references: Campbell’s operative orthopaedics 11th edition Text book of orthopaedics & fractures 5th edition Dr B. Aalami Harandi Gray’s anatomy 2nd edition Clinical anatomy Richard S. Snell

1. Clinical Examination
of the Hand and Wrist
• Campbell’s operative orthopaedics 11th edition
• Text book of orthopaedics & fractures 5th edition Dr B. Aalami Harandi
• Gray’s anatomy 2nd edition
• Clinical anatomy Richard S. Snell

2. Anatomy of the wrist
Distal radioulnar joint
Radiocarpal joint
Ulnocarpal joint
8 carpal bones (proximal and distal row and attached
ligaments)

3. Proximal:
1. Scaphoid
2. Lunate
3. Triquetrum
4. Pisiform (smallest)
Distal:
1. Trapezium
2. Trapezoid
3. Capitate (largest)
4. hamate

5. Variations
Fourth carpometacarpal articulation
Scaphotrapeziotrapezoid articulation
Capitolunate articulation
Hamatolunate articulation

6. Articulations
 Radiocarpal joints
 Triquetrum and triangular fibrocartilage
 Midcarpal articulations
 Distal row articulations with the matacarpals
1. Mobility in the thumb
2. Stability in the index and long finger metacarpals
3. Increased mobility in the ring and little finger

7. Triangular fibrocartilage complex
Ulnar collateral ligament
Dorsal and volar radioulnar ligament
Articular disc(Compressed with Pronation and
Extension Compressed with Ulnar deviation)
Meniscal homologue
Extensor carpi ulnaris sheat
Ulnolunate and ulnotriquetral ligament

8. Carpal Ligaments
The major ligaments of the wrist include the
palmar intrinsic ligaments, the volar extrinsic
and the dorsal extrinsic and intrinsic
ligaments
The extrinsic palmar ligaments provide the
majority of the wrist stability
The intrinsic ligaments serve as rotational
restraints, binding the proximal row into a unit of
rotational stability

9. Radiocarpal Joint
 Formed by the large articular concave surface of the distal
end of the radius, the scaphoid and lunate of the proximal
carpal row, and the TFCC

10. extensor retinaculum
The extensor retinaculum compartments,
from lateral to medial, contain the tendons of:
Abductor pollicis longus and extensor pollicis
brevis
Extensor carpi radialis longus and brevis
Extensor pollicis longus
Extensor digitorum and indicis
Extensor digiti minimi
Extensor carpi ulnaris

11. The Flexor Retinaculum
Transforms the carpal arch into a tunnel, through
which pass the median nerve and some of the
tendons of the hand
 Proximally, the retinaculum attaches to the tubercle of the
scaphoid and the pisiform
 Distally it attaches to the hook of the hamate, and the tubercle
of the trapezium
In the condition known as ‘carpal tunnel syndrome’
the median nerve is compressed in this relatively
unyielding space

12. Carpal Tunnel
Serves as a conduit for the median nerve and nine
flexor tendons
 The palmar radiocarpal ligament and the palmar ligament
complex form the floor of the canal
 The roof of the tunnel is formed by the flexor retinaculum
(transverse carpal ligament)
 The ulnar and radial borders are formed by carpal bones
(trapezium and hook of hamate respectively)
 Within the tunnel, the median nerve divides into a motor
branch and distal sensory branches

13. Tunnel of Guyon
A depression superficial to the flexor retinaculum,
located between the hook of the hamate and the
pisiform bones
 The palmar (volar) carpal ligament, palmaris brevis muscle,
and the palmar aponeurosis form its roof
 Its floor is formed by the flexor retinaculum (transverse
carpal ligament), pisohamate ligament, and pisometacarpal
ligament
The tunnel serves as a passage way for the ulnar
nerve and artery into the hand

14. Phalanges
Fourteen in number
Each consist of a base, shaft, and head
Two shallow depressions, which correspond to
the pulley-shaped heads of the adjacent
phalanges, mark the concave proximal bases
Two distinct convex condyles produce the pulley-
shaped configuration of the phalangeal heads

15. Metacarpophalangeal (MCP) Joints
of the 2nd-5th Fingers
The 2nd-5th metacarpals articulate with the
respective proximal phalanges in biaxial joints
The MCP joints allow flexion-extension and
medial-lateral deviation associated with a slight
degree of axial rotation

16. Carpometacarpal Joints
Articulation between the distal borders of the
distal carpal row bones and the bases of the
metacarpals
Stability of the CMC joints is provided by the
palmar and dorsal carpometacarpal and
intermetacarpal ligaments

17. First Carpometacarpal Joint
 Functionally the sellar (saddle-shaped) carpometacarpal
(CMC) joint is the most important joint of the thumb
 Consists of the articulation between the base of the first
metacarpal and the distal aspect of the trapezium
 Motions that can occur at this joint include flexion/extension,
adduction/abduction and opposition (which includes varying
amounts of flexion, internal rotation, and palmar adduction)

18. Metacarpophalangeal Joint of the
Thumb
 A hinge joint
 Consists of a convex surface on the head of the metacarpal, and
a concave surface on the base of the phalanx

19. Interphalangeal (IP) Joints
 Adjacent phalanges articulate in hinge joints that allow motion in
only one plane
 The congruency of the IP joint surfaces contributes greatly to
finger joint stability
 The proximal IP joint is a hinged joint capable of flexion and extension
 The distal IP joint has similar structures but less stability and allows
some hyperextension.

