2. The hand and the wrist are the most active
and the most intricate parts of the upper
extremity. Vulnerable to injury and does not
respond well to serious trauma.
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.
4. 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. 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
8. 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
9. 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
10. 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
16. Carpal Tunnel Syndrome
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
17. common condition in which the median nerve
in the wrist becomes compressed, causing
pain and numbness •
most common repetitive strain injury (RSI) –
the fastest growing type of occupational
injury
18.
19. a rigid canal lying between the carpal bones
and a fibrous tissue sheet called the flexor
retinaculum
a group of nine tendons enveloped by
synovium share space with the median
nerve in the carpal tunnel
when the synovium becomes swollen or
thickened, the nerve is compressed
20.
21. median nerve
supplies motor, sensory, and autonomic
function for the 1st three digits of the hand
and the palmar aspect of the 4th digit
because of its proximity to other structures
wrist flexion causes nerve impingement against
the flexor retinaculum
extension causes increased pressure in distal
portion of carpal tunnel
22.
23. o Causes of Acute CTS –
excessive hand exercise
edema or hemorrhage into carpal tunnel
thrombosis of median artery
24. common complication of certain metabolic
and connective tissue diseases
ex: synovitis in RA – hypertrophied
synovium compresses median nerve
DM – inadequate blood supply can cause median
nerve neuropathy, or dysfunction, resulting in
CTS
25. retitive strain injury
job requiring repetitive hand activities involving
pinch or grasp during wrist flexion (factory
workers, computer operators, jackhammer
operators)
overuse in sports activities
golf, tennis, racquetball
familial or congenital, manifesting in
adulthood
space-occupying lesions (ganglia, tophi, lipomas)
26. peaks between 30 and 60 yrs
but children are adolescents are getting
common –due to use of computer
women – 5 times more common
affects dominant hand, but can occur both
hands simultaneously
27. if use computer regularly
use appropriate ergonomically designed work
stations
take regular breaks
if beginning symptoms – tell medical attention
28. numbness and pain on hand
pain
worse at night as result of flexion or direct
pressure during sleep
may radiate to arm, shoulder and neck, or chest
paresthesia (painful tingling)
sensory changes – usually precedes motor
manifestations by weeks or months
29.
30. (+) Phalen’s wrist test or Phalen’s maneuver
ask client to relax wrist into flexion
or place he back of hands together and flex
both wrists simultaneously
(+) paresthesia in median nerve
distribution (palmar side of thumb, index,
and middle finger, radial half of ring finger)
within 60 secs
31.
32. o Tinel’s sign
tap lightly over the area of median nerve in
wrist
if test is unsuccessful – a BP cuff can be
placed on upper arm and inflated to
clients systolic pressure;
result – pain and tingling
33.
34. motor changes
weak pinch, clumsiness, difficulty with fine
movements
progress to muscle weakness and wasting
(muscle atrophy)
assess task performance
assess pinching ability by asking client to
perform a fine-movement task (ex:
threading a needle)
35. strenuous hand activity worsens the
subjective complaints
wrist swelling
autonomic changes
skin discoloration
nail changes (e.g., brittleness)
increased or decreased palmar sweating
36. routine x-rays
to visualize bone changes, space-occupying
lesions, synovitis
for uncertain definitive dx:
EMG – reveals nerve dysfunction b4 muscle atrophy
MRI – enlarged median nerve within carpal tunnel
UTZ –
37. nonsurgical mgmt
drug therapy
NSAIDs
inject corticosteroid directly into carpal
tunnel – weekly or monthly
immobilization
splint to immobilize wrist – during day or
during night, or both
38. surgical mgmt
to relieve pressure on median artery by
providing nerve decompression
Open Carpal Tunnel Release (OCTR)
Endoscopic Carpal Tunnel Release (ECTR)
synovectomy when synovitis is caused by
RA
removal of excess synovium thru a small
inner-wrist incision
removal of space-occupying lesions
39. postop care
ECTR – less invasive but pain and
numbness longer time postop
check dressing carefully for drainage and
tightness
elevate above the heart for several days
postop – reduce swelling from surgery
check neurovascular status of digits 9 hr
40. postop care
hand movements – including lifting heavy
objects – restricted for 4 to 6 wks postop
encourage t o move all fingers of affected
hand frequently
teach client to expect weakness and
discomfort for weeks or perhaps months
41. postop care
offer pain meds
multiple operations and other treatments –
common
may need assistance with routine daily
tasks or even self-care activities
43. common problem
can be bilateral
cause:
unknown
incidence:
older men, tend to
occur in families
44.
45. Treatment
when function becomes impaired, surg ical
release is required
partial or selective fasciectomy
splint application - post removal of dressing and
drain
nursing care
same with carpal tunnel repair
46. a round, cystlike lesions
often overlying wrist joint or tendon
synovium surrounding the tendon
degenerates, allow tendon sheath tissue to
become weak and distended
47.
48. painless on palpation, but can cause joint
discomfort after prolonged joint use or minor
trauma (ex: strain)
can disappear and then recur
common: 15 to 50 yrs old
50. 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
51. 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
52. 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
53. 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
54. 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
55. 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
56. Ape Hand Deformity
Median nerve palsy
Wasting of the thenar eminence of the hand
Inability to oppose or flex the thumb
57. 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
58. Wrist Drop Deformity
Radial nerve palsy
Paralysis of the extensor muscles of the wrist
59. 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
60. 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
