Wrist And Hand Lecture Flashcards
How much of the upper limb movement occurs in the hand?
90%
What part of the hand is involved in the most function?
Thumb (40-50%)
What 2 fingers together are involved in 40% of hand movement?
The index finger (20%)
The middle finer (20%)
What is the strongest finger?
The chiropratic index finder.
important for percision and power.
What type of joint is the distal radioulnar joint?
double piviot
What is the triangular fibrocartilage complex?
TFCC - a fibrocartilage disc that helps with the indirect articulation of the ulna. It improve the congruency of the joint surfaces and acts as a cousion against compressive forces.
Which side (ulnar or radial) has more deviation? Why?
Ulnar - the styloid process is about .5 inch shorter on the ulnar side. This allows for greater ROM (more space to move)
What does the ulnar head articulate with?
ulnar notch of the radius laterally, and the TFCC distally
What is the difference between Collies’ Fracture and Revers Collies’ Fracture? Give the AKAs for each.
They are both fractures within 25-30mm of the wrist joint.
Collies (AKA Dinner Fork Fracture) - the segment after the fracture line goes POSTERIOR
Revers Collies (AKA Smith’s Fracture) - the segment after the fracture line goes ANTERIOR
How much of the axial load’s transmission between hand and forearm is though the (Triangular Fibrocartilage Complex) TFCC?
20%
What is the most commonly fractured bone in the wrist?
Nevicular (AKA Scaphoid)
What is the largest carpal bone on the proximal row?
Scaphoid
What is the largest carpal bone?
Capitate
What tendon covers the capitate posteriorly?
Extensor carpi radialis brevis tendon
Extensor carpi radialis brevis: OINAB?
O: Lateral epicondyle
I: Base of the 3rd metacarpal posteriorly
N: Deep Radial Nerve (C6 C7)
A: Extends hand at the wrist. Radially deviates the hand at the wrist
B: Radial Recurrent Artery
Extensor carpii radialis longus: OINAB:
O: Lateral Epicondyle
I: Base of the 2nd metacarpal posteriorly
N: Radial or Deep Radial Nerve (C5 C6)
A: Extends the hand at the wrist. Radially deviates the hand at the wrist. Weak elbow flexor/supinator
B: Radial Recurrent Artery
What is the most commonly sublexated carpal bone?
Lunate
What carpal bone is the secound most commonly fractured?
Lunate
Which carpal bone articulates with the largest metacarpal base?
Capitate
Which carpal bone takes the most stress? Why?
Lunate
When the hand extends the capal arch flattens, and all of the extra stress is placed on the Lunate since it is at the center of that arch.
Describe the midcarpal joints.
Compound articulation, since each row has both a concave and a convex surface
Proximal Row: convex laterally, concave medially
What provides stability to the carpometacarpal joints? Where are the caropmetacrapal joints?
palmar and dorsal carpometacarpal and intermetacarpal ligaments
joints are between the distal carpals and the bases of the metacarpals
What ligaments originate from the TFCC?
- ulnolunate
- ulnotriquetral ligaments
- the ulnar collateral,
- the radioulnar ligaments
- the ulnocarpal ligaments
What capal bones articulate with the Radius?
Scaphoid and lunate
Which carpal bones articulate with 2 metacarpals?
Hamate (4th and 5th metacarpal bases)
Trapezium (mostly the thumb but also a small articulation with the 2nd metacrpal base
Which carpal bone is the smallest?
Trapezoid
What type of bone is the pisiform?
Sesmoid bone which forms from the flexor carpi ulnaris tendon
Which carpal bones articulate with the TFCC?
Lunate and Triqutrium
What type of joint is between the 1st metacarpal base and the trapizum?
Seller joint (saddle shaped joint)
What is the resting attitude of the hand?
Slight flexion of the MCP and IPs
Describe Bennett’s Fracture
A fracture of the 1st metacarpal neck which displaces posterior (dorsal) and lateral (radial)
What type of joint is the metacarpophalangeal joint of the thumb?
a hinge joint
- metacarpal is convex
- phalanx is concave
Describe a bar room fracture.
fracture the fourth or fifth metacarpal neck with anterior displacement of the head.
True or false: a boxers fracture is a fracture of the second or third metacarpal neck with posterior displacement of the head.
False
Anterior displacement of the metacarpal head
Aside from location, what is the difference between the PIP and the DIP joints?
Both are hinge joints but the DID joints have slightly more mobility which allows for hyperextension, which is not possible at the PIP joints.
Which joints can Heberden’s Nodes be found at?
