Hand 2009 (2) Questions Included Not To Post

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  • Need arches for functional hand If develop flat hand will not have a functional hand
  • Articulations at the 4 th and 5 th CMC joints allow the “cupping” of the hand
  • 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
  • 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)
  • All Ulnar Nerve Hypothenar muscles Opponens Digiti Minimi Abductor Digiti Minimi Flexor Digiti Minimi Brevis Palmaris Brevis
  • 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
  • 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.
  • 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
  • Hood slides forward here over proximal phalanx. During flexion the lateral bands move volarly.
  • Early – FDP and FDS and interossei muscles actively flex the joints Late – lumbricals still inactive, assembly (hood) moves over proximal phalanx
  • 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
  • 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
  • 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”.
  • 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
  • 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
  • Loss of musculocutaneous = profound weakness of forearm flexion, extension and supination Statically – forearm is pronated and extended
  • Most wrist and extrinsics muscles originating in the area of the medial epicondyle
  • 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
  • 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 =
  • 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.
  • 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)
  • Posterior compartment of the arm Superficial branch = Cutaneous only
  • Most wrist and extrinsics muscles originating in the area of the lateral epicondyle
  • 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
  • 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.
  • Extensor muscles of the wrist are paralyzed as a result of radial nerve palsy. Wrist and fingers can not be extended.
  • 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
  • Chronic synovitis – periarticular tissue strength is reduced resulting in destruction of mechanical integrity of joint (deformities) from the various forces acting on the joint.
  • 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
  • Fibrous contracture of the palmar fascia Most common in ring and little fingers

Transcript

  • 1. Hand 19 Bones 19 Articulations 29 Muscles
  • 2. Bones of the Hands
  • 3. Arches of the Hand
    • Transverse carpal arch
    • Transverse metacarpal arch
    • Longitudinal arch
  • 4. Mobility of 4 th and 5 th 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
  • 10. Intrinsics
    • Four Lumbricals
    • Three Palmar Interossei
    • Four Dorsal Interossei
    • Thenar muscles
      • Opponens Pollicus
      • Abductor Pollicus Brevis
      • Adductor Pollicus
      • Flexor Pollicus Brevis
  • 11. Intrinsics
    • Hypothenar muscles
      • Opponens Digiti Minimi
      • Abductor Digiti Minimi
      • Flexor Digiti Minimi Brevis
    • Palmaris Brevis
  • 12. Flexor Tendons
  • 13.  
  • 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
  • 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 Mechanism
  • 19. Extensor Mechanism
  • 20. Extensor Mechanism Closed pack position
    • MCP 70 degrees
    • PIP/DIP extension
  • 21. Closing Hand
  • 22. Opening Hand
  • 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
    • Metacarpalphalangeal joints in 60 to 70 degrees of flexion
    • PIP and DIP joints extended
  • 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/Reposition
  • 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
  • 31. Intrinsic and extrinsic plus hand
    • Intrinsic=(Lumbricals and interosseus =table top)
    • Extrinsic=ED, FDS, FDP) = Hook
  • 32. Intrinsic Plus and Minus
  • 33. Types of Prehension
    • Power grip
      • Spherical
      • Cylindrical
    • Precision grip
    • Power (key) pinch
      • Lateral pinch
    • Precision pinch
    • Hook grip
  • 34. Match
    • Power grip
      • Spherical
      • Cylindrical
    • Precision grip
    • Power (key) pinch
      • Lateral pinch
    • Precision pinch
    • Hook grip
  • 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
  • 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
  • 42. Tenodesis- 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
  • 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
  • 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
  • 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)
  • 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. 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)
      • 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
  • 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)
  • 52. Ulnar nerve injury
    • More severe deformity with low injury
    • High injury also loose FDP so fingers are less flexed
  • 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)
  • 54. Ulnar Nerve Injury
    • Flexion Deformity of the 4 th and 5 th 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”
  • 55. Froment’s Sign
    • Therapist has client hold paper with a lateral pinch
  • 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
  • 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
  • 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.
  • 60. 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
  • 62. Wrist Drop (Radial Nerve Injury)
  • 63. Mallet Finger
    • 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
  • 65.  
  • 66. Boutonniere 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.
  • 67.  
  • 68. Zig Zag Deformities of the Fingers
  • 69. Zig Zag Deformity of the Thumb
  • 70. DeQuervain’s Disease
    • Tenosynovitis of thumb “tendons at the radial styloid process
      • abductor pollicus longus
      • extensor pollicus brevis
    • Maybe a swelling in the area, tenderness
  • 71. Anatomical Snuff Box
    • Abductor pollicus longus
    • Extensor pollicus brevis
    • 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
  • 75.