Wrist and Hand Flashcards
1
Q
The Wrist and Hand
A
- The wrist and hand are vulnerable to injury because it is the move active and detailed parts of the upper extremity
- There can be large functional difficulties because of their role in ADL’s and they do not respond well to trauma
- There are 28 bones with numerous articulations and 19 intrinsic and 20 extrinsic musacles of the wrist and hand which provide a wide variability of movement
- The joints of the forearm, wrist and hand do not act in isolation but as functional groups
2
Q
Anatomy of the Distal Radioulnar Joint
A
- The distal radioulnar joint is a uniaxial, pivot joint that has 1° of freedom
- The radius moves over the ulna, but the ulna is not stationary. The radius moves back and laterally during pronation and forward and medially during supination in relation to the ulna
- Resting position: 10° of supination
- Closed packed position: 5° of supination
- Capsular pattern: Full range of motion, pain at extremes of rotation
3
Q
Anatomy of the Radiocarpal Joint (wrist)
A
- The radiocarpal joint is a biaxial, ellipsoid joint
- The radius articulates with the scaphoid and lunate. The distal radius is not straight but is angled towards the ulna (15°-20°)
- The lunate and triquetrum also articulate with the triangular cartilaginous disc (triangular cartilaginous complex-TFCC) which sits between the ulna and the lunate and triquetrum
- The TFCC is made up of the ulnolunate and ulnotriquetral ligament, the extensor carpi ulnaris tendon and its sheath, the ulnar capsule, the anterior and posterior radioulnar ligaments, the ulnomeniscal homolog (an organ corresponding to another organ) and the triangular fibrocartilaginous disc
- The TFCC helps to stabilize the distal radioulnar joint and adds stability to the ulnocarpal articulations
- The TFCC is tight on pronation and prevents posterior displacement of the ulna while the posterior part is tight on supination and prevents anterior displacement of the ulna
- Forced ulnar deviation increases the load on the TFCC
- With the triangular disc in place and a neutral ulna, the radius bears 60% of the load and the ulna through the triangular disc bears 40%
- If the disc is removed, the radius transmits 95% of the axial load and the ulna transmits 5%
- The triangular cartilaginous disc acts as a cushion for the wrist joint and as a major stabilizer of the distal radioulnar joint
- The most common mechanism of injury to the TFCC is forced extension and pronation
- The distal end of the radius is concave and the proximal row of carpals in convex but the curvatures are not equal
- The joint has 2° of freedom
- The stability of the carpals is primarily maintained by a complex configuration of ligaments and bones
- The ligaments stabilizing the scaphoid, lunate and triquetrum are the most important
- The radioscapholunate ligament, the scapholunate and the lunotriquetral ligaments are the most important intrinsic ligaments and are the ligaments most commonly disrupted
- They are most likely to be injured with a pronated fall on an outstretched hand injury
- Resting position: Neutral with slight ulnar deviation
- Closed packed position: Extension with radial deviation
- Capsular pattern: Flexion and extension equally limited
4
Q
Anatomy of the Intercarpal Joints
A
- The intercarpal joints include the joints between the individual bones of the proximal row of carpal bones and the joints between the individual bones of the distal row of carpal bones
- They are bound together by small intercarpal ligaments (dorsal, palmar and interosseous) which allow only a slight amount of gliding movement between the bones
- Resting position;
Neutral or slight flexion with ulnar deviation - Closed packed position:
Extension with ulnar deviation - Capsular pattern: Flexion and extension equally limited
5
Q
Anatomy of the Midcarpal Joints
A
- The midcarpal joints form a compound articulation between the proximal and distal rows of carpal bones with the exception of the pisiform bone
- On the medial side, the scaphoid, lunate and triquetrum articulate with the capitate and hamate, forming a compound sellar joint
- On the lateral side, the scaphoid articulates with the trapezoid and trapezium, forming another sellar joint
- The articulations are bound together by dorsal and palmar ligaments, however there are no interosseous ligaments between the proximal and distal rows of bones
