1. The Wrist and Hand
Chapter 19

2. Structure and Function of the wrist and hand
Figure 19.1 illustrates bones of the wrist and hand complex.

3. Joints of the Wrist Characteristics and Arthrokinematics
Radiocarpal joint
Midcarpal joint
Box 19.1 summarizes Arthrokinematics of the Wrist and Hand Joints.

4. Joints of the Hand Characteristics and Arthrokinematics
Carpometacarpal joints of digits 2 through 5
Carpometacarpal joint of the thumb (digit 1)
Metacarpophalangeal joints of digits 2 through 5
Interphalangeal joints and MCP joint of the thumb

5. Hand Function Muscles of the Wrist and Hand
Length-tension relationships
Extensor mechanism
Control of the unloaded (free) hand
Grips and Prehension Patterns
Power grips
Precision patterns
Combined grips
Table 19.1 outlines Muscles of the Wrist and Hand.
Figure 19.2 illustrates the extrinsic and intrinsic muscles of the wrist and hand.
Figure 19.3 illustrates anatomical structures of the extensor mechanism.

6. Major Nerves Subject to Pressure and Trauma at the Wrist and Hand
Nerve Disorders in the Wrist
Median nerve
Ulnar nerve
Referred Pain and Sensory Patterns

7. management of wrist and hand disorders and surgeries
Table 19.2 summarizes Wrist and Hand Pathologies/Surgical Procedures and Preferred Practice Patterns.

8. Joint Hypomobility: Nonoperative Management
Common Joint Pathologies and Associated Impairments
Rheumatoid arthritis
Osteoarthritis and post-traumatic arthrosis
Postimmobilization hypomobility
Common Activity Limitations and Participation Restrictions

9. Joint Hypomobility: Nonoperative Management (cont'd)
Management: Protection Phase
Control pain and protect joints
Patient education
Pain management
Splinting
Activity modification
Maintain joint and tendon mobility and muscle integrity
Passive, assistive, or active ROM
Tendon-gliding exercises
Multiple-angle muscle setting exercises
Box 19.2 summarizes Joint Protection in the Wrist and Hand.

10. Joint Hypomobility: Nonoperative Management (cont'd)
Management: Controlled Motion and Return to Function Phases
Increase joint play and accessory motions
Joint mobilization techniques
Unlocking a subluxated ulnomeniscal-triquetral joint
Improve joint tracking and pain-free motion
MWM of the wrist
MWM of the MCP and IP joints of the digits

11. Joint Hypomobility: Nonoperative Management (cont'd)
Management: Controlled Motion and Return to Function Phases (cont’d)
Improve mobility, strength, and function
Neuromuscular control and strength
Functional activities
Conditioning exercises
Joint protection

12. Wrist Arthroplasty Indications for Surgery Procedures
Implant designs, materials, and fixation
Operative overview
Joint Surgery and Postoperative Management
Box 19.3 summarizes Surgical Intervention for RA or DJD of the Wrist and Hand.
Box 19.4 contains Contraindications to Arthroplasty of the Wrist or Digits.

13. Wrist Arthroplasty (cont'd)
Postoperative Management
Immobilization
Exercise
Maximum and moderate protection phases
Minimum protection/return to functionphase
Outcomes
Pain relief
Wrist and forearm ROM, strength, and function
Complications
Joint Surgery and Postoperative Management
Box 19.5 contains Precautions After Wrist Arthroplasty.

14. Metacarpophalangeal Implant Arthroplasty
Indications for Surgery
Procedures
Implant design, materials, and fixation
Operative overview
Joint Surgery and Postoperative Management

15. Metacarpophalangeal Implant Arthroplasty (cont'd)
Postoperative Management
Immobilization
Exercise
Maximum protection phase
Moderate and minimum protection phases
Outcomes
Pain relief and patient satisfaction
ROM and hand function
Complications
Joint Surgery and Postoperative Management

16. Proximal Interphalangeal Implant Arthroplasty
Indications for Surgery
Procedure
Implant design, materials, and fixation
Operative overview
Joint Surgery and Postoperative Management
Table 19.3 compares Surgical Approaches for PIP Joint Arthroplasty.

17. Proximal Interphalangeal Implant Arthroplasty (cont'd)
Postoperative Management
Immobilization
Exercise
Maximum and moderate protection phases
Boutonnière deformity
Swan-neck deformity
Minimum protection/return to function phase
Outcomes
Complications
Joint Surgery and Postoperative Management
Table 19.4 outlines Position of Immobilization After PIP Arthroplasty.

18. Carpometacarpal Arthroplasty of the Thumb
Indications for Surgery
Procedure
Background and surgical options
Operative overview
Tendon interpositional arthroplasty
Surface replacement arthroplasty
Joint Surgery and Postoperative Management

19. Carpometacarpal Arthroplasty of the Thumb (cont'd)
Postoperative Management
Immobilization
Exercise
Maximum protection phase
Moderate and minimum protection phases
Outcomes
Pain relief and patient satisfaction
ROM and hand function
Complications
Joint Surgery and Postoperative Management
Box 19.8 contains Precautions After CMC Arthroplasty of the Thumb.