DID joints (which means not on the thumb since there is no DIP)
How large are Heberden’s Nodes? What symptoms are associated with these?
2-3mm in diameter
They are painless and do not effect motion. It is a localized form of OA
What causes Heberden’s Nodes? Are there any differences in how these present between populations?
Women: causes is usually hereditary and appear around menopause
Men: single joint more commonly involved. usually a result of trama
Your patient has noticeable nodules on the PIP joints. What x-ray would you want to see before adjusting them? What are you looking for/why?
I would want to see a lateral cervical - I am looking for an increased ADI.
Bouchard’s Nodes are often caused by the swelling of the synovial joints in the fingers as a secondary sign of RA, and RA is the leading cause of an increased ADI.
The patients PIP is hyperextended and the DIP is flexed. Name the deformity and primary cause.
Swan Neck Deformity.
MOI = usually RA
The patients PIP is flexed and the DIP is extended. Name the deformity and the primary cause.
Boutonniere Deformity
Trama causing the extensor digitorum communis tendon to avulse.
extensor digitorum communis: OINAB:
O: Lateral Epicondyle I: Base of the middle phlanx of each of the 4 fingers N: Posterior interosseous A: Finger Extension B: Posterior Interosseous
What ligaments provide the majority of wrist stability?
Extrinsic palmar ligaments
Which ligaments serve as rotational restraints in the wrist?
The intrinsic ligaments which hold the proximal row together and make them a unit of rotational stability. (NO MUSCLES attach here, the ligaments are all these bones have to make a strong house).
What are the AKAs for the MCL and LCL in the fingers?
MCL = Grayson’s Ligaments LCL = Cleland’s Ligaments
What structures from the radiocarpal joint?
concave surface of the distal end of the radius
the scaphoid and lunate
theTFCC
What is the funtion of the antbrachial fascia?
it encases the forarm to maintain the relationship between the structures which crisscross the wrist
What is the function of the Extensor Retinaculum?
Prevents the structures from Bow-stringing
Name the contents of the extensor retinaculum from lateral to medial.
Abductor Pollicies longus and Extensor Pollicies Brevis (which we know go together bc finkilsteins)
Extensor Carpi Radialis longus and brevis (which we have palpated, so this makes sence)
Extensor Pollicies longus (make the snuff box and you can see it running kind of in the middle)
Extensor Digitorm Indicies
Extensor Digiti Minnimi
Extensor Carpi Ulnaris (has to be all the way on the ulnar side of the hand)
Where does the extensor retinaculum attach?
Lateral Distal Radius
Ulnar Styloid Process
Wraps around to the Pisiform
Where does the flexor Retinaculum attach?
Proximally: scaphoid and the pisiform
Distally: hook of the hamate and the trapezium
What does the Flexor Retinaculum do?
It transforms the carpal arch into the carpal tunnel. Remember, when weight bearing the arch flattens, and now there the flexor retinaculum takes all of the weight and squishes everything inside.
What structures pass deep to the Flexor Reinaculum?
MEDIAN NERVE (this is what gets pissed off in carpal tunnel syndrome)
flexor digitorum superficialis (FDS) - 4 tendons
flexor digitorum profundus (FDP) - 4 tendons
flexor pollicis longus (FPL) - 1 tendon
felxor carpi radialis (FCR) (separated from the rest of the carpal tunnel by the radial synovial sheathe)
What structures pass superficial to the flexor retinaculum?
ulnar nerve and artery;
the tendon of the palmaris longus;
the sensory branch (palmar branch) of the median nerve
What test will stretch the median nerve?
Revers phaleans
Which test will compress the median nerve?
Phaleans
What is a Jersey Finger?
Avulsion of the flexor digitorum profundus tendon.
Flexor Digitorm Profundus: OINAB:
O: anterior ulna
I: distal phalanx of 2-5 fingers
N: Medial portion Ulnar N (C8 T1)
Lateral portion Ant Interossious of median nerve (C8 T1)
A: Flexes the DIP joint/wrist if fingers are extended
B: Ulnar and Radial Arteries
What is the MOI for Jersey Finger?
the finger gets caught in an object and actively flexed DIP joint is suddenly and forcible extended resulting in a rupture
(I am flexing my dip trying to cheet at sports and grab the neck of of the opposing teams jersey. The guy runs away and now it extends my DID forcable and causes an avulsion. serves me right too, cheater)
Name the borders of the carpal tunnel.
