Title: Hand and Wrist
1Hand and Wrist
- KSPE 4650
- Leeann Hinton
- Anna Thames
- Joey Thomas
2Bony Anatomy
- distal radius and ulna
- 8 carpal bones
- 5 metacarpals
- 14 phalanges
3Bony Anatomy
- Distal radius-
- broadens to form a small ulnar notch on its
medial surface - Radial styloid process-
- projects off the anterolateral border
4Bony Anatomy
- Ulnar head-
- more circular, with the ulnar styloid process
arising from the medial surface
5Carpal Bones
- Aligned in two rows
- Proximal row
- Distal row
-
6Proximal Row(lateral to medial)
- scaphoid- articulates proximally with the radius
and has a prominent tubercle - lunate- articulates proximally with the radius
and is broader anteriorly than posteriorly - triquetrum- articulates proximally with the
articular disc of the distal radioulnar joint - pisiform- lies on the palmar surface of the
triquetrum
7Distal Row(lateral to medial)
- trapezium- 4 sided
- trapezoid- wedge shaped
- capitate- rounded head
- hamate- wedge shaped and has a hooked process,
the hook of the hamate
8Metacarpal Bones
- numbered I-V
- body and two ends
- proximal ends or bases
- distal ends or heads
9Metacarpal Bones
- bases of the metacarpals
- concave to articulate with the carpal bones
- heads of the metacarpals
- convex to articulate with the proximal phalanges
10Metacarpal Bones
- 1st metacarpal (thumb)
- thickest and shortest
- two sesamoid bones over the distal ends
-
- 3rd metacarpal
- distinguished by a styloid process on the lateral
side of its base
11Phalanges
- each digit has 3 phalanges, except the thumb (2)
- BASE (proximally)
- BODY (center)
- HEAD (distally)
12Distal Radioulnar Joint
- formed by the ulnar head and the ulnar notch of
the radius - allows 1 of freedom of movement
- pronation/supination
13Radiocarpal Joint
- Formed by the distal end of radius articulating
with the scaphoid lunate and the triangular
disk articulating with the lunate triquetrum - Provides 2 of freedom of movement
- flexion/extension
14Ligaments of Radiocarpal Joint
- Radial collateral ligament (RCL)
- origin- styloid process
- insertion- scaphoid trapezium
- limits ulnar deviation
15Ligaments of Radiocarpal Joint
- Ulnar collateral ligament (UCL)
- origin- ulnar styloid process
- insertion- triquetrum dorsally pisiform
palmarly - limits radial deviation
16Ligaments of Radiocarpal Joint
- Palmar (volar) radiocarpal ligament
- most important ligament for controlling motion
and wrist stability - origin- anterior surface of distal radius
- insertion- courses obliquely and medially to
split into the radiocapitate ligament, the
radiotriquetrum ligament, and the radioscaphoid
ligament.
17Ligaments of Radiocarpal Joint
- Dorsal radiocarpal ligament
- origin- posterior surface of the distal radius
styloid process - insertion- lunate triquetrum
- limits wrist flexion
18Intercarpal Joints
- Interconnecting the carpal bones by small palmar,
dorsal, and interosseous ligaments. - very little gliding occurs between the bones
19Midcarpal Joints
- The proximal and distal carpal rows are separated
by a single joint cavity with small fibrous
projections connecting the rows. - This structure allows limited movements
- flexion/extension
- radial/ulnar deviation and glide
20Carpometacarpal Joints
- The first three metacarpals articulate with a
single carpal - MC I- with the trapezium
- MC II- with the trapezoid
- MC III- with the capitate
- 4th and 5th articulate with the hamate to form
one of the carpometacarpal (CMC) joints
21Ligaments of Carpometacarpal Joint
- Bones are united by anterior carpometacarpal and
metacarpal ligaments as well as by the posterior
and interosseous ligaments.
22Transverse Carpal Ligament
- encloses the median nerve, FPL, FDP, and FDS on
the palmer surface of the hand.
