Exam 2 Flashcards
what comprises the carpus, or wrist
- a core structure of 8 bones
- more than 20 radiocarpal, intercarpal, and carpometacarpal joints
- 26 named intercarpal ligaments
- the six or more parts of the triangular fibrocartilage complex (TFCC)
the hand accounts for about ___ % of upper limb funciton
90%
the thumb is involved in _____ of hand function
40-50%
the index finger (2nd digit) is involved in about ____ of hand function
20 %
this finger accounts for about 20% of all hand function, is the strongest finger, and is important for both precicsion and power fucntions
the middle finger (3rd digit) aka chiropractic index finger
distal radio-ulnar joint is what kind of joint
double pivot joint
distal radio-ulnar joint unites the
distal radius and the ulna and an articular disc (TFCC)
what does the rounded head of the ulnar head contact
it contacts both the ulnar notch of the radius laterally, and the TFCC distally
since the ulnar styloid process is approximately one-half inch shorter than the radial styloid process what does this result in
more ulnar deviation than radial deviation (ROM 30 degrees vs 20 degress)
fracture of the radius within 20-35 mm of the wrist joint with posterior angulation of the distal fragment
colle’s fracture
colle’s fracture is also known as a
dinner fork fracture
Mr. Smiths at the front door and cole is at at the back door
.
fracture of the radius within 20-35mm of the wrist joint with anterior angulation of the distal fragment
smiths fracture
smiths fracture is aka
garden spade deformity
the fibrocartilage disc in between the medial proximal row and the distal ulna within the medial aspect of the wrist
Triangular fibrocartilage complex (TFCC)
what is the primary function of the TFCC
to imporve joint congruency and to cushion against compressive forces
Scaphoid, lunate, and radius
3 bones involved in a direct articulation of the wrist
bones involved in indirect articulation of the wrist
ulna, triquentrium, pisiform
the TFCC transmits about _____ of the axial load from the hand to the forearm
20%
TFCC is made of
fibrocartilage (so are IVD’s * you should know this you future doc)
what is the wrist comprised of
distal radius and ulna, 8 carpal bones, 5 metacarpal bones
the carpal bones lie in
two transverse rows
what does the proximal row contain
(lateral to medial) scaphoid (navicular) lunate triquetrum pisiform
what does the distal row contain
trapezium
trapezoid
capitate
hamate
what is the most commonly fracture wrist bone
navicular
what is the largest bone of the proximal row
navicular (scaphoid)
ulnar deviation helps to slide which bone
navicular bone slides out from under the radial styloid process for palpation
what is the largest most prominent of the MCP bases
capitate
which is the largest of all carpal bones
capitate
what is the 2nd most often fractured and the most commonly subluxated
lunate
what bones are covered up by the extensor carpi radials brevis tendon which inserts into the base of the 3rd metacarpal
lunate
capitate
base of the 3rd metacarpal
which bones is the easiest to fall and become subluxed
lunate
(this forms the arch on the dorsum of the hand and a lot of our actions flatten out this curve and cause it to fall anterior)
the mid carpal joint lies between the
two rows of carpals
a _____ articulation because each row has both a concave and convex segment
compound
the proximal row of the carpals is ____ laterally and ____ medially
convex
concave
which bones present with a concave surface to the distal row of carpals
scaphoid lunate trapezium trapezoid triquetrum
which bones present with a convex surface to a reciprocally arranged distal row
scaphoid
capitate
hamate
articulation between he distal borders of the distal carpal row bones and the bases of the metacarpals
carpometacarpal joints
____ of the CMC joints is provided by the palmar and dorsal carpometacarpal and inter metacarpal ligaments
stability
what do the 2nd-5th metacarpals articulate with
the respective proximal phalanges in biaxial joints
the MCP joints allow ____ -____ and _____-_____ deviation associated with a slight degree of axial rotation
flexion-extension
medial-lateral
what shape is the first carpometacarpal joint
functionally the seller (saddle-shaped) carpometacarpal (CMC)
which joint is the most important of the thumb
first carpometacarpal joint
what articulation does the first carpometacarpal joint consists of
the articulation between the base of the first metacarpal and the distal aspect of the trapezium
what motions occur in the first carpometacarpal joint
flexion/extension
adduction/adduction
and opposition (which includes varying amounts of flexion, internal rotation, and palmar adduction)
how are the MCP’s and the IP’s normally held in during rest
a position of slight flexion
consider inspecting for damage
fracture though the base of the first metacarpal neck with dorsal and radial displacement of the shaft
bennett’s fracutre
posterior lateral
(doral medial)?
