Wrist and Hand - a Review
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MINETTE RICO FERNANDEZ, PTRP
WRIST and HAND
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Wrist and Hand
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)
Vulnerable to injury and does not respond well to serious trauma. (Magee, David; Orthopedic Physical Assessment 4th Ed)
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)
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Topic contents:
BonesJointsMusclesCommon Hand ConditionsAssessment / Special TestsMini Quiz
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Bones of the Wrist and Hand
Styloid process of ulna & radius
8 carpal bonesProximal row: scaphoid, lunate,
triquetrum, pisiform
Distal row: trapezium, trapezoid, capitate, hamate
5 metacarpals
14 phalanges
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The Carpals
Some Lawyers Tender Proposals That They Cannot Handle
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The Carpal Bones
Navicular/ 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
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How do you remember that the trapezium comes before the trapezoid?
TRAPEZIUM
Greater Multangular (TrapeZOOM)
The trapeziUM supports the thUMb
TRAPEZOID
Lesser Multangular
The trapezoid’s on the inZOID
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Joints of the Wrist and Hand
Carpus/Wrist complex• Distal Radioulnar Joint(magee)• Radiocarpal joints (norkin)• Midcarpal joints• Intercarpal Joint• Carpometacarpal jts• Intermetacarpal jts.
Fingers & thumb• Metacarpophalangeal • Interphalangeal
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Joints of the Wrist and Hand
Distal Radioulnar Joint• 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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Joints of the Wrist and HandMidcarpal 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
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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Joints of the Wrist and Hand
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) RP – 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
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Joints of the Wrist and Hand
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
Metacarpal Joints• Condyloid joints with 2 degrees of freedom• RP - slight flexion• CP – full opposition ; fingers full flexion• CPP – flexion then extension
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Joints of the Wrist and Hand
Interphalangeal Joints• Uniaxial hinge joint with 1 degree of freedom• RP - slight flexion• CP – full extension• CPP – flexion then extension
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Muscles of the Wrist and Hand
Wrist extensors• Brachioradialis• ECRL• ECRB• Extensor digitorum• Extensor carpi ulnaris
Wrist flexors• Palmaris longus• Flexor carpi radialis• Flexor carpi ulnaris• Flexor digitorum superficialis
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Muscles of the Wrist and Hand
Ulnar abductors• Extensor carpi ulnaris• Flexor carpi ulnaris
Radial abductors• ECRL• Flexor carpi radialis• Abductor pollicis longus• Extensor pollicis brevis
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Muscles of the Wrist and Hand
Extrinsic hand muscles• 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
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Intrinsic hand muscles
• 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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Common Wrist and Hand Conditions
Dupuytren’s contractureSwan-neck deformityBoutonniere deformityMallet fingerJersey fingerUlnar driftTrigger fingerClaw fingersApe hand deformityBishop’s handWrist drop deformityDe Quervain’s deformity
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Common Wrist and Hand Conditions
Dupuytren’s Contracture 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
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Common Wrist and Hand Conditions
Swan-Neck DeformityResult of contracture of the intrinsic muscles Often seen after trauma or in patients with RAFlexion of the MCP & DIP joints & extension of the
PIP joint
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Common Wrist and Hand Conditions
Boutonniere DeformityResult of the rupture of the central tendinous slip
of the extensor hoodMost common after trauma or in RAExtension of the MCP & DIP joints & flexion of the
PIP joint
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Common Wrist and Hand Conditions
Mallet FingerResult 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
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Common Wrist and Hand Conditions
Jersey FingerCaused by rupture of the flexor digitorum
profundus tendonCommon among football playersOccurs most often in the ring fingerInability to flex the affected DIP joint which
becomes apparent when the patient is asked to make a fist
Positive sweater finger sign
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Common Wrist and Hand Conditions
Ulnar Drift
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 RAUlnar deviation of the digits
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Common Wrist and Hand Conditions
Claw FingersIntrinsic minus handLoss of intrinsic muscle action & the overaction of
the extrinsic muscles on the proximal phalanx of the fingers
Combined median & ulnar nerve palsyMCP joints are hyperextended & the PIP & DIP
joints are flexed
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Common Wrist and Hand Conditions
Ape Hand DeformityMedian nerve palsyWasting of the thenar eminence of the handInability to oppose or flex the thumb
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Common Wrist and Hand Conditions
Bishop’s Hand or Benediction Hand Deformity
Ulnar nerve palsyWasting of the hypothenar muscles of the hand, the
interossei muscles, & the two lumbrical musclesFlexion of the 4th & 5th fingers
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Common Wrist and Hand Conditions
Wrist Drop DeformityRadial nerve palsyParalysis of the extensor muscles of the
wrist
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Common Wrist and Hand Conditions
De Quervain’s SyndromeSeen 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
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Wrist and Hand
SPECIAL TESTS FOR TENDON AND MUSCLE PATHOLOGY
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1.FINKELSTEIN -- PASSIVEPROCEDURE
- 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
SPECIAL TEST FOR WRIST AND HAND
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2. SWEATER FINGER / JERSEY TESTPROCEDURE
- THE Pt WILL FLEXED ALL THE MCP JOINTSPOSITIVE
- IF THE DIP WILL NOT FLEXINDICATION
- FDP RUPTURE
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Bunnel-Littler Test
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.
(+) Response
PIP joint does not move into flexion. If MCP is flexed & PIP does move into more flexion, then intrinsic muscle tightness.
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Wrist and Hand
TESTS FOR NEUROLOGIC DYSFUNCTION
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Tinel’s Sign at the Wrist
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.
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3. PHALEN’SPROCEDURE
- 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
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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
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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 /
INDICATION - AIN SYNDROME PATHOLOGY KILOH – NEVIN SYNDROME
NO SENSORY SYMPTOMS
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6. FROMENT’S TESTPROCEDURE
- 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
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7. WRINKLE / SHRIVEL TESTPROCEDURE
- Pt FINGER PLACE IN WARM WATER FOR 5 TO 20 MINS.
POSITIVE- NO WRINKLING OF PULP
INDICATIVE - DENERVATION
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Allen Test for Radial & Ulnar Nerve Patency
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.
(+) Response
Blanching remains in the palm after pressure is released from the artery. Can also be used to test individual fingers.
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The End.
Thank You!