Hand Flashcards
Purpose of the hand
Opposition of thumb to digits
- Manipulation and precision greater than any other animal
* Grasp
* Pinch
* Writing, sewing, surgery
Intake of sensory information-greatest connection to the brain
Vital for functional performance
Key for development
Emotional and Social Connections
- Communication
- Aesthetics
Haptic perception: knowing what something feels like without actually touching it
Excessive hand decorations are a sign of personality disorder, bipolar disorder, psychopaths, narcissists
Types of grasps
Grasps (involve manipulation)
- Power
* Hook (FDP and FDS)
* Disc
* Cylindrical
* Spherical
- Precision (pinch)
* Tip to tip/pincer/Two point
* Lateral/Key
* 3 jaw-chuck/3 pt/tri-tip
Types of fists
Flat
Composite
Claw
Arches of the hand
Balance stability and mobility in the hand
Flat hands =paddles
Distal (metacarpal) transverse arch
- Runs along the metacarpal head
- Controls thumb opposition
* 2 & 3 are stable, 4 & 5 are mobile
- Strength, precision (mobility of digits, superimposed on stability-arch)
* writing
Longitudinal (runs length wise the hand)
- Digits mobilize around it
- The middle finger is the center pole of the hand (with lunate & capitate)
- Grasp
Proximal transverse
- Most rigid
- Bone arch that is the posterior boarder of the carpal tunnel
- Runs along the neck of the metacarpal
- Forms the fulcrum (mechanical advantage) for the flexor tendons
* Supported by the flexor retinaculum (scaphoid to hamate)
Creases of the hand
Functional position of the hand
Wrist in 20 - 30º of extension and slight ulnar deviation
Fingers in 45º of MCP flexion, 15º of PIP and DIP flexion
Thumb is in 45º of abduction
Position for long term immobilization
Also known as antideformity position or intrinsic plus position
MCP joint in 60-70º of flexion
Thumb in 45º abduction
PIP and DIP joints extended
10-20º wrist extension
Anatomical snuffbox
Radial border-abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons
Ulnar border-extensor pollicis longus (EPL) tendon
Radial artery and nerve run through the middle
tunnel of Guyon
Holds the ulnar nerve
Hook of hamate is the lateral or radial border
The pisiform is the medial or ulnar border
Joints of the hand
CMC joint of the thumb (fingers too, but slide)
- Saddle joint: highly mobile, which means it is not very stable
- Flex/ext, abd/add
- Opposition
- Circumduction
- Volar plate: fibrocartilaginous plate that is lined with hyaline cartilage; increases the articular surface of the MP joint
MP or MCP (metacarpophalangeal joint): condyloid joint
- Biaxial: flex/ext, abd/add
IP/PIP or DIP
- Uniaxial hinge
- flex/ext
Biomechanical failure of CMC joint
The mechanics seriously change
- Shortening of adductor
- Hyperextension of MP
- Flexion deformity of IP
Radiocarpal joint
Radius to the scaphoid and lunate (central column)
Connection between lunate and capitate (midcarpal joint)
During wrist extension
- Lunate rolls dorsally (on the radius) (convex on concave) and slides palmarly
- The head of the capitate rolls dorsally (on the lunate) and slides palmarly
During wrist flexion it does the opposite.
Wrist joint in ulnar deviation
Scaphoid, lunate, and triquetrum roll ulnarly and slide radially
- Capitate follows same
- Triquetrum smacks the articular disc (TFCC)
- Scaphoid and lunate compress against the radial styloid
* Stability for grasp
The proximal row of carpal bones extend or flatten out
Wrist joint in radial deviation
Opposite of ulnar deviation
The radial styloid impinges the scaphoid and trapezium
The capitate (midcarpal joint) moves more
- Less motion overall
The proximal row of carpal bones flex or cup
Other parts of the wrist
Ulna to the articular disc of the TFCC
- Slack in extension
- Taut in flexion
Distal radioulnar joint
- Stabilized by the TFCC
- Piano key test
- DRUJ stability test
Biomechanical failures of the carpal bones
Carpal collapse or zig zag deformity (windswept hand)
- The connection between the radius, lunate, and capitate fail, usually ligamental damage or Keinbock’s disease
- MP ulnar deviation, IP radial deviation
- result of osteoarthritis or rheumatoid arthritis
Ulnar translocation (impaction)
- Too short: chronic tears and sprains
- Too long: early arthritis and tears
- ANY abnormal length
Hand ligaments
Ulnar and radial collateral ligaments
- MPs: taught in flexion
- PIPs: taught in extension
Annular Pulleys - A1-A5
- Trigger finger A1
- Bow stringing (A2-A5, C1-C3)
* multiple pulleys affected
* can’t make composite fist
Cruciate ligaments (actually pulleys) C1-C3
Intrinsic muscles
Key to extension and abduction
4 Lumbricals
- Always on the radial side of the digits (not the thumb)
- Come from palmar surface and attach to dorsal hood to cause extension of PIP and DIP
4 dorsal and 3 palmar interossei
- Help the lumbricals and abduct/adduct
Opponens digiti minimi
Opponens pollicis
Abductor pollicis brevis
Adductor pollicis - two heads
Biomechanical failures of intrinsic muscles
Boutonniere deformity
- Central slip of extensor hood disruption
- Lateral bands palmer
- DIP extension, PIP flexion
Swan neck deformity
- Often starts as unresolved mallet
- Lateral bands displace dorsally
- Tears terminal tendon
- PIP extension, DIP flexion
Extrinsic muscles
Key to wrist motion and digit flexion
Supinator and biceps brachii
Pronator teres and pronator quadratus
Flexor digitorum superficialis (FDS): make a fist
Extensor & Flexor carpi radialis (ECR)(FCR)
Extensor & Flexor carpi ilnaris (ECU) (FCU)-to get the ECU-move thumb
Extensor carpi radialis brevis (ECRB)
Extensor digitorum (communis) ED or EDC
Flexor digitorum profundus (FDP)
Flexor digiti minimi (FDM)
Flexor pollicis brevis (FPB)
Flexor pollicis longus (FPL)
Extensor pollicis brevis (EPB)
Extensor pollicis longus (EPL)-top of snuff box
Abductor pollicis longus (APL)
How to determine if it’s intrinsic or extrinsic muscles that are affected
The MP joint is the KEY!!