- The distal row of carpals (hamate, capitate, trapezoid and trapezium) are bound together by strong interosseous ligaments that limit motion between them and the metacarpals
- Resting position: Neutral or slight flexion with ulnar deviation
- Closed packed position: Extension with ulnar deviation
- Capsular pattern: Flexion and extension equally limited
6
Q
Proximal Transverse Arch
A
The proximal transverse arch that forms the carpal tunnel is formed by the distal row of carpal bones
The capitate bone acts as a central keystone structure
7
Q
Anatomy of the Carpometacarpal Joint
A
- At the thumb, the carpometacarpal joint is a sellar joint with 3° of freedom, whereas the 2nd-5th carpometacarpal joints are plane joints
- The bones of these joints are held together by dorsal and palmar ligaments
- The thumb articulation has a strong lateral ligament extending from the lateral side of the trapezium to the radial side of the base of the first metacarpal and the medial four articulations have an interosseous ligament similar to that found in the carpal articulation
- Resting position:
+ Thumb: midway between abduction and adduction and midway between flexion and extension
+ Fingers: midway between flexion and extension
- Closed packed position:
+ Thumb: full opposition
+ Fingers: full flexion
- Capsular pattern:
+Thumb: abduction, extension
+ Fingers: equal limitation in all directions
8
Q
Anatomy of the Intermetacarpal Joints
A
The 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
9
Q
Anatomy of the Metacarpophalangeal Joints
A
- Condyloid joints
- The collateral ligaments of these joints are tight on flexion and relaxed on extension
- The articulations are also bound by palmar ligaments and deep transverse metacarpal ligaments
- The dorsal extensor hood reinforces the dorsal aspect of the metacarpophalangeal joints while volar and palmar plates reinforce the palmar aspect
- The dorsal or extensor hood reinforces the dorsal aspect of the metacarpophalangeal joints while volar or palmar plates reinforce the palmar aspect
- The flexor tendons and finger annular pulleys are key anatomical structures for the grasping function of the hand
- The pulleys orient the force of the flexor tendons and covert linear translation into rotation at the interphalangeal joints and prevent bowstringing
- Each joint has 2 ° of freedom while the first MCP joint has 3° of freedom, thus facilitating the movement of the CMC joint of the thumb
- The distal transverse arch passes through the MCP joints and has greater mobility than the proximal transverse arch, allowing the hand to form or fit around different objects
- The 2nd and 3rd MCP joints form the stable portion of the arch while the 4th and 5th MCP joints form the mobile portion
- The longitudinal arch follows the more rigid portion of the hand running from the carpals to the CMC joints, providing longitudinal stability to the hand
- The 2nd and 3rd MCP joints are the keystone to both the distal transverse arch and the distal longitudinal arch
- Resting position: Slight flexion
- Closed packed position:
+ Thumb: full opposition
+ Fingers: full flexion
- Capsular pattern: Flexion, extension
10
Q
Anatomy of the Interphalangeal Joints
A
- The interphalangeal joints are uniaxial hinge joints with 1° of freedom
- The bones of these joints are bound together by a fibrous capsule and by the palmar and collateral ligaments
- During flexion, there is some rotation in these joints so that the pulp of the fingers face more fully the pulp of the thumb
- Resting position: Slight flexion
- Closed packed position: Full extension
- Capsular pattern: Flexion, extension
11
Q
Patient History
A
- Age?
- What is the client’s occupation?
- What was the mechanism of injury?
- A FOOSH may lead to a lunate dislocation, Colles fracture, scaphoid fracture, injury to the TFCC
- Extension may cause dislocation of the fingers
- A rotational force applied to the wrist or near it may lead to a Galeazzi fracture, which is a fracture of the radius and dislocation of the distal end of the ulna
- Racquet sports, golf, baseball and tennis can lead to a fracture of the hook of hamate
- What tasks is the client able or unable to perform?
- For functionally at the wrist, a client should have 40° flexion, 40° extension, 15° radial deviation, 20° ulnar deviation
- When did the injury or onset occur and how long has the client been incapacitated?
- Which hand is the clients dominant hand?