Floor: The palmar radiocarpal ligament + palmar ligament complex
Roof: the flexor retinaculum (transverse carpal ligament)
Sides: trapezium and hook of hamate respectively
What passes though the tunnel of guyon?
The ulnar artery and ulnar nerve
What are the borders of the tunnel of guyon?
Roof: The palmar (volar) carpal ligament, palmaris brevis
muscle, and the palmar aponeurosis
Floor: the flexor retinaculum (transverse carpal ligament), pisohamate ligament, and pisometacarpal ligament
Sides: Hook of Hamate and Pisiform
What nerve and artery are involved in cyclers hand?
Ulnar Nerve and Ulnar Artery (the structures in the tunnel of guyon).
What is Dupuytren’s contracture? What will it feel like around palpation?
Nodule formation or scaring of the palmar apponerouses, often leading to finger flexion contracture.
This will feel like a hard cord over the flexor tendons if you palpate at the base of the digits. Passive extension will make these cords easily visible
What tendons create the extensor hood?
extensor digitorum
extensor indicis
and extensor digiti minimi
+ lumbricls and interossi distally
What actions are assisted by the extensor hood?
Extension: MCP and IP joints,
Flexion: lumbricals, and possibly interosseous muscles on the MCP joints
What causes a cycst on the dorsal wrist?
possibly biomechanical alterations
- it is an out pouch of fluid from a tiny tear in the joint capsule allowing for synovial fluid to escape
What structrure is damaged in a mallet finger?
The extensor tendon is ruptured (sometimes avlsion frature) leading to a permanently flexed DIP
What creates the contour of the palmer surface of the hand?
Hills = Neurovascular bundles Vallys = tendons
What holds the flexor tendons to the MCPs and phalanges?
Annular (A) and cruciate (C) pulleys
What are the borders of the surgical no man’s land?
Distal hand crees to the PIP joints.
What makes the sugical no man’s land so delicate?
There are already 2 muscle tendons (Flexor Digitorm superficialus and profundus) fitting into one small sheet, so very little space for stitches. Any additional material would likely limit voluntary movements here.
Your patient is a 40 year old female who is complaining of pain in the dorsum of her hand whenever she extends the 4th digit. What do you suspect the problem is?
Trigger Finger.
What digits are most often effected with trigger finger?
4th and 5th
What population is most offten effected with trigger finger?
Women 40-60
What is actually happening in trigger finger?
There is a microtrama that creates a nodule which sits outside the tendon sheeth. When the pt extends the finger the tendon snaps over the nodule. This is painful and can sometimes refer pain to the dorsum of the hand.
How many muscles are there within the hand?
19 intrinsic
24 extrinsic
What muscles are in the anterior compartment of the forearm?
Superficial: Pronator Teres, Flexor Carpi Radialis, Palmaris longus, Flexor Carpi Ulnaris
Intermediate: Flexor Digitorm Superficialis
Deep: Flexor Digitorm profundus, Pronator Qudratus, flexor pollicis longus
What muscles are in the posterior compartment of the forearm?
Superficial: Extensor carpi radialus longus and brevis, extensor digitorum, extensor digiti minnimi, extensor carpi ulnaris
Deep: Abductor Pollicis longus, Extensor Pollicies brevis, extensor polliecies longus, Extensor indicis
What makes up the borders of the anatomical snuff box?
Laterally: Abductor Pollicus longus/extensor pollicies brevis
Medially: extensor pollicies longus
Floor: deep branch of the radial artery and the tendinous insertion of the ECRL. Underneath these structures are scaphoid and trapezium bones
Where do we see swelling in DeQurevian’s Disease?
Tunnel 1
What is the MOI for De Quervain’s Disease?
Overuse injury from repetitive ulnar/radial deviations of the wrist
What is the female to male ratio for De Quervain’s Disease?
8:1 (women)
What are the short muscles of the hand?
Abductor pollicis brevis (APB)
Flexor pollicis brevis (FPB)
Opponens pollicis (OP)
Adductor pollicis (AP)
What causes Skier’s thumb?
Hyperextension of the thumb which leads to an Ulnar collateral ligament avulsion.
AKA for Skier’s thumb?
Gamekeeper’s Thumb
Short muscles of the 5th digit
Abductor digiti minimi (ADM)
Flexor digiti minimi (FDM)
Opponens digit minimi (ODM)
Name the deep muscles of the hand.
Palmer interossei (3) - ADD Dorsal interossei (4) - ABD Lumbricles (4) - IP extension/help with MCP extension
What are the funtional archs of the hand?
