Examination Of The Hand & Wrist


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  • The importance of hand & wrist in the exam , a slide show published 23.1.1422=17.4.2001,Tuesday at 3:16 PM.
  • Examination Of The Hand & Wrist

    1. 1. Examination of the Hand & Wrist By Dr.Abdullah H.A. Juma Orthopaedics Department
    2. 2. Medical Institutes <ul><li>The role of medical Institutes is to provide medical education tools in a multimedia form to upgrade the art of education & learning with the era of advanced technology. </li></ul>
    3. 3. The objectives <ul><li>To improve the learning scale of basic study linked with observatory media. </li></ul><ul><li>To apply the basic textbook knowledge in a clinically applied sense. </li></ul>
    4. 4. Hand & Wrist <ul><li>The anatomy of the hand & wrist is important to understand the multi-functions of both when considering the normal and abnormal pathological conditions affecting both.The delicate structures entails the precision of work needed to carry out different modalities of activities in life.Hands & wrists are the path to every thing in life. </li></ul>
    5. 5. The arches of the hand <ul><li>The arches of the hand is a vital component for the proper functions carried out by the anatomically related structures of bones,joints,capsules and tendons. </li></ul><ul><li>If the hand is flat then it will be typically malfunctioning as stated in the Holy Koran : “ كباسط كفيه الى الماء ليبلغ فاه وما هو ببالغه ” </li></ul>
    6. 6. The mobile & rigid segments <ul><li>The rigid segments are the middle ones and they are the 2 nd & 3d metacarpal bones which provide stability for the efficiency of power grip. </li></ul><ul><li>The mobile columns are the peripheral ones to accommodate different shapes and sizes of objects. </li></ul>
    7. 7. The hand & wrist skeleton <ul><li>Formed of carpal bones in 2 rows proximally : scaphoid,lunate,pisiform& triquetrum. </li></ul><ul><li>distally : </li></ul><ul><li>capitate,hamate,trapezium & trapezoid. </li></ul><ul><li>5 metacarpal bones articulate proximally to form part of the wrist joint and distally to form the hand . </li></ul>
    8. 8. The dorsum of the hand <ul><li>The direction of the skin creases and elastic tissues are illustrated . </li></ul><ul><li>The importance when a surgical incision is planned for to give a good looking scar. </li></ul>
    9. 9. The anatomy of a finger <ul><li>The lateral structures of the index finger are illustrated. </li></ul><ul><li>The vascular bundles , the nerves and the lymphatics run on the radial & ulnar compartments of each finger. </li></ul>
    10. 10. The anatomy of a finger <ul><li>The side view of the anatomical structures are illustrated. </li></ul><ul><li>The relation of the vascular branches & it’s distal network in the pulp space indicates it’s role in the blood supply. </li></ul>
    11. 11. Fingers & hand proportions in the brain <ul><li>Fingers & hands are predominantly represented in comparison to the other parts of the body. </li></ul><ul><li>A thumb has more topographical sites of pesentation. </li></ul>
    12. 12. Wrist dissection <ul><li>Surgical dissection of the wrist reveals the superficial structures. </li></ul><ul><li>Deeper structures are illustrated by retracting the overlying tendons. </li></ul>
    13. 13. Sensory tools <ul><li>2 points of sensory discrimination, pin prick and light touch sensations are the examination tools to assess the sensory changes affecting the dorsal & palmar surfaces of the hand and the wrist. </li></ul>
    14. 14. The power of grip <ul><li>Gross grip is the action manifested when holding large objects in the palm of the hand and certain power is required to do the action. </li></ul><ul><li>Delicate,fine grip requires little power but more precision. </li></ul>
    15. 15. Test for ulnar nerve function <ul><li>Interosseous muscle is supplied by the ulnar nerve and is attached to the base of the proximal phalanx to move the finger side way. </li></ul><ul><li>Affection of the ulnar nerve causes paralysis of those intrinsic small muscles of the hand. </li></ul>
    16. 16. The dorsum of the hand <ul><li>The extensors of the fingers & wrist are illustrated as they pass behind the extensor retinuculum within their tendon sheaths. </li></ul><ul><li>They form distally the extensor expansion. </li></ul>
    17. 17. The collateral ligaments <ul><li>The lateral ligaments are shown. </li></ul><ul><li>They stabilize the joints and allow safe flexion & extension and side way movements. </li></ul>
    18. 18. The ligaments in relation to the tendon <ul><li>The tendon sheath & it’s related tendon are closely applied to the collateral ligaments. </li></ul><ul><li>The flexor tendon gives a secure excursion enabled by the efficiency of those ligaments. </li></ul>
    19. 19. Instability of the MC/P <ul><li>Rupture of the lateral ligaments & the volar plate cause marrked instability of the joint especially in the sagittal plane. </li></ul><ul><li>This is seen more obviously when flexing the finger aided by the pull of the tendon. </li></ul>
