Transcript WRIST and HAND

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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)
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Vulnerable to injury and does not respond well to
serious trauma. (Magee, David; Orthopedic Physical Assessment
4th Ed)
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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)
 Bones
 Joints
 Muscles
 Common
Hand Conditions
 Assessment / Special Tests
 Mini Quiz
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Styloid process of ulna &
radius
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8 carpal bones
Proximal row: scaphoid,
lunate,
triquetrum, pisiform
Distal row: trapezium,
trapezoid,
capitate, hamate
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5 metacarpals
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14 phalanges
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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
TRAPEZIUM
TRAPEZOID
 Greater
 Lesser
Multangular
Multangular
(TrapeZOOM)
The trapeziUM
supports the thUMb
 The
trapezoid’s on
the inZOID
Carpus/Wrist complex
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Distal Radioulnar Joint
Radiocarpal joints
Midcarpal joints
Intercarpal Joint
Carpometacarpal jts
Intermetacarpal jts.
Fingers & thumb
• Metacarpophalangeal
• Interphalangeal
(magee)
(norkin)
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Distal Radioulnar Joint
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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
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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
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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
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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)
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
◦ RP –
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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
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Metacarpal Joints
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Condyloid joints with 2 degrees of freedom
RP - slight flexion
CP – full opposition ; fingers full flexion
CPP – flexion then extension
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Wrist extensors
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Brachioradialis
ECRL
ECRB
Extensor digitorum
Extensor carpi ulnaris
Wrist flexors
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Palmaris longus
Flexor carpi radialis
Flexor carpi ulnaris
Flexor digitorum superficialis
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Ulnar abductors
• Extensor carpi ulnaris
• Flexor carpi ulnaris
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Radial abductors
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ECRL
Flexor carpi radialis
Abductor pollicis longus
Extensor pollicis brevis
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Extrinsic hand muscles
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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
• 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
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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
Dupuytren’s Contracture
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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
Swan-Neck Deformity
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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
Boutonniere Deformity
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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
Mallet Finger
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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
Jersey Finger
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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
Ulnar Drift
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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
Claw Fingers
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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
Ape Hand Deformity
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Median nerve palsy
Wasting of the thenar eminence of the hand
Inability to oppose or flex the thumb
Bishop’s Hand or Benediction Hand
Deformity
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Ulnar nerve palsy
Wasting of the hypothenar muscles of the hand, the
interossei muscles, & the two lumbrical muscles
Flexion of the 4th & 5th fingers
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Wrist Drop Deformity
Radial nerve palsy
Paralysis of the extensor muscles of the wrist
De Quervain’s Syndrome
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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
SPECIAL TEST FOR WRIST AND HAND
1.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
2. SWEATER FINGER / JERSEY TEST
PROCEDURE
- THE Pt WILL FLEXED ALL THE MCP JOINTS
POSITIVE
- IF THE DIP WILL NOT FLEX
INDICATION
- FDP RUPTURE
Tests for …
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.
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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
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.
3. 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
5. 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 /
NO SENSORY
INDICATION
SYMPTOMS
- AIN SYNDROME PATHOLOGY
KILOH – NEVIN SYNDROME
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
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.
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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
1. Median nerve
2. Anterior interosseus
3. Posterior interosseous
4. Median nerve
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:
1. Ignore
2. Splint the finger in hyperextension
3. Surgical repair of the flexor tendon
4. Buddy strapping
In hand surgery which area is called no mans land:
1. Proximal phalanx
2. Distal phalanx
3. Wrist
4. Between distal phalanx crease and proximal phalanx.
True regarding mallet finger is:
1. Avulsion of tendon at the base of the middle phalanx
2. Avulsion of extensor tendon at the base of the distal phalanx
3. Fracture of distal phalanx
4. Fracture of proximal phalanx
Froment sign is positive in:
1.Ulnar nerve injury
2. Radial nerve injury
3. Median nerve injury
4. Erbs palsy