what type of joint is the metacarpophalaneal joint of the thumb
a hinge joint
what does the metacarpophalangeal joint of the thumb consists of
a convex surface on the head of the metacarpal, and a concave surface not he base of the phalanx
how many phalanges
14
what does a phalange consist of
base
shaft
head
what mark the concave proximal bases of the phalanges
two shallow depressions, which correspond to the pulley-shaped heads of the adjacent phalanges
what produce the pulley-shaped configuration of the phalangeal heads
two distinct convex condyles
fracture of the fourth or fifth metacarpal neck with ANTERIOR displacement of the head
Bar Room Fracture
fracture of the second or third metacarpal neck with ANTERIOR displacement of the head
Boxer’s fracture
what type of joints are interphalangeal joints
hinge joints that allow motion in only one plane
what contributes greatly to finger joint stability
the congruency of the IP joint surfaces
this joint is a hinged joint capable of flexion and extension
Proximal IP (PIP) joint
this joint has similar structures but less stability and allows some hyperextension
distal IP (DIP)
explain Heberden’s Nodes
1) found on one or more fingers, except the thumb
2) distal joints are enlarged by hard nodules, 2 to 3 mm in diameter, one on either side of the dorsal midline
3) nodules are painless; motion is unlimited
4) process is a localized OA
5) involvement of several joints is more common in women in home they appear at the menopausal age
6) condition in women is usually hereditary
7) single joint is more commonly involved in men
8) condition in men is usually the result of trauma
abnormal fusiform enlargement at the PIP joint which can indicate SYNOVITIS secondary to RA
Bouchard’s Nodes
MOI=RA
PIP joint deforms into hyperextension and the DIP joint is flexed
Swan Neck Deformity
the central slip of the extensor digitorum communist tendon is avulsed from the insertion in to the middle base of the middle phalanx, the PIP is flexed and the DIP is extended
MOI=trauma
Boutonniere Deformity
looks like a button over the PIP joint
what do the major ligaments of the wrist include
palmar instrinsic ligaments
volar extrinsic
dorsal extrinsic
intrinsic ligaments
the extrinsic palmar ligaments provide the majority of the
wrist stability
the intrinsic ligaments serve at _____ _____, binding the proximal row into a unit of rotational stability
rotational restraints
medial and lateral collateral ligaments of the fingers are named
Graysons (medial) and Cleland’s (lateral)
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
radiocarpal joint
a dense CONNECTIVE tissue “bracelete” that encases the forearm and maintains the relationships of the tendons that cross the wrist
antebrachial fasica
serves to prevent the tendons from “bow stringing” when the tendons turn a corner at the wrist
extensor retinaculum (this sister cries a lot)
what are the tunnel-like structures formed by the retinaculum and the underlying bones called
fibro-osseous compartments
what are the extensor retinaculum compartments, from lateral to medial,
- abbudctor pollicis longus and extensor pollicis brevis
- extensor pollicis longus
- extensor digitorum and indicis
- extensor digiti minimi
- extensor carpi ulnaris
this transforms the carpal arch into a tunnel, through which pass the median nerve and some of the tendons of the hand
flexor retinaculum
proximally, the retinaculum attaches to the
tubercle of the scaphoid and the pisiform
distally the retinaculum attaches to the
hook of hamate, and the tubercle of the trapezium
what is the condition known as when the median nerve is compressed in this relatively unyielding space
carpal tunnel syndrome
phalanx sign
avulsion of the flexor digitorum profundus tendon
jersey finger
what is the MOI for the jersey finger
the finger gets caught int an object and actively flexed DIP joint is suddenly and forcible extended resulting in a rupture
serves as a conduit for the median nerve and nine flexor tendons
carpal tunnel
what make the floor of the canal
the palmar radoiocarpal ligament + palmer ligament complex
what is the root of the tunnel
the flexor retinaculum (transverse carpal ligament)
within the tunnel the ulnar and radial borders are
trapezium and hook of hamate respectively
within the tunnel the median nerve divides into a
motor branch and distal sensory branches
a depression superficial to the flexor retinaculum, located between the hook of the hamate and the pisiform bones
tunnel of guyon
what forms the roof of the tunnel of guyon
palmar (volar) carpal ligaments
palmaris brevis mucles
palmar aponeurosis
what forms the floor of the tunnel of guyon
flexor retinaculum (transverse carpal ligament)
pisohamate ligament
pisometacarpal ligament
what does the tunnel serve as
a passage way for the ulnar nerve and artery into the hand
ulnar nerve and artery compression injuries between the pisiform and the hook of the hamate
cyclist hand
also caused my crutch use and weight lifting
a dense fibrous structure continuous with the palmaris longs tendon and fascia covering the thinner and hypothenar muscles
palmar aponeurosis
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
Dupuytren’s Contracture
what is some evidence of Dupuytren’s contracture
small painless nodule that can be palpated in the palmar aponeurosis near the base of the digit
Within Dupuytren’s Contracutre palpation of the palm reveals a______.