20. Palmar Aponeurosis
A dense fibrous structure continuous with the
palmaris longus tendon and fascia covering the
thenar and hypothenar muscles
Dupuytren’s contracture is a fibrotic condition of
the palmar aponeurosis that results in nodule
formation or scarring of the aponeurosis, and
which may ultimately cause finger flexion
contractures

21. Extensor Hood
A complex tendon, which covers the dorsal
aspect of the digits is formed from a combination
of the tendons of insertion from extensor
digitorum, extensor indicis, and extensor digiti
minimi
Creates a ‘cable’ system that provides a
mechanism for extending the MCP and IP joints,
and allows the lumbrical, and possibly
interosseous muscles, to assist in the flexion of
the MCP joints

22. Synovial Sheaths
 Long narrow balloons filled with synovial fluid, which wrap around
a tendon so that one part of the balloon wall (visceral layer) is
directly on the tendon, while the other part of the balloon wall
(parietal layer) is separate

23. Flexor Pulleys
Annular (A) and cruciate (C) pulleys restrain the
flexor tendons to the metacarpals and phalanges
and contribute to fibro-osseous tunnels through
which the tendons travel
 A1 from the MP joint and volar plate
 A2 from the proximal phalanx
 A3 from the PIP joint volar plate
 A4 from the middle phalanx
 A5 from the DIP joint volar plate

24. Muscles of the Hand
 Short muscles of the thumb
 Abductor pollicis brevis (APB)
 Flexor pollicis brevis (FPB)
 Opponens pollicis (OP)
 Adductor pollicis (AP)

25. Muscles of the Hand
 Short muscles of the 5th digit
 Abductor digiti minimi (ADM)
 Flexor digiti minimi (FDM)
 Opponens digit minimi (ODM)

26. Muscles of the hand
 Interosseous muscles of the hand
 Three palmar interossei. Each functions to adduct the digit, to which it
is attached, toward the middle digit
 Four dorsal interossei. Each functions to abduct the index, middle and
ring fingers from the mid-line of the hand

27. Muscles of the hand
 Lumbricales
 Function to perform the motion of IP joint extension with the MCP joint
held in extension
 Can assist in MCP flexion

28. Anatomic Snuff Box
A depression on the dorsal surface of the hand
at the base of the thumb, just distal to the radius
Formed by the tendons of the APL and EPB,
while the ulnar border is formed by the tendon of
the EPL
Along the floor of the snuffbox is the deep
branch of the radial artery and the tendinous
insertion of the ECRL. Underneath these
structures, the scaphoid and trapezium bones
are found

29. Neurology
 The three peripheral nerves that supply the skin and muscles of
the wrist and hand include the median, ulnar, and radial nerve

30. Vasculature of the wrist and hand
 The brachial artery bifurcates at the elbow into radial and ulnar
branches, which are the main arterial branches to the hand
 Vascular arches of the hand
 Dorsal arches
 Palmar arches

31. Biomechanics
 The wrist contains several segments whose combined
movements create a total range of motion that is greater than
the sum of its individual parts

32. Pronation
 Approximately 90° of forearm pronation is available
 During pronation, the concave ulnar notch of the radius glides around
the peripheral surface of the relatively fixed convex ulnar head
 Pronation is limited by the bony impaction between the radius and the
ulna

33. Supination
 Approximately 85-90° of forearm supination is available
 Supination is limited by the interosseous membrane, and the bony
impaction between the ulnar notch of the radius, and the ulnar styloid
process

34. Wrist flexion and extension
 The movements of flexion and extension of the wrist are shared
among the radiocarpal articulation, and the intercarpal
articulation, in varying proportions

35. Wrist flexion and extension
During wrist flexion, most of the motion occurs in
the midcarpal joint (60% or 40° versus 40% or
30° at the radiocarpal joint), and is associated
with slight ulnar deviation and supination of the
forearm
During wrist extension, most of the motion
occurs at the radiocarpal joint (66.5% or 40°
versus 33.5% or 20° at the midcarpal joint), and
is associated with slight radial deviation and
pronation of the forearm

36. Radial Deviation
 Radial deviation occurs primarily between the proximal and distal
rows of the carpal bones
 The motion of radial deviation is limited by impact of the scaphoid
onto the radial styloid, and ulnar collateral ligament

37. Ulnar deviation
 Ulnar deviation occurs primarily at the radiocarpal joint
 Ulnar deviation is limited by the radial collateral ligament

38. The hand
The hand accounts for about 90% of upper
limb function
The thumb is involved in 40-50% of hand function
The index finger is involved in about 20% of hand
function
The middle finger, which accounts for about 20%
of all hand function, is the strongest finger, and is
important for both precision and power functions

