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MINETTE RICO FERNANDEZ, PTRP
WRIST and HAND
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)
Topic contents:
 Bones
 Joints
 Muscles
 Common Hand Conditions
 Assessment / Special Tests
 Mini Quiz
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
The Carpals
Some Lawyers Tender Proposals That
They Cannot Handle
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Common Wrist and Hand Conditions
Wrist Drop Deformity
 Radial nerve palsy
 Paralysis of the extensor muscles of the wrist
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
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
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
2. SWEATER FINGER / JERSEY TEST
PROCEDURE
- THE Pt WILL FLEXED ALL THE MCP JOINTS
POSITIVE
- IF THE DIP WILL NOT FLEX
INDICATION
- FDP RUPTURE
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.
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
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.
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
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
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
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
7. WRINKLE / SHRIVEL TEST
PROCEDURE
- Pt FINGER PLACE IN WARM WATER FOR
5 TO 20 MINS.
POSITIVE
- NO WRINKLING OF PULP
INDICATIVE
- DENERVATION
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.
The End.
Thank You!

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Wrist and Hand - a Review

  • 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
  • 18.
  • 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.