hard cord over the flexor tendon
passive extension of the finger raises the cord taut where it can be readily seen
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 indices, and extensor digit minimi
extensor hood
what does the extensor hood do
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 int eh flexion of the MCP joints
class rant related to dorsal wrist?
a small tiny tear in the joint capsule allowing for synovial fluid to escape, the body then tries to put a wall around the fluid
occasionally a cystic, pea-sized swelling (ganglion) occurs on the dorsal or solar aspect of the wrist
Dorsal wrist
MOI for dorsal wrist
perhaps biomechanics alterations
terminal phalanx of the finger is permanently flexed at the distal joint; it cannot be voluntarily extended
mallet finger
what occurs with mallet finger
- rupture of the extensor tendon that inserts on the terminal phalanx
- possibly a fracture of the distal phalanx
avulsion fractures- tendon pulls some of the bone off
this won’t present with a mallet finger
what is the contour of the palmar surface
the MCP joints area= hills and valleys
what are the hills/mounds/peaks of the palmar surface
the neuromuscular bundles that supply the fingers and lumbrical muscles
what are the valleys of the palmar surface
the paths of the flexor tendons at the point where they cross the joints
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
Synovial sheaths
what do the annular and cruciate pulleys do?
restrain the flexor tendons to the MCP’s and phalanges and contribute to fiber-osseous tunnels through which the tendons travels
from the MP joint and volar plate
A1
from the proximal phalanx
A2
from the PIP joint volar plate
A3
from the DIP joint solar plate
A5
the distal palmar crease (approximately at the knuckles of the MCP’s) =
the proximal border of surgical “no man’s land”
the surgical no mans land wi where
2 flexor tendons run into 1 sheath
the distal border of the surgical no mans land is
PIP joints
flexion of the finger feels norma;: but re-extension is accompanied by a painful snap that the patient sometimes refers to the dorsal of the hand
trigger finger
what finger is usually involved with trigger finger
either the 4th or 5th finger
True or False: Trigger finger is more common in women than men
TRUEf
what age group does trigger finger occur in
ages of 40-60 years old
trigger finger is more common in people with certain medical problems that include
diabetes
rheumatoid arthrits
where are the flexors located
the anterior compartment (these flex the wrist and digits)
where are the extensors located
the posterior compartment (extend the wrist and the digits)
what muscles are part of the anterior compartment and are the superficial muscles
pronator teres
flexor carpi radialis
palmaris longus
flexor carpi ulnaris
what muscles are part of the anterior compartment and are the intermediate muscles
flexor digitorum superficialis
what muscles are part of the anterior compartment and are the deep muscles
flexor pollicis longus
flexor digitorum profundus
pronator quadratus
what muscles are part of the posterior compartment and are the superficial muscles
- extensor carpi radialis longus
- extensor carpi radialis brevis
- extensor digitorum and extensor digiti minimi
- extensor carpi ulnaris
what muscles are part of the posterior compartment and are the deep muscles
- abductor pollicis longus
- extensor pollicis brevis
- extensor pollicis longus
- extensor indicis
a depression on the dorsal of the hand at the base of the thumb, just distal to the radius
anatomic snuff box
what is the anatomic snuff box formed by
the tendons of APL and EPB, the ulnar border formed by the tendon of the EPL
what lies on the floor of the anatomic snuff box
the deep branch of the radial artery and the tendinous insertion of the ECRL. underneath these structures= scaphoid and trapezium bones
floor of anatomic snuff box
scaphoid
ulnar border of anatomic snuff box
ulnar border
radial border of anatomic snuff box
radial border
overuse and repetitious ulnar and radial deviation of the wrist
-swelling and inflammation in Tunnel 1
De Quervians Disease
what is De Quervians disease aka
Stenosing tenosynovitis
what tendons are involved with De Quervian’s Disease
- abductor pollicus longus
- extensor pollicus brevis
what test gives a positive for De Quervian’s Disease
Finkelstein test
De Quervians Disease appears to be significantly more common in women
TRUE: some sources even quote a female- to -male ratio as high as 8:1
patients with De Quervians Disease usually report
pain at the dorsolateral aspect of the wrist referral of pain toward the thumb and/or lateral forearm. This condition responds well to nonsurgical treatment.