39. Thumb motions
Within the first CMC joint, the longitudinal
diameter of the articular surface of the trapezium
is generally concave from a palmar to dorsal
direction
The transverse diameter is generally convex
along a medial to lateral direction
The proximal articular surface of the first
metacarpal is reciprocally shaped to that of the
trapezium

40. Thumb flexion and extension
 Thumb flexion and extension occur around an anterior-posterior
axis in the frontal plane that is perpendicular to the sagittal plane
of finger flexion and extension
 In this plane, the metacarpal surface is concave, and the
trapezium surface is convex

41. Thumb abduction and adduction
 Thumb abduction and adduction occur around a medial-lateral
axis in the sagittal plane, that is perpendicular to the frontal plane
of finger abduction and adduction
 During thumb abduction and adduction, the convex metacarpal
surface moves on the concave trapezium

42. A number of grips have been
recognized:
Fist grip
Cylindrical grip
Ball grip
Hook grip
Ring grip
Pincer grip
Pliers grip

43. history
What is the cause of pain?
Mechanism of injury?
Previous history?
Location, duration and intensity of pain?
Creptitus, numbness, distortion in temperature?
Sounds or sensations?
Technique changes?
Weakness or fatigue?
What provides relief?

44. Observation
The clinician inspects for lacerations, surgical
scars, masses, localized swelling, or erythema
Scars should be examined for degree of
adherence, degree of maturation, hypertrophy
(excess collagen within boundary of wound), and
keloid (excess collagen that no longer conforms
to wound boundaries)
The location and type of edema should be noted

45. Examination
 AROM, then PROM with over pressure
 The gross motions of wrist, hand, finger and thumb flexion,
extension, and radial and ulnar deviation are tested, first actively
and then passively
 Any loss of motion compared with the contralateral,
asymptomatic wrist and hand should be noted

46. Palpation
 Palpation of the muscles, tendon, insertions, ligaments, capsules,
bones of the wrist and hand should occur as indicated, and be
compared with the uninvolved side

47. Pain provocation tests
 These tests are used to determine the cause of a painful or
dysfunctional motion by systematically testing each of the
articulations to see whether the maneuvers reproduce the
patient’s symptoms

48. Strength testing
Isometric tests are carried out in the extreme
range, and if positive, in the neutral range
These isometric tests must include the interossei
and lumbricales
The straight plane motions of wrist flexion,
extension, ulnar and radial deviation are tested
initially
Pain with any of these tests requires a more
thorough examination of the individual muscles

49. Examination
 Functional Assessment
 The functional range of motion for the hand is the range in which
the hand can perform most of its grip and other functional
activities
 A number of assessment tools are available

50. Examination
 Passive Physiological Mobility Testing
In each of the tests, the clinician
notes the quantity of motion as well
as the joint reaction (end feel).
The tests are always repeated on,
and compared to, the same joint in
the opposite extremity

51. Passive Accessory Mobility Tests
 In each of the tests, the clinician notes the quantity of accessory
joint motion as well as the joint reaction
 The tests are always repeated on, and compared to, the same
joint in the opposite extremity

52. Ligament Stability
 A number of tests are available to evaluate the ligamentous
stability of the forearm, wrist, hand and finger joints

53. Neurovascular Status
 Allen Test
 Tinel’s test for Carpal Tunnel Syndrome

54. Examination
 Sensibility Testing
 The assessment of sensibility of the hand is an important
component of every hand examination because sensation is
essential for precision movements and object manipulation
 Two types of sensibility are assessed
 Protective
 Functional

55. Examination
Special tests
 Carpal Shake test
 Sit to Stand test
 Ulnar Impaction test
 Finkelstein’s test
 Flexor digitorum superficialis (FDS) test
 Flexor digitorum profundus test
 Extensor Hood rupture test
 Froment’s sign
 Murphy’s sign

56. Examination
Diagnostic testing
Diagnostic testing of the forearm, wrist and hand
is limited to plain radiographs for most patients
Bony tenderness with a history of trauma or a
suspicion of bone or joint disruption indicates a
need for radiographs
Standard projections for the wrist are the
posteroanterior, lateral, and oblique
For the patient with a suspicion of a scaphoid
injury, a scaphoid view should be added

62. Radiographic Anatomy
Wrist AP

63. Adult Wrist - Lateral View

65. CT scan:

66. CT
Radius
ulna
scaphoid
Lunate
triquetrum
hamate
Capitate
Trapezoid Trapezium

67. surface anatomy

68. MRI

74. ROM
Distal Radioulnar joint
 Supination and Pronation – 80-90o
 Ulna moves posteriorly and laterally with pronation
Radiocarpal joint (and Ulnocarpal joint)
 Flexion (80-90o) and Extension (75-85o)
 Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints
 Gliding

76. palpation
Bony and Soft Tissue Palpation
 Are they where they should be?
 Do they feel like they should feel?
Circulatory and Neurological Evaluation
 Hands should be felt for temperature
 Cold hands indicate decreased circulation
 Take pulse – radial artery
 Pinching fingernails can also help detect circulatory problems
(capillary refill)
 Hand’s neurological functioning should also be tested
(sensation and motor functioning)