23Metacarpophalangeal Interphalangeal Joints
- Metacarpophalangeal articulations are condyloid
joints with movement in two planes - flexion/extension adduction/abduction
- Interphalangeal articulations are hinge joints
with - flexion/extension only
24Ligaments of the MCP IP Joints
- Each fibrous capsule is strengthened by
-
- Two collateral ligaments
- pass distally from the
- heads of the MCP and
- phalanges to the bases of the phalanges
- limits amount of abduction/adduction
25Ligaments of MCP IP Joints
- Palmar ligament (plate)
- Reinforces the palmar aspect of the MCP joints
- Dorsally, the MCP joints are reinforced by the
extensor hood and the transverse metacarpal
ligament. - Limit abduction/adduction and reinforce the
palmar ligaments
26MUSCLES OF THE HAND
27Pronator Teres
- Proximal AttachmentMedial epicondyle of humerus
coronoid process of ulna - Distal Attachment Middle of lateral surface of
radius - Innervation Median nerve (C6-C7)
- Main Action Pronates flexes forearm
- (at elbow)
28Flexor Carpi Radialis
- Proximal Attachment Medial epicondyle of
humerus - Distal AttachmentBase of 2nd
- metacarpal bone
- InnervationMedian nerve (C6-C7)
- Main ActionFlexes abducts
- hand (at wrist)
29Palmaris Longus
- Proximal Attachment Medial epicondyle of
humerus - Distal Attachment Distal half of flexor
retinaculum palmar aponeurosis - InnervationMedian nerve (C7-C8)
- Main ActionFlexes hand (at wrist)
- tightens palmar aponeurosis
30Flexor Carpis Ulnaris
- Proximal Attachment Humeral head medial
epicondyle of humerus Ulnar head olecranon
posterior border of ulna - Distal AttachmentPisiform bone, hook of hamate
bone, 5th metacarpal bone - InnervationUlnar nerve (C7-C8)
- Main ActionFlexes adducts hand
- (at wrist)
31Flexor Digitorum Superficialis
- Proximal Attachment Humeroulnar head med.
epicondyle of humerus, ulnar collateral lig.
coronoid process of ulna - Radial Head superior 1/2 of ant. border of
radius - Distal Attachment Bodies of middle phalanges of
medial four digits - Innervation Median nerve (C7, C8, T1)
32Continued Flexor Digitorum Superficialis
- Main ActionFlexes middle phalanges at proximal
interphalangeal joints - of medial 4 digitsacting more
- strongly, it also flexes proximal
- phalanges at metacarpo-
- phalangeal joints hand
33Flexor Digitorum Profundus
- Proximal Attachment Proximal 3/4 of medial
anterior surfaces of ulna interosseous membrane - Distal Attachment Bases of distal phalanges of
medial four digits - Innervation
- Medial part Ulnar nerve (C8 T1)
- Lateral part Median nerve (C8 T1)
34Cont Flexor Digitorum Profundus
- Main Action Flexes distal phalanges at distal
interphalangeal joints of medial four digits
assists with flexion of hand
35Flexor Pollicus Longus
- Proximal Attachment Ant. Surface of radius
adjacent interosseus membrane - Distal Attachment Base of distal
- phalanx of thumb
- InnervationAnterior interosseus
- nerve from median (C8 T1)
- Main ActionFlexes phalanges
- of 1st digit (thumb)
36MUSCLES OF THE THUMB
37Pronator Quadratus
- Proximal Attachment Distal 4th of anterior
surface of ulna - Distal Attachment Distal 4th of anterior
surface of radius - InnervationAnterior interosseus nerve from
median (C8 T1) - Main ActionPronates forearm deep fibers bind
radius ulna together
38Brachioradialis
- Proximal Attachment Proximal 2/3 of lateral
supracondylar ridge of humerus - Distal AttachmentLateral surface of distal end
of radius - InnervationRadial nerve (C5, C6,and C7)
- Main Action Flexes forearm
39Extensor Carpi Radialis Longus
- Proximal Attachment lateral suprocondylar ridge
of humerus - Distal AttachmentBase of 2nd
- metacarpal
- InnervationRadial nerve
- (C6 C7)
- Main ActionExtend abduct hand at wrist
40Extensor Carpi Radialis Brevis
- Proximal Attachment lateral epicondyle of
humerus - Distal AttachmentBase of 3rd metacarpal
- InnervationDeep branch of radial nerve (C7 C8)
- Main ActionExtend abduct hand at wrist
41Extensor Digitorum
- Proximal Attachment lateral epicondyle of
humerus - Distal AttachmentExtensor expansion of medial 4