what are the short muscles of the thumb
- abductor pollicis brevis
- flexor pollicis brevis
- opponens pollicis
- adductor pollicis
ulnar collateral ligament avulsion of the MCP joint aka Game Keepers thumb
Skier’s Thumb
what are the short muscles of the 5th digit
- abductor digiti minimi
- flexor digiti minimi
- opponens digit minimi
what are the interosseous muscles of the hand
- three palmar interpose. Each functions to adduct the digit, to which it is attached, toward the middle digit
- four dorsal interpose. Each functions to abduct the index, middle and ring fingers from the mid-line of the hand
function to perform the motion of IP joint extension with the MCP joint held in extension -can assist in MCP flexion
lumbricales
what forms the transverse arch
formed with the palmar concavity of the carpal bones, scaphoid + trapezium laterally, and pisiform + hamate medially
what forms the metacarpal arch
metacarpal heads
what forms the longitudinal arch
formed by the 3rd and 5th digit, spans lengthwise, keystone at the MCP joints
what forms the oblique arches
formed by the thumb in opposition to the other fingers
what are the 3 peripheral nerves that supply the skin and muscles of the wrist and hand
median
ulnar
radial nerve
what its he vasculature of the wrist
the brachial artery bifurcates at the elbow into radial and ulnar branches, which are the main arterial branches to the hand
what are the vascular arches of the hand
dorsal arches
palmar arches
- occurs in males 20-40 yrs of age
- previous trauma, occupational excessive dominant hand use
- usually unilateral- pt presents with localized and radiating wrist pain; swelling and disability
- entrapment neuropathy, DJD
Keinboch’s Disease
what is Keinboch’s Disease aka
avascular necrosis
what occurs with Keinboch’s Disease
- increased lunate density
- short ulnar bone (in 75% of cases)
- treatment- reduction of hand trauma
- replace lunate with plastic implant
how many degrees of forearm pronation is available
90 degrees
what occurs during pronation
the concave ulnar notch of the radius glides around the peripheral surface of the relatively fixed convex ulnar head
what is pronation limited by
the bony impaction between the radius and the ulna
how many degrees of forearm supination is available
85-90 degrees
what is supination limited by
the interosseous membrane, and the bony impaction between the ulnar notch of the radius and the ulnar styloid process
what are the movements of flexion and extension of the wrist shared by
radiocarpal ariculation intercarpal articulation (in varying proportions)
during wrist flexion where does most of the motion occur
midcarpal jiont (60% or 40degrees verseus 40% or 30degrees at the radoiocarpal joint)
what is wrist flexion and extension associated with
slight ulnar deviation and supination of the forearm
during wrist extension most of the motion occurs at the
radiocarpal jiont (66.5% or 40 degrees versus 33.5% or 20 degrees at the mid carpal joint)
what is wrist extension associated with
slight radial deviation and pronation of the forearm
where does radial deviation occur
between the proximal and distal rows of the carpal bones
what is the motion of radial deviation limited by
impact of the scaphoid onto the radial styloid, and ulnar collateral ligament
where does ulnar deviation occur
primarily at the radoiocarpal joint
where is ulnar deviation limited by
radial collateral ligament
where does thumb flexion and extension occur
in the frontal plane that is perpendicular to the sagittal plane of finger flexion and extension
what happens in the plane of thumb flexion and extension
the metacarpal surface is concave, and the trapezium surface is convex
where does thumb abduction and adduction occur
in the sagittal plane, that is perpendicular to the frontal plane of finger abduction and adduction
what occurs during thumb abduction and adduction
the convex metacarpal surface moves on the concave trapezium
name the power grips that have been recognized
fist grip
cylindrical grip
ball grip
hook grip
what is the grip called where the digits work together to provide support and static control
Power
when the digits hold the object against the hand which muscles are working
extrinsic
grip limited to MCP joints and mainly involves the radial side of the hand
Precision and Prehension
how do digits provide control
by working with the thumb to form a tripod for precision handling
intrinsic muscles are important in
precision grips
lateral or key pinch, and tip pinch or tip-to-tip prehension
chuck aka three fingered pinch
the examination of the forearm, wrist and hand requires
sound knowledge of differential diagnosis, and must include an examination of the entire upper KINETIC CHAIN, and the cervical and thoracic spine
what is the importance of a HISTORY of forearm, wrist and hand include
- helps focus examination
- relevant information must be gathered about the site, nature, behavior, and onset of the current symptoms
- should include information about the patient’s age, hand dominance, hobbies/activities, and occupation
during a systems review a clinician should be able to determine
the suitability of the patient for chiropractic care
during a systems review, if the clinician is concerned with any signs or symptoms of a visceral, vascular, neurogenic, psychogenic, or systemic disorder what should they do?