Transverse Arch
Metacarpal Arch
Longitudinal Arch
Oblique Archs
What forms the Transverse arch?
the palmar concavity of the carpal bones, scaphoid + trapezium laterally, and pisiform + hamate medially
(funny that sounds just like the things that the flexor retinacum connect to, which has the AKA of the transverse carpal ligament)
What forms the metacarpal arch?
formed by metacarpal heads
thats pretty straight forward
What forms the longitudinal arch?
the 3rd and 5th digit MCP joints
(the ulnar side ofthe hand curls in the meet the thumb. do some gypsy hands - index finger really won’t move at all. Its just the rolling of the 3rd -5th, making this arch)
What forms the oblique archs?
The thumb as it moves to meet each finger individually in opposition
What nerves supply the skin/muscles of the wrist and the hand?
Radial - dorsal thumb - lateral 3rd
Ulnar - Palmer: medial 4th and 5th, dorsal medial 3rd, 4th and 5th
Median - palmer thumb-lateral 1/2 of 4th. dorsal tips of 2nd-lateral 1/2 of 4th
What is the main vascular supply to the wrist and hand?
Radial and ulnar artery. (both branches from the brachial)
On the hand also have dorsal and palmer arches
What is Keinboch’s Disease? What population do we see it in most commonly?
Avascular Necrosis of Lunate - a fractured lunate entrapes the neurovascular bundle
Seen most often in males age 20-40
in 75% of cases the pt had a short ulnar bone (which placed more stress on lunate)
Does Keinboch’s Disease usually present unilaterally or bilaterally? give some other signs/symptoms associated.
Unilaterally (usually on the dominate hand)
The bone will look bright white on x-ray (increased density)
palpable tenerdness
reduced ROM
generally presents with localized pain but pain can radiate down into the wrist.
Can lead to DJD
What limits pronation?
The boney impaction between radius and ulna
What limits supination?
interosseous membrane, and the bony impaction between the ulnar notch of the radius, and the ulnar styloid process
Where does the majority of wrist flexion occur? What motions is it coupled with?
midcarpal joint
coupled with slight ulnar devation and slight supination
Where does the majority of wrist extension occur? What motions is it coupled with?
radiocarpal joint
coupled with slight radial deviation and pronation
Where dose radial deviation occur and what limits it?
Radial devation occurs between the proximal and distal carpal bones. Limited by the scaphoid hitting the radial styloid process and by tension in the ulnar collateral ligament.
Where does ulnar deviation occur and what limits it?
Ulnar devation occurs at the radiocarpal joint. It is limited by the radial collateral ligament
What plane does thumb flextion/extension occur in? describe the relationship between the MCP and the Trapizium
Frontal Plane
MCP = Concave
Trapizium = convex
Describe the biomechanics of the MCP and Trapizium in ABduction and ADduction.
convex metacarpal surface moves on the
concave trapezium
Define a power grip.
The digits work together to provide static support and control. They hold an object against the hand. Extrinsic muscles are involved.
Define a Precision or Prehension grip.
Grip between the MCP joints. Mostly involves the radial side of the hand. The digits and thumb form a tripod. Intrinsic muscles important.
For each of the following state if it is a power or precision grip:
Chuck three fingered pinch Fist grip lateral key pinch Cylindrical grip Ball grip tip pinch tip-to-tip prehension Hook grip
Chuck - percision three fingered pinch - percision Fist grip - power lateral - percision key pinch - percision Cylindrical grip - power Ball grip - power tip pinch - percision tip-to-tip prehension - percision Hook grip - power
What causes Koilonychia?
Koilonychia AKA Spooning of the finger Nails
Comes from a sever fungal infection
iron deficiency anemia
Most common causes of clubbed finger nails?
- Pulmonary Disease
- Cardiac Disease
in both cases it is because there is a lack of blood flow to the distal ends of the hands
What is a Felon?
Inflammation of the terminal finger pad is confined by
tough fascia attached to the periosteum
How can a felon be identified? What is the progession of symptoms?
ID: dull pain. if you press on the distal tuft it will have an indent that stays
Pain will increase to become a throbbing or intense tenerness. If the pressure increasses enugh it can cause the cyst to bust though the volar surface –> can lead to osteomyletis
What is a Paronychia?
A hang nail
Skin becomes swollen, red, and painful. Light palpation produces pain
Pain from pressure on the nail indicates subungual abscess, between nail plate and periosteum
What is throwers wrist?
Usually a cumulative overuse trama to the extensor muscles ligaments and tendons (O’Donohuges to distinguish)
What may be associated with anhydrosis?
nerve damage