    20. 20. Metacarpal Head <ul><li>The CAM-like action of the MC head is seen clearly in flexion & extension. </li></ul><ul><li>Those are different from the PIP & DIP joints. </li></ul>
    21. 21. Testing the flexor tendons <ul><li>The flexor digitorum profundus runs distally. </li></ul><ul><li>It is tested by stabilizing the proximal joints and allowing flexion of the DIP joint. </li></ul>
    22. 22. The ROM of the thumb <ul><li>The C / MC joint of the thumb has more ROM in all directions. </li></ul><ul><li>This is vitally important for it to perform the multi functional activities. </li></ul>
    23. 23. Opposition movements <ul><li>Fingers are brought in apposition to the thumb to perform delicate functions of a fine grip. </li></ul><ul><li>Hence thumb’s actions are considered >50% of the other fingers. </li></ul>
    24. 24. The types of grip <ul><li>Delicate & fine grip requires the thumb , fingers and intrinsic small muscles of the hand to be in an optimal normal functions. </li></ul><ul><li>Gross grip requires normal functioning of previous factors plus tendons. </li></ul>
    25. 25. The inferior radio-ulnar joint <ul><li>The inferior R/U joint forms with the proximal row of the carpal bones the WRIST joint. </li></ul><ul><li>The triangular cartilage is illustrated and is vulnerable to injury. </li></ul>
    26. 26. Tendons of the wrist joint <ul><li>The attachment of extensor & flexor tendons of the wrist distally to the MC bones. </li></ul><ul><li>They pass over the radius & carpal bones and their main functions are to move the wrist joint. </li></ul>
    27. 27. The ROM at the wrist joint <ul><li>Dorsiflexion is compared with the other side in an indian style of prayer. </li></ul><ul><li>The ROM is recorded in a measurable angle. </li></ul>
    28. 28. ROM of the wrist together with the fingers movement <ul><li>Dorsiflexion og the wrist joint while flexing & extending the fingers. </li></ul><ul><li>The power & excursion of the grip are both reduced in this position and increased in neutral position. </li></ul>
    29. 29. ROM of the wrist in relation to the functions of the fingers <ul><li>The power of the grip is reduced in palmar-flexion. </li></ul><ul><li>The best grip to get is when the wrist joint in a neutral position. </li></ul>
    30. 30. ROM of the DIP joint <ul><li>Flexion of the distal interphalangeal joint is taking place by the flexor digitorum profundus. </li></ul><ul><li>This is illustrated by stabilizing the proximal joints. </li></ul>
    31. 31. ROM of the PIP joint <ul><li>Flexion of the proximal interphalangeal joint is taking place by the flexor digitorum sublimis( superficilis). </li></ul><ul><li>Other fingers are held in extension to allow the pip joint to flex. </li></ul>
    32. 32. Injury to the wrist area <ul><li>Injury to this area can cause a lot of damage especially the tendons and the neurovascular bundle. </li></ul><ul><li>Careful examination is essential prior to take any action. </li></ul>
    33. 33. Deep structures <ul><li>Deep structures are seen distally in the fingers such as : pulleys,volar plates,zones of the tendon sheaths. </li></ul><ul><li>Proximally, the lumbrical muscles are seen with the carpal tunnel. </li></ul>
    34. 34. The hand as a flag in a Titanic ship <ul><li>The hand leads the body ( the Ship ) in the ocean ( Life ). </li></ul><ul><li>The strings to the body direct the ship to sail in the ocean. If any thing goes wrong then the hand is the cause to sink. </li></ul>
    35. 35. Tendons around the finger <ul><li>The delicate arrangement of the tendons around the finger allow them to perform their sophisticated functions. </li></ul>
    36. 36. Dissection of the dorsum of the finger
    37. 37. Lateral dissection of the finger
    38. 38. The action of flexors & extensors
    39. 39. Clawing of the fingers
    40. 40. Clawing of fingers & wasting of the 1 st dorsal interosseous muscle
    41. 41. Extension of the thumb
    42. 42. 1 st dorsal interosseous muscle in action
    43. 44. Swan neck deformity
    44. 45. Testing DIP joint
    45. 46. Finger flexion & extension
    46. 47. Segments of the hand during action
    47. 48. Different postures at function
    48. 49. Grip ( prehension )
    49. 50. Difference in the grip facility
    50. 51. Demo of the 2 grips
    51. 52. Delicate & fine & precise
    52. 53. Factors precipitating in action
    53. 54. A test
    54. 55. Tests for Median nerve
    55. 56. Pointing index finger test
    56. 57. Flex. Dig. Profundus
    57. 58. Wasting of the thenar eminence
    58. 59. Detailed anatomy
    59. 60. Deformity
    60. 61. Sublaxation & instability
    61. 62. Grip
    62. 63. Topographic presentation
    63. 64. Wasting dorsally
    64. 65. Ulnar nerve testing
    65. 66. Dorsum of the hand
    66. 67. Deep structures
    67. 68. Radiological involvement of deep layers
    68. 69. MC heads & MC/P joints
    69. 70. Volar & dorsal movements
    70. 71. Combined actions
    71. 73. The arches of the hand
    72. 74. Anatomy of the finger
    73. 75. Review of median nerve testing
    74. 76. Different forces applied
    75. 77. A hand in a Titanic ship
    76. 78. Tendons required
    77. 79. Review of further deep structures