the patient should be REFERRED back to their physician because that is out of the scope of practice
what should the physical examination begin with
a general observation of the patients posture-especially the cervical spine, and the thoracic spine, and the position of the hand in relation to the body
- the contour of the palmar surface, including the arches, should be examined
- if a finger is involved, its attitude should be observed
what all should the clinician be observing
- inspect for lacerations, surgical scars, masses, localized swelling, erythema
- scars should be examined for degree of adherence, degree of maturance, hypertrophy (excess collagen within boundary of would), and keloid (excess collagen that no longer conforms to wound boundaries)
- the location and type of edema should be noted
- the nails should be inspected for abnormalities
- natural convexity is replaced by concave nails in a saucer form
- nail plate is thinner and weaker
- result of a severe fungus infection
spoon nails (koilonychia)
- pulmonary disease is the most common cause
- cardiovascular disease is the second cause
clubbed nails
-caused by emphysema and COPD
- inflammation of the terminal finger pad is confined by tough fascia attached to the periosteum
- swelling of the fingertip and dull pain
- pain gradually heightens and becomes throbbing
- tenderness is intense
- presence of pus is indicated by induration of the pulp and loss of resilience
- pressure in the confined space may cause the abscess to burst through the solar surface of the finger pad
Felon
what can Felon produce
osteomyelitis
- skin over the mantle of the nail and the lateral nail folds is swollen, reddened, painful and tender
- pus is over the nail, light palpation over the inflamed area provokes exquisite pain
- pain from pressure on the nail indicates subungqual abscess, between nail plate and periosteum
Paronychia aka Hangnail
what type of motions occur during an examination
- AROM, then PROM with over pressure
- the gross motions of wrist, hand, finger and thumb flexions, 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
- over extension of the carpals, possibly straining or spraining structures
- O’Donoghue’s is used to differentiate between which structures are affected
Thrower’s Wrist
with palpation of the muscles, tendons, insertions, ligaments, capsules, bones of the wrist and hand should occur
as INDICATED, and be compared with the uninvolved side
what 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
pain provocation tests
these tests are carried out in the extreme range, and if positive, tin the neutral range
isometric strength testing
the isometric tests must include
the interossei and lumbricales
this motions of wrist flexion, extension, ulnar and radial deviation are tested initially
straight plane motions
if pain occurs with any strength tests this will
require more thorough examination of the individual muscles
the ___ for the hand is the range in which the hand can performs of its grip and other functional activities
functional assessment
during the examination the tests are always
repeated on, and compared to, the same joint in the opposite extremity
what happens during a neuromuscular status examination
check the skin for unusually warm or dry areas of the hand-excessive localized warmth of the skin= infection
what does unnaturally dry condition (anhydrosis) may indicate
nerve damage
what Ortho tests are used to test neuromuscular status
allen test
tinel’s test for carpal tunnel syndrome
diagnosting testing of the forearm, wrist and hand is limited to
plain radiographs for most patients
bony tenderness with history of trauma or a suspicion of bone or joint disruption indicates
a need for radiographs
what are standard projections for the wrist
posteroanterior
lateral
oblique
what are some examples are acute phase goals
- protection of the injury site to allow healing
- control pain and inflammation
- control and then eliminate edema
- restoration of pain-free range of motion in the entire kinetic chain
- improve patient comfort by decreasing pain and inflammation
- retard muscle atrophy
- minimize detrimental effects of immobilization and activity restriction
- scar management if appropriate
- maintain general fitness
- patient to be independent with home exercise program
what are functional phase goals
- attain full range of pain free motion
- restore normal joint kinematics
- improve muscle strength to within normal limits
- improve neuromuscular control
- restore normal muscle force couple relationships
