Wrist & Hand Flashcards
Which rays of the hand are most mobile?
thumb, ring, and pinky finger
-this is seen in cupping motions and relaxed fist vs tight fist
How is thumb metacarpal positioned relative to rest of hand?
flexed & pronated position of ~80 degrees to compared to metacarpals of the fingers
What is the role of sesamoid bones?
alleviate or redistribute weight or stress along a tendon or joint surface
What carpal bone is most susceptible to fracture?
scaphoid
-makes up ~ 68% of carpal fractures
What is the common MOI for scaphoid fracture?
FOOSH
-wrist extended and radially deviated
Which carpal bone is most often dislocated?
Lunate
-most dependent on ligamentous support
-weak area of volar ligaments
What is the 2nd most commonly fractured carpal bone?
Triquetrum
~ 18% of carpal fractures
What is the most stable carpal bone?
Trapezoid
-very stable articulations w/ 2nd metacarpal, capitate, and trapezium
Largest carpal bone?
Capitate
“keystone” of the transverse arch of the wrist
Which is the most mobile carpal bone(distal row)?
Trapezium
-forms saddle joint w/ thumb
-at least the most mobilie relative to other distal row carpals
What is the normal slope of radial inclination?
15-20 degrees
-measured from distal articular surface vs line perpendicular to midshaft of radius
-essential tilted toward ulna
What is normal radial tilt?
~15 degrees
-volar or dorsal tilt of radial head
AROM norm forearm pronation
85-90 degrees
AROM norm forearm supination
85-90 degrees
AROM norm wrist flexion
90 degrees
AROM norm wrist extension
70 degrees
AROM norm wrist radial deviation
15-20 degrees
AROM norm wrist ulnar deviation
30-45 degrees
AROM norm MCP flexion
85-90 degrees
AROM norm MCP extension
30-45 degrees
AROM norm MCP abduction
20-30 degrees
AROM norm MCP adduction
0 degrees
AROM norm PIP flexion
100-110 degrees
AROM norm PIP extension
0 degrees
AROM norm DIP flexion
80-90 degrees
AROM norm DIP extension
0 degrees
AROM norm Thumb CMC flexion
20 degrees
AROM norm Thumb CMC radial abduction
50-55 degrees
AROM norm Thumb CMC palmar abduction
50-55 degrees
AROM norm Thumb MCP flexion
50-55 degrees
AROM norm Thumb MCP extension
0 degrees
AROM norm Thumb IP flexion
80-85 degrees
AROM norm Thumb IP extension
0 degrees
How do proximal and distal carpal rows move w/ wrist movements?
Radial deviation
-proximal row flexes slightly and glides ulnarly
-distal row moves radially
Ulnar deviation
-proximal row extends slightly and glides radially
-distal row slides ulnarly
Sensory distribution of median nerve
volar surface of thumb, index, middle and half of ring finger;
a portion of dorsal surface of fingers EXCEPT pinky and thumb
-typically from tips to PIP joint crease
Muscles innervated by median nerve
pronator teres, FCR, palmaris longus, FDS muscles
-AIN branch innervates FPL, FDP to index and long fingers, pronator quadratus
-small motor component to lumbricals 1 and 2
Muscles innervated by ulnar nerve
FCU, FDP to ring and small fingers
Sensory distribution of ulnar nerve
anterior and posterior aspect of ULNAR side of hand and distal forearm
-by palmar and dorsal cutaneous branches
pinky and ulnar side of ring finger
-by superficial sensory branch
Muscles innervated by ulnar nerve
hypothenar intrinsic muscles(ADM, ODM, FDM)
-all palmar and dorsal interossei
-lumbricals 3 and 4
-deep head of FPB
-AP(adductor pollicis)
Muscles innervated by radial nerve
ECRL is only directly innervated
PIN(motor nerve only)
-ECRB, ECU
-ED, EI, EDQ
-APL, EPB, EPL)
Zones 1-5 of flexor tendon injury at the hand
zone 1: fingertip to PIP joint crease
zone 2: PIP joint crease to distal palarm crease
zone 3: distal palmar crease to distal margin of flexor retinaculum
zone 4: carpal tunnel
zone 5: area proximal to wrist crease in forearm
early rehab for 2 strand flexor tendon repair
early PROM protocol
early rehab for 4 strand flexor tendon repair
tolerates 40N of force
-allows for early PROM and limited AROM
early rehab for 6 strand flexor tendon repair
tolerates 50-60N of force
-better early PROM and limited AROM
what is tendon gapping?
a separation or gap that occurs between 2 areas of repair of the torn tendon
> 2mm is a factor in greater resistance to tendon glide
3mm even greater resistance and propensity to catch on edge of pulleys
Early stage immobilization protocol for flexor tendon repair
generally 3-4 weeks if pt is unable to follow complex rehab program, but immobilization less and less common
wrist 20-25* flexion
MP joint 50-60* flexion
IP joints in mild flexion
for children-early mobilization with therapist, but immobilization outside of therapy
-teenagers encouraged to follow adult protocols
intermediate stage immobilization protocol for flexor tendon repair
-pt progresses to neutral wrist orthosis
-begins passive finger flexion and active extension of IP joints w/ MP joints flexed 60-70*
within 1-2 weeks following immobilization, pt beings AROM and tendon glides w/ wrist extended 10*
if difference between AROM and PROM is >50* there are likely considerable adhesions
-this indicates progression to late stage
late stage immobilization protocol for flexor tendon repair
dependent on tendon glide
-usually 4-6 weeks
-orthosis is DC
-pt begins gentle isolated joint exercises(blocking of PIP joint or other fingers to isolate FDS and FDP)
light resistance ~8 weeks s/p repair to improve composite flexion
if muscle/tendon unit shortening is an issue
-orthosis for finger and wrist extension, Low load long duration stretch
NO HEAVY(>10 pounds) resisted activities until >10-12 weeks s/p repair
protected mobilization protocol
early AROM and PROM
-generally preferred over immobilization
-recommending 3-5 days after surgery to begin therapy
immediate postop position protected mobilization protocol
slight flexion or neutral, progressing to slight extension over several weeks
fingers in intrinsic plus position(MP flexed 70-90* and IP joints fully extended)
-work towards full IP extension if not initially available
additional force required for tendon glide with pt who has edema
mild 1.7N
mod 7N
severe 9N
may need to delay AROM in presence of edema
weeks 1-3 rehab protected mobilization
-passive IP joint flexion w/ active IP extension
-half composite fist via AROM
weeks 3-6 rehab protected mobilization
-passive IP joint flexion maintained w/ wrist moving from flexion to extension
-combined wrist tenodesis and finger motion
-AROM exercises progress from half fist toward full fist
extension of MP joint increased incrementally
differential tendon gliding if not already started
LIGHT ADLS generally tolerated well
generally orthosis is DC at 6 weeks
-allows initiating full MP and IP joint extension
resistance exercises at 8 weeks
return to work usually ~12 weeks(even manual laborers)
difference between zones of flexor tendon injury
zone 1 only involves FDP tendon
zone 2 most difficult and likelihood for adhesions due to FDP and FDS presence
zones 3-5 less concern about tendon gliding in fibro-osseous tunnel or restriction at pulleys
-multiple repairs in zone 5 may have significant scarring and subsequent limited tendon excursion at fingers or wrist
-potential for neurovascular compromise as well as zone 5
