The document provides an overview of the anatomy, joints, muscles, common conditions, and assessment of the wrist and hand. It discusses the bones of the wrist and hand including the carpal bones. It describes the joints of the wrist including the radiocarpal joint, midcarpal joint, and distal radioulnar joint. It also outlines the muscles of the wrist and hand including the wrist extensors and flexors. Common conditions such as Dupuytren's contracture, trigger finger, and De Quervain's syndrome are mentioned. Finally, it discusses special tests used to assess the wrist and hand including Phalen's test, Tinel's sign, and Allen test.

1. MINETTE RICO FERNANDEZ, PTRP
WRIST and HAND

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

5. The Carpals
Some Lawyers Tender Proposals That
They Cannot Handle

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

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. 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. 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. 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

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.

43. The End.
Thank You!