Intrinsic tightness (Bunnell Test)
- Flex the pip joint twice (passive)
- Once with MP extended, once with it flexed
- Intrinsics are tight If the PIP flexes when MP is flexed but not when extended
Extrinsic tightness
- Same as Bunnell but PIP flexes when MP is extended but not when flexed (claw/hook)
Capsular tightness
- Restricted PIP with both
Extensor hood (retinacular ligament)
- DIP flexion is restricted when PIP is extended
Radial nerve
Supplies sensory only to the hand
Controls extrinsic wrist extensors
- Wrist drop
- MP drop
- Thumb drop
Extensor wad is the last muscle innervated
Branch: PIN
Median nerve
Sensory and motor to the hand
FDS, FDP 2 and 3, 1 and 2 lumbricals
All of thumb flexors except deep head of APB
- Carpal tunnel (sensory effect), ape hand, Benedict hand (no thumb, index, or middle finger; kinda claw)
Ulnar nerve
Sensory and motor
FDP 4 and 5, 3 and 4 lumbricals
All interossi
Claw hand
Active insufficiency
Muscles can only contract ½ the length of the muscle body. This never increases so if the tendon has been stretched, the muscle will contract and there will be “slack” in the over stretched tendon, so we feel trace but there is no movement.
No amount of strengthening will help.
Splinting in neutral or slight extension for 3-4 weeks (maybe longer) with active extension and slight flexion (10-15 degrees)
ONE day out of the splint, you start ALL OVER!!
Prime mover
Insufficiency in concentric contraction
Passive insufficiency
If the client stays in this position, or is unable to actively extend, the flexors will shrink and then prevent extension.
If you can’t get full passive extension, they most likely have passive insufficiency of the flexors.
Insufficiency in eccentric contraction.
Antagonist muscle
When is active/passive insufficiency a good thing?
Tenodesis action
C6 spinal cord injury
- Extension of wrist actively
* Natural passive insufficiency of the finger flexors
- Flexion by way of gravity
* Natural passive insufficiency of the finger extenders
- We want it to get worse (slight contracture)
* Never stretch wrist extensors and digit extensors together
or finger and wrist flexors together
Wrist flexion ROM
Expected = 60-80º
End feel = firm
Position
1. Ulnar side
- Seated with arm hanging off table
- Stationary arm: midline of ulnar
- Axis: over the triquetrum
- Movable arm: midline of fifth metacarpal
2. Radial side
- Seated with arm resting on ulnar boarder
- Stationary arm: midline of the radius
- Axis: over the radial styloid
- Movable arm: midline of 2nd metacarpal
3. Over the top
- Stationary arm: midshaft of forearm
- Axis: over the capitate
- Moveable arm: third metacarpal
Wrist extension ROM
Expected = 60-70º
End feel = firm
Position
1. Ulnar side, exactly the same, flip goniometer over
2. Radial Side, exactly the same, flip goniometer over
3. Up from the bottom
Stationary arm: on the palmer surface, mid line
Axis: palmer surface under the capitate
Moveable arm: on the palm with third metacarpal
Radial and ulnar deviation ROM
Expected = Radial - 20º, Ulnar - 30º
End feel = hard for radial, firm for ulnar
Position (same, just flip it)
- Hand flat on table
- Stationary arm: midline of forearm
- Axis: dorsal wrist over the capitate
- Moveable arm: midline of third metacarpal (NOT phalanx!!)
