Post on 16-Dec-2015
Arches of the HandArches of the Hand
Transverse carpal arch
Transverse metacarpal arch
Longitudinal arch
Creases of Creases of the Handthe Hand
Distal digital crease
Middle digital crease
Proximal digital crease
Distal palmar crease
Proximal palmar crease
Thenar creaseDistal wrist creaseProximal wrist
crease
Volar or Volar or Palmar Palmar PlatesPlates
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)
Motions at the MP JointsMotions at the MP Joints
Flexion and Extension◦Axis - Lateral◦Plane - Sagittal
Abduction and Adduction◦Axis - Anterior/Posterior ◦Plane – Frontal
Motions at the PIP and DIP Motions at the PIP and DIP JointsJoints
Flexion and Extension◦Axis - Lateral◦Plane - Sagittal
ExtrinsicsExtrinsicsMuscles 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
IntrinsicsIntrinsicsFour LumbricalsThree Palmar
InterosseiFour Dorsal
InterosseiThenar muscles
◦Opponens Pollicus◦Abductor Pollicus
Brevis◦Adductor Pollicus◦Flexor Pollicus Brevis
IntrinsicsIntrinsics
Hypothenar muscles◦Opponens Digiti Minimi◦Abductor Digiti Minimi◦Flexor Digiti Minimi Brevis
Palmaris Brevis
Flexor Digitorum Flexor Digitorum SuperficialisSuperficialisTest for Tendon IntegrityTest 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.
Flexor Digitorum Flexor Digitorum ProfundusProfundusTest for Tendon IntegrityTest 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
Annular PulleysAnnular Pulleys
Hold flexor tendons relatively close to joint (functional insertions)
Rupture results in bowstringing with less ROM and strength
Trigger finger
Extensor AssemblyExtensor AssemblyOver 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 MechanismExtensor MechanismClosed pack positionClosed pack position
MCP 70 degrees
PIP/DIP extension
Relationship of AB & Adduction to Relationship of AB & Adduction to Flexion and Extension at MP JointsFlexion 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
Position for Long Term Position for Long Term ImmobilizationImmobilization
Metacarpalphalangeal joints in 60 to 70 degrees of flexion
PIP and DIP joints extended
Thumb Movements at CMC Thumb Movements at CMC JointJoint
Thumb Flexion/Extension (Radial Adduction/Abduction) ◦Axis - Anterior/Posterior ◦Plane – Frontal
Thumb Palmar Adduction/Abduction◦Axis – Lateral◦Plane - Sagittal
Thumb Thumb Movements at Movements at CMC JointCMC Joint
Flexion/Extension◦(Radial AB/Adduction)
AB/Adduction◦(Palmar AB/Adduction)
Opposition/Reposition
Functional Position of HandFunctional 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
Intrinsic Intrinsic PlusPlus
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.
Intrinsic Intrinsic MinusMinus
Hyperextension of the MP joints and flexion of the PIP joints or “Clawhand”
Paralysis of interossei and lumbrical muscles
Intrinsic and extrinsicIntrinsic and extrinsicplus handplus hand
Intrinsic=(Lumbricals and interosseus =table top)
Extrinsic=ED, FDS, FDP) = Hook
Types of PrehensionTypes of Prehension
Power grip◦Spherical◦Cylindrical
Precision gripPower (key)
pinch◦Lateral pinch
Precision pinchHook grip
MatchMatch
Power grip◦Spherical◦Cylindrical
Precision gripPower (key) pinch
◦Lateral pinchPrecision pinchHook grip
Problems of the HandProblems of the Hand
Intrinsic TightnessNerve 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
Bunnell-Lister Test for Bunnell-Lister Test for Intrinsic TightnessIntrinsic TightnessMCP 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.