- Has the client injured the forearm, wrist or hand in the past?
- Which part of the forearm, wrist or hand is injured?
+ If the flexor tendons are injured, they respond much more slowly to treatment than do extensor tendons
- Does pain or abnormal sensation predominate?
- Where is it painful?
12
Q
Observations
A
- The dominant hand tends to be larger than the non dominant hand
- The presence of Heberden or Bouchard nodes should be recorded. Heberden nodes appear on the dorsal surface of the distal IP joints and are associated with OA. Bouchard nodes are on the dorsal surface of the PIP joints and often associated with gastrectasis and OA
- Skin colour changes can give an indication of the state of the vascular system to the hand
+ Hyperemia may be the result of infection
+Dry and shiny skin may indicate systemic disease
- Any ulcerations may indicate neurological or circulatory problems
- Any rotational or angulated deformities of the fingers or wrist may be indicative of previous fracture
- The nails beds are normally parallel to one another. The fingers when extended are slightly rotated towards the thumb to aid pinch
- Ulnar drift may be seen in RA, owing to the shape of the MCP joints and the pull of the long tendons
- Fingernails should be examined
Spoon-shaped nails are often the result of fungal infection, anemia, iron deficiency, long term diabetes, local injury, developmental abnormality, chemical irritants or psoriasis - Clubbed nails may result from hypertrophy of the underlying soft tissue or respiratory or cardiac problems
13
Q
Ape Hand
Common Hand Deformities
A
- Wasting of the thenar eminence of the hand
- Occurs as a result of a median nerve palsy and the thumb falls back in line with the fingers as a result of the pull of the extensor muscles
- The client is unable to oppose or flex the thumb
14
Q
Bishop’s Hand
Common Hand Deformities
Hypothnar Eminence
A
- Also known as Benediction Hand Deformity or Duchene’s Sign
- Wasting of the hypothenar muscles of the hand, the interossei muscle and the two lumbrical muscles occurs because of the ulnar nerve palsy
- There is hyperextension of the MCP joint and flexion of the IP joints
- If the wrist flexes with MCP extension when the extrinsic extensors contract, it is a positive sign called the Andre-Thomas sign
15
Q
Boutonniere Deformity
Common Hand Deformities
A
- Extension of the MCP and DIP joints and flexion of the PIP joint (primary deformity) are seen with this deformity
- The result of a rupture of the central tendinous slip of the extensor hood and is most common after trauma or in RA
16
Q
Claw Fingers
Common Hand Deformities
A
- This deformity results from the loss of intrinsic muscle action and the overaction of the extrinsic extensor muscles on the proximal phalanx of the fingers
- The MCP joints are hyperextended and the PIP and DIP joints are flexed
- If intrinsic function is lost, the hand is called an intrinsic minus hand
- Normal cupping of the hand is lost, both longitudinal and transverse arches of the hand disappear and there is intrinsic muscle wasting
- The deformity is most often caused by a combined median and ulnar nerve palsy
17
Q
Dinner Fork Deformity
Common Hand Deformities
A
This deformity is seen with a malunion distal tradition fracture (Colles fracture) with the distal radial fragment angulated posteriorly
18
Q
Drop Wrist Deformity
Common Hand Deformities
A
The extensor muscles of the wrist are paralyzed as a result of a radial nerve palsy and the wrist and fingers cannot be actively extended by the client
19
Q
Dupuytren’s Contracture
Common Hand Deformities
A
-This progressive disease of genetic origin results in contracture of the palmar fascia
- There is a fixed flexion deformity of the MCP and PIP joints
- Usually seen in the ring or little finger and the skin is often adherent to the fascia
20
Q
Extensor Plus Deformity Common Hand Deformities
A
- Caused by adhesions or shortening of the extensor communis tendon proximal to the MCP joint
- If results in the inability of the client to simultaneously flex the MCP and PIP joints, although they may be flexed individually
21
Q
Mallet Finger
Common Hand Deformities
A
- A mallet finger deformity is the result of a rupture or avulsion of the extensor tendon where it inserts into the distal phalanx of the finger
- The distal phalanx rests in a flexed position
22
Q
Polydactyly and Triphalangism