Possible substitution
- Flex wrist
Metacarpophalangeal (MCP or MP) flexion ROM
Expected = 90-100º (90º is most common)
End feel = hard
Position
- Stabilize the wrist, can do it in sidelying or on elbow (“aim for the imaginary line”)
- Stationary Arm: dorsal midline of corresponding metacarpal
- Axis: dorsal aspect of MCP joint
- Moveable arm: midline of proximal phalanx
Metacarpophalangeal (MCP or MP) extension ROM
Expected = 0 is the neutral position with 20-45º of extension or hyperextension (20 is most common)
End feel = firm
Position
- Same as flexion except you have to use a full circle goniometer or measure from the palmer surface
- Stabilize the wrist, can do it in sidelying or on elbow (“aim for the imaginary line”)
- Stationary Arm: dorsal midline of corresponding metacarpal
- Axis: dorsal aspect of MCP joint
- Moveable arm: midline of proximal phalanx
Metacarpophalangeal abduction ROM
No norm with this one, typically 10-20º, compare to adjacent digits and other hand
End feel = loose in extension, firm in flexion
Position
- Hand flat on table
- Stationary arm: midline of metacarpal
- Axis: over the MCP joint
- Moveable arm: over the proximal phalanx
Proximal interphalangeal joint (PIP) flexion ROM
Expected = 100-110º
End feel = firm
Position
- Joint blocking is often required
- Cut off goniometer works well
- Sidelying or up on elbow
- Block MP and ask them to flex (aim for the “fat pads”)
- Stationary arm: midline of proximal phalanx
- Axis: over the PIP joint
- Moveable arm: midline of middle phalanx
Proximal interphalangeal joint (PIP) extension ROM
Expected = 0º, however, 10º hyperextension is normal if all are like that
End feel = firm
Position: same as flexion, but from the palmer surface
- Stationary arm: midline of proximal phalanx
- Axis: over the PIP joint
- Moveable arm: midline of middle phalanx
Distal interphalangeal joint (DIP) flexion ROM
Expected = 70-90º
End feel = firm
Position: same as PIP, but move a phalanx
- Will need to joint block
- Can measure with PIP if they can isolate
- “Touch the fat pad”
- Stationary arm: midline of proximal phalanx
- Axis: over the PIP joint
- Moveable arm: midline of middle phalanx
Distal interphalangeal joint (DIP) extension ROM
Expected = 0º - up to 10º hyperextension is expectable if all others have it
Position: same as PIP, but move a phalanx
- Will need to joint block
- Can measure with PIP if they can isolate
- “Touch the fat pad”
- Stationary arm: midline of proximal phalanx
- Axis: over the PIP joint
- Moveable arm: midline of middle phalanx
Thumb carpometacarpal (CMC) joint flexion ROM
Flexion (across the palm)
Expected = 15º
End feel = soft
Position
- Hand is positioned FLAT with the thumb aligned with index finger
- This means you may not start at 0
- Stationary arm: palmer surface, along the radial shaft
- Axis: over CMC joint
- Moving Arm: along the shaft of the first metacarpal (don’t follow the IP!!)
Thumb carpometacarpal (CMC) joint extension ROM
Expected = 0-20º of motion (you may see larger numbers, up to 70º)
Position
- Hand is positioned FLAT with the thumb aligned with index finger
- This means you may not start at 0
- Stationary arm: palmer surface, along the radial shaft
- Axis: over CMC joint
- Moving Arm: along the shaft of the first metacarpal (don’t follow the IP!!)
Thumb carpometacarpal (CMC) joint abduction ROM
Expected = 30-70º
Also called palmer abduction
Position:
- Hand in sidelying with radial side up
- Axis: lateral aspect of radial styloid
- Stationary arm: midline of 2nd metacarpal
- Moveable arm: midline of 1st metacarpal
NOTE START POSITION!!!!!!!!!!
Thumb carpometacarpal (CMC) joint adduction ROM
Only measured if unable to do it
Common with CMC replacements
Should be able to come in to 0º, if not record the lack of motion in negative
-10º adduction
Thumb opposition
Occurs due to the CMC, MP and IP joint
Primarily the CMC
Several ways to measure
To tip of small or 5th digit
To base of small or 5th digit
Can use a tape or ruler to measure distance off palm
Thumb metacarpophalangeal joint (MP) flexion and extension ROM
Expected= 50-60º (flexion), 0-10º hyperextension (extension)
Position:
- Hand in sidelying
- Axis: dorsal aspect of MP
- Stationary arm: dorsal midline of metacarpal
- Moveable arm: dorsal midline of proximal phalanx
Extension is measured in negative
Thumb interphalangeal joint (IP) flexion and extension ROM
Expected = 80º flexion
Position
- In sidelying
- Axis: over the dorsal IP joint
- Stationary arm: over midline of dorsal proximal phalanx
- Moveable arm: over midline of dorsal distal phalanx
Expected = 0º extension
- Measured just like MP
MMT
Typically when looking at the wrist and digits, we do not do full MMT.
MMT are commonly done on the wrist
Typically use a dynamometer to get grip strength for digits
MMT for wrist flexion
Position
- Forearm in supination AG or sidelying GM
Palpation: flexor wad or over tendon at the wrist
Resistance: into palm of hand
Check each flexor
MMT for wrist extension
Position:
- Hand in prone AG and sidelying for GM
Palpation: at extensor wad or over the wrist
Resistance: over dorsal metacarpals