digits - InnervationPosterior interosseous nerve(C7 C8),
the continuation of deep branch of radial nerve - Main ActionExtends medial 4 digits at
- metacarpophalangeal joints extends hand at
wrist joint
42EXTENSOR DIGITORUM
43Extensor Digiti Minimi
- Proximal Attachmentlateral epicondyle of humerus
- Distal AttachmentExtensor expansion of 5th digit
- InnervationPosterior interosseous nerve (C7
C8), the continuation of deep branch of radial
nerve - Main ActionExtends 5th digit at
metacarpo-phalangeal interphalangeal joints
44Extensor Carpi Ulnaris
- Proximal Attachment lateral epicondyle of
humerus and posterior border of ulna - Distal AttachmentBase of 5th metacarpal
- InnervationPosterior interosseous nerve(C7 C8),
the continuation - of deep branch of radial nerve
- Main ActionExtends and adducts
- hand at wrist joint
45Supinator
- Proximal Attachment Lateral epicondyle of
humerus, radial collateral anular ligaments,
supinator fossa, crest of ulna - Distal AttachmentLateral, posterior, anterior
surfacesof proximal 1/3 of radius - InnervationDeep branch of radial nerve (C5 C6)
- Main ActionSupinates forearm (rotates radius to
turn palm anteriorly)
46Abductor PollicusLongus
- Proximal Attachment Posterior surfaces of ulna,
radius, interosseus membrane - Distal AttachmentBase of 1st metacarpal
- InnervationPosterior interosseous nerve (C7
C8) the continuation of Deep branch of radial - Main ActionAbducts thumb extends it at
carpometacarpal joint
47Extensor Pollicus Brevis
- Proximal Attachment Posterior surface of radius
interosseous membrane - Distal AttachmentBase of proximal phalanx of
thumb - InnervationPosterior interosseous nerve (C7
C8) the continuation of Deep branch of radial - Main ActionExtends proximal phalanx of thumb at
carpometacarpal joint
48 Extensor Digitorum Longus
49Extensor Pollicus Longus
- Proximal Attachment Posterior surface of middle
1/3 of ulna interosseous membrane - Distal AttachmentBase of distal phalanx of thumb
- InnervationPosterior interosseous nerve (C7
C8) the continuation of Deep branch of radial - Main ActionExtends distal phalanx of thumb at
metacarpophalangeal interphalangeal joints
50Extensor Indicis
- Proximal Attachment Posterior surface of ulna
interosseus membrane - Distal AttachmentExtensor expansion of 2nd digit
- InnervationPost. interosseous nerve (C7 C8)the
continuation of deep branch of radial - Main ActionExtends 2nd digit help
- to extend hand
51THENAR MUSCLES
- Abductor Pollicus Brevis
- Flexor Pollicus Brevis
- Opponens Pollicis
52Abductor Pollicus Brevis
- Proximal Attachment Flexor retinaculum
tubercles of scaphoid trapezium - Distal AttachmentLateral side of base of
proximal phalanx of thumb - InnervationRecurrent branch of median nerve
(C8T1) - Main ActionAbd. Thumb helps oppose it
53Flexor Pollicus Brevis
- Proximal Attachment Flexor retinaculum
tubercles of scaphoid trapezium - Distal AttachmentLateral
- side of base of proximal
- phalanx of thumb
- InnervationRecurrent branch
- of median nerve (C8T1)
- Main ActionFlexes thumb
54Opponens Pollicis
- Proximal Attachment Flexor retinaculum
tubercles of scaphoid trapezium - Distal AttachmentLateral side of 1st metacarpal
- InnervationRecurrent branch of median nerve (C8
T1) - Main ActionDraws 1st metacarpal bone
- laterally to oppose thumb toward center of palm
rotates it medially
55Adductor Pollicus
- Proximal Attachment Oblique head bases of 2-3
metacarpals, capitate, adjacent carpals - Transverse head anteroir surface of body of 3rd
metacarpal - Distal AttachmentMedial side of base of proximal
phalanx of thumb - InnervationDeep branch of ulnar (C8 T1)
- Main ActionAdducts thumb toward middle
- digit
56ADDUCTOR POLLICUS
57HYPOTHENAR MUSCLES
- Abductor digiti minimi
- Flexor digiti minimi brevis
- Opponens digiti minimi
58Abductor Digiti Minimi
- Proximal Attachment Pisiform
- Distal AttachmentMedial side of base of proximal
phalanx of little finger - InnervationDeep branch of
- ulnar (C8 T1)
- Main Action Abducts digit 5
59Flex. Digiti Minimi Brevis
- Proximal Attachment Hook of hamate flex.
