23 Relationship of AB & Adduction to Flexion 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

24 Position for Long Term Immobilization
Metacarpalphalan geal joints in 60 to 70 degrees of flexion PIP and DIP joints extended At MCP joints the collateral ligaments are taut or stretched to prevent shortening and prevent flexion contractures At the PIP and DIP joints there is equal tension of collateral ligaments throughout the ROM, hence splinted in extension

25 Thumb Movements at CMC Joint
Thumb Flexion/Extension (Radial Adduction/Abduction) Axis - Anterior/Posterior Plane – Frontal Thumb Palmar Adduction/Abduction Axis – Lateral Plane - Sagittal

26 Thumb Movements

27 Thumb Movements at CMC Joint
Flexion/Extension (Radial AB/Adduction) AB/Adduction (Palmar AB/Adduction) Opposition/Repositio n

28 Functional 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

29 Intrinsic Plus 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.

30 Intrinsic Minus Hyperextension of the MP joints and flexion of the PIP joints or “Clawhand” Paralysis of interossei and lumbrical muscles Deformity results from loss of intrinsic muscle action and overaction of the extrinsic extensor muscles on the proximal phalanx of the fingers. Arches of hand disappear and hand becomes “flat”.

31 Intrinsic and extrinsic plus hand
Intrinsic=(Lumb ricals and interosseus =table top) Extrinsic=ED, FDS, FDP) = Hook Intrinsic and extrinsic plus hand

32 Intrinsic Plus and Minus

33 Types of Prehension Power grip Precision grip Power (key) pinch
Spherical Cylindrical Precision grip Power (key) pinch Lateral pinch Precision pinch Hook grip Power grip - hammer Spherical Cylindrical Precision grip – holding an egg; holding a baseball Power (key) pinch Lateral pinch Precision pinch – tip to tip; pulp to pulp Hook grip - suitcase Types of Prehension

34 Match Power grip Precision grip Power (key) pinch Precision pinch
Spherical Cylindrical Precision grip Power (key) pinch Lateral pinch Precision pinch Hook grip Match

35 Common hand disorders

36 Problems of the Hand Intrinsic Tightness Nerve 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 Mallet Finger - Tear of the extensor tendon from the attachment on the distal phalanx Swan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contract Boutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIP Zig Zag Deformities from Rheumatoid Arthritis DeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tenderness Dupuytren’s Contracture - fibrous contracture of the palmar fascia Problems of the Hand

37 Bunnell-Lister Test for Intrinsic Tightness
MCP 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.

38 Bunnell-Lister Test for Intrinsic 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

39 Bunnell-Lister Test for Intrinsic 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

40 Bunnell-Lister Test for Intrinsic Tightness: Step 3
If when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture

41 Musculotaneous nerve (C5, C6 – Continuation of the lateral cord) Points 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 Loss of musculocutaneous = profound weakness of forearm flexion, extension and supination Statically – forearm is pronated and extended

42 http://video. google. com/videosearch
-8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0 Tenodesis- C6

43 Median Nerve Injury Unable to oppose thumb
Unable to make a complete fist Atrophy of thenar eminence Weak wrist flexion Weak pronation of the forearm Median Nerve Injury

44 Median Nerve = C5-C6, Medial and Lateral cords
1.) Ligament of struthers/supracondylar process (medial ridge) 2.) Bicipital aponeurosis 3.) 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 Median Nerve = C5-C6, Medial and Lateral cords

45 Muscles Innervated by the Median Nerve
Flexor Carpi Radialis Palmaris Longus Flexor Digitorum Superficialis Radial Half of Flexor Digitorum Profundus Two Radial Lumbricals Flexor Pollicus Longus Superficial portion of Flexor Pollicus Brevis Opponens Pollicus Abductor Pollicus Brevis (may have ulnar innervation) Most wrist and extrinsics muscles originating in the area of the medial epicondyle

46 Carpal Tunnel Syndrome

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

48 Phalen’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.

49 Wasting of thenar eminence
Wasting of thenar eminence. Thumb falls back into line with fingers as a result of pull of extensor muscles. Unable to oppose or flex thumb Ape Hand Deformity

50 Median Nerve Injury (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) In forearm = all flexor compartment EXCEPT FCU, ulnar half of FDP = Ulnar A median nerve palsy due to a wound on the palmar aspect of the wrist. This is causing wasting and paralysis of the thenar muscles. High injury can only pronate to midpoint = 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 Median Nerve Injury (ape or pope)

