2. 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)
3. Topic contents:
Bones
Joints
Muscles
Common Hand Conditions
Assessment / Special Tests
Mini Quiz
4. Bones of the Wrist
and Hand
Styloid process of ulna & radius
8 carpal bones
Proximal row: scaphoid, lunate,
triquetrum, pisiform
Distal row: trapezium, trapezoid,
capitate, hamate
5 metacarpals
14 phalanges
6. 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
7. 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
8. 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
9. 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
10. Joints of the Wrist and Hand
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
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
11. 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
12. 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
13. 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
19. Common Wrist and Hand Conditions
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
20. 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
21. Common Wrist and Hand Conditions
Swan-Neck Deformity
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
22. Common Wrist and Hand Conditions
Boutonniere Deformity
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
23. Common Wrist and Hand Conditions
Mallet Finger
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
24. Common Wrist and Hand Conditions
Jersey Finger
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
25. 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 RA
Ulnar deviation of the digits
26. Common
Wrist and Hand Conditions
Claw Fingers
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
27. Common Wrist and Hand Conditions
Ape Hand Deformity
Median nerve palsy
Wasting of the thenar eminence of the hand
Inability to oppose or flex the thumb
28. Common Wrist and Hand Conditions
Bishop’s Hand or Benediction
Hand Deformity
Ulnar nerve palsy
Wasting of the hypothenar muscles of the hand, the
interossei muscles, & the two lumbrical muscles
Flexion of the 4th & 5th fingers
29. Common Wrist and Hand Conditions
Wrist Drop Deformity
Radial nerve palsy
Paralysis of the extensor muscles of the wrist
30. Common Wrist and Hand Conditions
De Quervain’s Syndrome
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
31. Wrist and Hand
S P E C I A L T E S T S F O R T E N D O N A N D M U S C L E
P A T H O L O G Y
32. 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
SPECIAL TEST FOR WRIST AND HAND
33. 2. SWEATER FINGER / JERSEY TEST
PROCEDURE
- THE Pt WILL FLEXED ALL THE MCP JOINTS
POSITIVE
- IF THE DIP WILL NOT FLEX
INDICATION
- FDP RUPTURE
34. 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.
35. Wrist and Hand
T E S T S F O R N E U R O L O G I C D Y S F U N C T I O N
36. 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.
37. 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
38. 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
39. 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
40. 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
41. 7. WRINKLE / SHRIVEL TEST
PROCEDURE
- Pt FINGER PLACE IN WARM WATER FOR
5 TO 20 MINS.
POSITIVE
- NO WRINKLING OF PULP
INDICATIVE
- DENERVATION
42. 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.