Bunnell-Lister Test for Bunnell-Lister Test for Intrinsic Tightness: Step 1Intrinsic 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
Bunnell-Lister Test for Bunnell-Lister Test for Intrinsic Tightness: Step 2Intrinsic 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
Bunnell-Lister Test for Bunnell-Lister Test for Intrinsic Tightness: Step 3Intrinsic Tightness: Step 3
If when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture
Musculotaneous nerve (C5, C6 – Musculotaneous nerve (C5, C6 – Continuation of the lateral cord)Continuation of the lateral cord)Points of entrapmentPoints 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
Tenodesis- C6Tenodesis- C6
http://video.google.com/videosearch?sourceid=navclient&rlz=1T4ADBF_enUS296US296&q=tenodesis&um=1&ie=UTF-8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0
Median Nerve InjuryMedian Nerve Injury
Unable to oppose thumbUnable to make a complete fistAtrophy of thenar eminenceWeak wrist flexionWeak pronation of the forearm
Median Nerve = C5-C6, Median Nerve = C5-C6, Medial and Lateral cordsMedial and Lateral cords
1.) Ligament of struthers/supracondylar process (medial ridge)
2.) Bicipital aponeurosis3.) 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
Muscles Innervated by the Muscles Innervated by the Median NerveMedian Nerve
Flexor Carpi Radialis Palmaris LongusFlexor Digitorum SuperficialisRadial Half of Flexor Digitorum
Profundus Two Radial LumbricalsFlexor Pollicus Longus Superficial portion of Flexor Pollicus
BrevisOpponens Pollicus Abductor Pollicus Brevis (may have
ulnar innervation)
Carpal Tunnel Syndrome – Carpal Tunnel Syndrome – Tinel’s SignTinel’s Sign
Tinel’s Sign – When therapist taps over the carpal tunnel, the client will feel parasthesias or tingling distally
Phalen’s TestPhalen’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.
Median Nerve Injury Median Nerve Injury (ape or pope)(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)
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
Ulnar nerve- points of Ulnar nerve- points of entrapmententrapment
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 injuryUlnar nerve injury
More severe deformity with low injury
High injury also loose FDP so fingers are less flexed
Muscles innervated by the Muscles innervated by the Ulnar nerveUlnar nerve
Flexor carpi ulnarisMedial 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 minimiFlexor policis brevis
(also has median innervation)
Ulnar Nerve InjuryUlnar Nerve Injury
Flexion Deformity of the 4th and 5th fingers (due to paralysis of the lumbricals)
Atrophy of hypothenar eminence
Atrophy of interrosseiAtrophy of thumb web
spaceDifficulty holding a paper
between thumb and index finger
“Claw Hand”
Cubital Tunnel SyndromeCubital Tunnel Syndrome
Surgery consists of a.) "decompression",
(removal of the roof or one wall of the tunnel
ORb.) "transposition"
which moves the ulna nerve out of the cubital tunnel to another place.
Radial Nerve- Points of Radial Nerve- Points of entrapmententrapment
Spiral Groove – with fracture, (Saturday night palsy- when compressed between bone and hard surface)
Lateral intermuscular septum
Radial TunnelSuperficial branch-
(posterior interosseous nerve) – vulnerable to external forces, and as it branches through fascia
Muscles Innervated by the Muscles Innervated by the Radial NerveRadial Nerve Extensor Carpi Radialis LongusExtensor Carpi Radialis BrevisExtensor Carpi UlnarisExtensor DigitorumExtensor Indicis PropriusExtensor Pollicus LongusExtensor Pollicus BrevisAbductor Pollicus Longus
Radial Nerve Injury = Wrist Radial Nerve Injury = Wrist drop or Saturday night drop or Saturday night palsypalsy
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.
Radial Nerve InjuryRadial Nerve Injury
Wrist dropLack of MP extensionLack of thumb IP extensionLack of thumb abductionGrip affected due to lack of wrist
extension
Swan Neck DeformitySwan Neck DeformityMCP joint
subluxes volarly and PIP extends as intrinsics contract.
Is a result of contracture of the intrinsics
Boutonniere DeformityBoutonniere Deformity
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.
DeQuervain’s DiseaseDeQuervain’s Disease
Tenosynovitis of thumb “tendons at the radial styloid process◦ abductor pollicus longus ◦extensor pollicus brevis
Maybe a swelling in the area, tenderness
Anatomical Snuff BoxAnatomical Snuff Box
Abductor pollicus longus
Extensor pollicus brevis
Extensor pollicus brevis
Finkelstein Finkelstein TestTest
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.