20. Tendon Rupture Associated With RA
Background and Indications for Surgery
Procedures
Tendon transfer
Tendon graft reconstruction
Tendon anastomosis (side-to-side tenorrhaphy)
Direct end-to-end repair
Joint Surgery and Postoperative Management

21. Tendon Rupture Associated With RA (cont'd)
Postoperative management
Immobilization
Exercise
Maximum protection phase
Moderate and minimum protection phases
Outcomes
Joint Surgery and Postoperative Management
Box 19.9 contains Precautions After Extensor Tendon Transfers or Reconstruction in the Rheumatoid Hand.

22. Repetitive Trauma Syndromes/ Overuse Syndromes
Tendinopathy
Etiology of symptoms
Common structural and functional impairments
Common activity limitations and participation restrictions
Management
Protection phase
Controlled motion and return to function phases

23. Simple Sprain Nonoperative Management
Common functional and structural impairments
Common activity limitations and participation restrictions
Management
Traumatic Lesions in the Wrist and Hand

24. Lacerated Flexor Tendons of the Hand
Background and Indications for Surgery
Procedures
Types and timing of operative procedures
Immediate primary repair
Delayed primary repair
Secondary repair
Late reconstruction
Staged repair
Traumatic Lesions in the Wrist and Hand
Figure illustrates Flexor Tendon Zones.
Box describes Flexor Tendon Zones: Anatomical Landmarks.

25. Lacerated Flexor Tendons of the Hand (cont'd)
Procedures (cont’d)
Operative overview
Surgical approach
Suturing technique
Closure
Traumatic Lesions in the Wrist and Hand

26. Lacerated Flexor Tendons of the Hand (cont'd)
Postoperative Management
General considerations
Approaches to postoperative management
Immobilization
Duration
Type or method
Position
Traumatic Lesions in the Wrist and Hand
Box contains Indications for Use of Prolonged Immobilization and Delayed Motion After Flexor Tendon Repair.

27. Lacerated Flexor Tendons of the Hand (cont'd)
Postoperative Management (cont’d)
Exercise
Early controlled motion approaches
Passive motion
Active motion
Maximum protection phase
Moderate protection phase
Minimum protection/return to function phase
Delayed motion approach
Outcomes
Traumatic Lesions in the Wrist and Hand
Figure illustrates splinting and exercise for early active motion postflexor tendon repair.

28. Lacerated Extensor Tendons of the Hand
Background and Indications for Surgery
Procedures
Types of repair and reconstruction
Operative overview
Zone III/IV primary repair
Traumatic Lesions in the Wrist and Hand
Figure illustrates extensor tendon zones.
Box outlines Extensor Tendon Zones: Anatomic Landmarks.

29. Lacerated Extensor Tendons of the Hand (cont'd)
Postoperative Management
Immobilization
Duration
Types
Exercise
Early controlled active motion approach
Use of customized static volar splints
Delayed mobilization approach
Outcomes
Traumatic Lesions in the Wrist and Hand
Box summarizes Special Considerations for Exercise After Extensor Tendon Repair and Extended Immobilization.

30. Exercise interventions for the wrist and hand

31. Tendon-Gliding and Tendon-Blocking Exercises
Place-and-Hold Exercises
Flexor Tendon-Gliding Exercises
Hook (claw) fist position
Full fist
Straight fist (sublimis fist)
Thumb flexion
Techniques for Musculotendinous Mobility
Figure illustrates the five finger positions used for flexor tendon-gliding exercises.

32. Tendon-Gliding and Tendon-Blocking Exercises (cont'd)
Flexor Tendon-Blocking Exercises
Isolated MCP flexion (lumbricales and palmar interossei)
PIP flexion (flexor digitorum superficialis)
DIP flexion (flexor digitorum profundus)
Full fist
Techniques for Musculotendinous Mobility
Figure illustrates flexor tendon-blocking exercises.

33. Tendon-Gliding and Tendon-Blocking Exercises (cont'd)
Exercises to Reduce Extensor Lag
Isolated MCP extension
Isolated PIP and DIP extension
Terminal range extension of IP joints
Extensor Tendon-Gliding Exercises
Techniques for Musculotendinous Mobility

34. Scar Tissue Mobilization for Tendon Adhesions
To Mobilize the Long Finger Flexor Tendons
To Mobilize the Extensor Tendons and the Extensor Mechanism
Techniques for Musculotendinous Mobility

35. Exercise Techniques to Increase Flexibility and Range of Motion
General Stretching Techniques
To increase wrist extension
To increase wrist flexion
To increase flexion or extension of individual joints of the fingers or thumb

36. Exercise Techniques to Increase Flexibility and Range of Motion (cont'd)
Stretching Techniques for the Intrinsic and Multijoint Muscles
Self-stretching the lumbricales and interossei muscles
Self-stretching the interossei muscles
Self-stretching the adductor pollicis
Manual stretching of the extrinsic muscles
Self-stretching the flexor digitorum profundus and superficialis
Self-stretching the extensor digitorum communis

37. Exercise to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement
Techniques to Strengthen Muscles of the Wrist and Hand
To strengthen wrist musculature
To strengthen weak intrinsic musculature
To strengthen weak extrinsic musculature
Mechanical resistance techniques for combined intrinsic and extrinsic muscle function

38. Exercise to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement (cont'd)
Dexterity and Functional Activities
Fine finger dexterity
Functional activities

39. Independent Learning Activities
Critical Thinking and Discussion
Laboratory Practice
Case Studies