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Wrist and Hand - a Review

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Wrist and Hand - a Review

  1. 1. MINETTE RICO FERNANDEZ, PTRP WRIST and HAND
  2. 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. 3. Topic contents:  Bones  Joints  Muscles  Common Hand Conditions  Assessment / Special Tests  Mini Quiz
  4. 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
  5. 5. The Carpals Some Lawyers Tender Proposals That They Cannot Handle
  6. 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. 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. 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. 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. 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. 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. 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. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Common Wrist and Hand Conditions Wrist Drop Deformity  Radial nerve palsy  Paralysis of the extensor muscles of the wrist
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 2. SWEATER FINGER / JERSEY TEST PROCEDURE - THE Pt WILL FLEXED ALL THE MCP JOINTS POSITIVE - IF THE DIP WILL NOT FLEX INDICATION - FDP RUPTURE
  33. 33. 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.
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 7. WRINKLE / SHRIVEL TEST PROCEDURE - Pt FINGER PLACE IN WARM WATER FOR 5 TO 20 MINS. POSITIVE - NO WRINKLING OF PULP INDICATIVE - DENERVATION
  41. 41. 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.
  42. 42. The End. Thank You!

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