51 Ulnar nerve- points of entrapment
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- points of entrapment

52 Ulnar nerve injury More severe deformity with low injury
High injury also loose FDP so fingers are less flexed FCU and Ulnar half of FDP Cutaneous branch The muscles paralyzed are the flexor carpi ulnaris, medial half of the flexor digitorum profundus, medial two lumbricals, all interossei and the adductor pollicis Injury to the nerve at or above the elbow results in paralysis of the medial half of the flexor digitorum profundus with the loss of flexion of the distal phalanges of the medial two digits. Flexion of the wrist joint will produce abduction due to the paralysis of the flexor carpi ulnaris. The hypothenar eminence muscles will be paralysed and the eminence may be wasted. Since the interossei are paralysed the patient will not be able to hold a sheet of paper between the fingers - loss of abduction and adduction. Adduction of the thumb is lost due to paralysis of the adductor pollicis muscle. The patient gets around this loss by strongly contracting the flexor pollicis longus to bring the terminal phalanx of the thumb against the index finger. The fourth and fifth MCP joints are hyperextended due to the loss of the lumbricals and interossei , while the interphalangeal joints of the same digits are flexed. The picture is that of a 'claw hand'. The sensory loss is to the palm and both palmar and dorsal aspects of the medial one and one-half digits. Injury to the nerve at the wirst spares the flexor carpi ulnaris and the flexor digitorum profundus so that wrist flexion is normal and the fourth and fifth interphalangeal nerves are even more flexed into a claw hand. Ulnar nerve injury

53 Muscles innervated by the Ulnar nerve
Flexor carpi ulnaris Medial 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 minimi Flexor policis brevis (also has median innervation) Muscles innervated by the Ulnar nerve

54 Flexion Deformity of the 4th and 5th fingers (due to paralysis of the lumbricals)
Atrophy of hypothenar eminence Atrophy of interrossei Atrophy of thumb web space Difficulty holding a paper between thumb and index finger “Claw Hand” Ulnar Nerve Injury

55 Froment’s Sign Therapist has client hold paper with a lateral pinch
Can’t hold paper in “lateral pinch”. If ulnar nerve injury (maybe cubital tunnel), can’t hold, IP joint will flex. (As interossei won’t hold)

56 Cubital Tunnel Syndrome
Surgery consists of a.) "decompression", (removal of the roof or one wall of the tunnel OR b.) "transposition" which moves the ulna nerve out of the cubital tunnel to another place.

57 Radial Nerve- Points of entrapment
Spiral Groove – with fracture, (Saturday night palsy- when compressed between bone and hard surface) Lateral intermuscular septum Radial Tunnel Superficial branch- (posterior interosseous nerve) – vulnerable to external forces, and as it branches through fascia Posterior compartment of the arm Superficial branch = Cutaneous only Radial Nerve- Points of entrapment

58 Muscles Innervated by the Radial Nerve
Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi Ulnaris Extensor Digitorum Extensor Indicis Proprius Extensor Pollicus Longus Extensor Pollicus Brevis Abductor Pollicus Longus Most wrist and extrinsics muscles originating in the area of the lateral epicondyle

59 Radial Nerve Injury = Wrist drop or Saturday night palsy
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. The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair, and now presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints. With the hand supinated (palm up) and the extensors aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will drop Radial Nerve Injury = Wrist drop or Saturday night palsy

60 Radial Tunnel Syndrome
Test = Resisted supination and resisted middle finger extension Confused with Lateral Epicondyilits 5 points of compression= Fibrous bands, vascular leash, ECRB, Supinator, At proximal or distal edge. The goal of surgery for radial tunnel syndrome is to relieve any abnormal pressure on the nerve where it passes through the radial tunnel. The surgeon begins by making an incision along the outside of the elbow and down the forearm, near the spot where the radial nerve goes under the supinator muscle. Soft tissues are gently moved aside so the surgeon can check the places where the radial nerve may be getting squeezed within the radial tunnel. The nerve can be pinched in many spots, so it is important to check all the areas that may be causing problems. Any parts of the tunnel that are pinching the nerve are cut. This expands the tunnel and relieves pressure on the nerve. At the end of the procedure, the skin is stitched together. Radial Tunnel Syndrome

61 Radial Nerve Injury Wrist drop Lack of MP extension
Lack of thumb IP extension Lack of thumb abduction Grip affected due to lack of wrist extension Radial Nerve Injury

62 Wrist Drop (Radial Nerve Injury)
Extensor muscles of the wrist are paralyzed as a result of radial nerve palsy. Wrist and fingers can not be extended. Wrist Drop (Radial Nerve Injury)

63 Mallet Finger Mallet Finger - Tear of the extensor tendon from the attachment on the distal phalanx Tear of the extensor tendon from the attachment on the distal phalanx

64 Swan Neck Deformity MCP joint subluxes volarly and PIP extends as intrinsics contract. Is a result of contracture of the intrinsics Swan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contract

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66 Boutonniere Deformity
Boutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIP 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.

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68 Zig Zag Deformities of the Fingers

69 Zig Zag Deformity of the Thumb
Chronic synovitis – periarticular tissue strength is reduced resulting in destruction of mechanical integrity of joint (deformities) from the various forces acting on the joint.

70 Tenosynovitis of thumb “tendons at the radial styloid process
abductor pollicus longus extensor pollicus brevis Maybe a swelling in the area, tenderness DeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tenderness DeQuervain’s Disease

71 Anatomical Snuff Box Abductor pollicus longus Extensor pollicus brevis

72 Finkelstein Test 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.

73 Palmar Aponeurosis Fascia in the palm of hand

74 Dupuytren’s Contracture
Fibrous contracture of the palmar fascia Fibrous contracture of the palmar fascia Most common in ring and little fingers

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