Common Hand Deformities
A
- Polydactyly is a congenital anomaly characterized by the presence of more than the normal number of fingers
- Triphalangism implies there are three phalanges instead of the normal two as would be seen in the thumb
23
Q
Swan Neck Deformity
Common Hand Deformities
A
- Involves only the fingers
- There is flexion of the MCP and DIP joints, but the real deformity is extension of the PIP joint
- The condition is a result of contracture of the intrinsic muscles or tearing of the volar plate and is often seen in clients with RA or following trauma
24
Q
Syndactyly
Common Hand Deformities
A
- This deformity is a congenital condition in which some fingers are wholly or partially united, joined or webbed
- In the hand, if present, webbing is most common between the ring and middle finger (57%), ring and little finger (27%), index and middle finger (14%) and thumb and index finger
25
Q
Trigger Finger
Common Hand Deformities
A
- AKA digital tenovaginitis stenosans
- The result of a thickening of the flexor tendon sheath (Notta’s nodule), which causes sticking of the tendon when the client attempts to flex the finger
- A low-grade inflammation of the proximal fold of the flexor tendon leads to swelling and constriction (stenosis) in the digital flexor tendon
- When the client attempts to flex the finger, the tendon sticks and the finger “let’s go” often with a snap
- As the condition worsens, eventually the finger will flex but not let go, and it will have to be passively extended until finally a fixed flexion deformity occurs
- The condition is more likely to occur in middle-aged women, whereas trigger thumb with a flexion deformity of the IP joint is more common in young children
- The condition usually occurs in the 3rd or 4th finger
- Commonly associated with RA
26
Q
Ulnar Drift
Common Hand Deformities
A
- Commonly seen in clients with RA but can occur with other conditions
- Results in ulnar deviation of the digits because of weakening of the capsuloligamentous structures of the MCP joints and the accompanying “bowstring” effect of the extensor communis tendons
36
Q
Power Grip
A
- Requires firm control and gives greater flexor asymmetry to the hand
- A power grip which is a standard fist grip, the ulnar side of the hand works with the radial side to give stronger stability
- The ulnar digits tend to work together to provide support and static control
- This grip is used whenever strength or force is the primary consideration
- With this grip, the digits maintain the object against the palm, the thumb may or may not be involved and the extrinsic (forearm) muscles are more important
37
Q
Hook grasp - Power Grips
A
All or the 2nd and 3rd fingers are used as a hook controlled by the forearm flexors and extensors
38
Q
Cylinder grasp - Power Grips
A
A type of palmar prehension
The thumb is used and the entire hand wraps around an object
39
Q
Fist grasp - Power Grips
A
- A digital palmar prehension
- The hand moves around a narrow object
40
Q
Spherical grasp - Power Grips
A
- A type of palmar prehension
- There is more opposition and the hand moves around the sphere
41
Q
Precision or Prehension Grip
A
- An activity limited mainly to the MCP joints and involves primarily the radial side of the hand
- Used whenever accuracy and precision are required
- The radial digits provide control by working in concert with the thumb to form a “dynamic tripod” for precision handling
- The thumb and fingers are used and the palm may or may not be involved; there is pulp-to-pulp contact between the thumb and fingers and the thumb opposes the fingers
- The intrinsic muscles are more important in precision than in power grips
42
Q
Three-point chuck: -Pinch Grips
A
- Digital prehension
- Palm pinch or subterminal opposition is achieved
- There is pulp-to-pulp pinch and opposition of the thumb and fingers is necessary
- Also called a precision grip with power
43
Q
Lateral key, pulp-to-side pinch, lateral prehension or subterminolateral opposition: - Pinch Grips
A
- The thumb and lateral side of the index finger come into contact
- No opposition is needed
- An example of this movement is holding keys or a card
44
Q
Tip pinch, tip-to-tip prehension, terminal opposition: - Pinch Grips
A
- The tip of the thumb is brought into opposition with the tip of another finger
- This pinch is used for activities requiring fine coordination rather than power