Retinaculum - Distal AttachmentMedial side of base of proximal
phalanx of little finger - InnervationDeep branch of ulnar (C8 T1)
- Main ActionFlexes proximal phalanx of
- digit 5
60Opponens Digiti Minimi
- Proximal Attachment Hook of hamate flex.
retinaculum - Distal AttachmentMedial border of 5th metacarpal
- InnervationDeep branch of ulnar (C8 T1)
- Main ActionDraws 5th metacarpal anteriorly
rotates it, bringing digit 5 into opposition with
thumb
61SHORT MUSCLES
- Lumbricals 1 2
- Lumbricals 3 4
- Dorsal interossei 1-4
- Palmar interossei
62Lumbricals 1 2
- Proximal Attachment Lateral 2 tendons of flexor
digitorum profundus (unipennate muscles) - Distal AttachmentLateral sides of extensor
expansions of 2-5 - Innervation Deep branch of ulnar nerve (C8 T1)
- Main ActionFlex digits at metacarpo-phalangeal
joints extend interphanalgeal joints
63Lumbricals 3 4
- Proximal Attachment Medial 3 tendons of flexor
digitorum profundus (bipennate muscles) - Distal AttachmentLateral sides of extensor
- expansions of 2-5
- InnervationDeep branch of ulnar nerve (C8 T1)
- Main ActionFlex digits at metacarpo-phalangeal
joints extend interphanalgeal joints
64Dorsal Interossei 1-4
- Proximal Attachment Adjacent sides of 2
metacarpals (bipennate muscles) - Distal AttachmentExtensor expansions bases of
proximal phalanges of digits 2-4 - Innervation Deep branch of ulnar nerve (C8 T1)
- Main ActionAbducts digits from axial line act
with lumbricals to flex metacarpophalangeal
joints and extend interphalangeal joints
65Palmar Interossei
- Proximal Attachment Palmar surfaces of 2nd,
4th, 5th metacarpals (unipennate muscles) - Distal AttachmentExtensor expansion of digits
bases of proximal phalanges of digits 2, 4, 5 - InnervationDeep branch of ulnar nerve (C8 T1)
66Cont Palmar Interossei
- Main ActionAdducts digits toward axial line
assists lumbricals in flexing metacarpophalangeal
joints extending interphalangeal joints
67INTEROSSEI
68Common Injuries of the Wrist and Hand
69Bony Injuries
70Wrist Fractures
- Acute onset
- Tensile, compressive, or shear forces
- Usually hyperextension mechanism
- Deformity of the long bones may be felt or seen
- Swelling occurs rapidly
- ROM testing is not applicable
- Radial and ulnar pulses should be located
- Colles Fx
- dorsal displacement
- (silver fork deformity)
- Smiths Fx
- palmar displacement
71Metacarpal Fractures
- Acute onset
- Compressive or shear forces
- Pain, swelling, pt. tenderness along shaft
- Deformity may be present
- ex. Boxers Fx 4th or 5th metacarpal fx
results in shortening
of the knuckle - ROM may be limited due to pain
- Positive long bone compression test
72Metacarpal Fractures (cont.)
- Bennets Fx
- 1st metacarpal
- Shear force
- Crepitus present around joint
- False joint motion may be present
- Distal fx will be displaced due to pull of
adductor pollicus longus
73Scaphoid Fractures
- Acute onset from a crushing mechanism
- Pain, swelling, pt. tenderness present in the
anatomical snuff box - APROM painful with ext. and ulnar dev.
- Grip strength may be reduced
- If suspected, should be treated as such until
ruled out by a physician - Radiograph images may not reveal the injury for
several weeks
74Lunate Dislocations
- Acute onset
- Forced hyperextension mechanism
- Pain present in lateral wrist and hand
- ROM in all planes limited due to pain
- Deformity may be seen due to displacement on the
palmar or dorsal aspect of the hand
75 Ligamentous Injury
76Wrist Sprains
- Acute onset
- Tensile force usually from hyperextension or
hyperflexion mechanism - Pain, swelling, and pt. tenderness along joint
line consistent with degree of injury
- APROM limited as ligament is placed on a stretch
- 3rd degree may reveal joint instabilities
- Conclusion of a sprain often based on exclusion
of other wrist injuries
77UCL Sprain of the ThumbGamekeepers Thumb
- Acute onset due to a combination of
hyperextension and abduction - Chronic onset due to repetitive motions of
flexion and adduction - Pain and pt. tenderness present over ulnar border
of the joint - Swelling localized over the thenar eminence
- PROM reveals pain with ext. and abd.
- ARROM reveal pain with flex. and add.
- Positive valgus stress test of the thumb
78Collateral Ligament Sprains of the Fingers
- Acute onset
- jamming mechanism
- Can occur at MCP, PIP, or DIP joints
- Pain, swelling, pt. tenderness present over
affected joint - ROM reduced due to pain and swelling
- Positive varus or valgus stress test of the
affected joint - Instability of joint consistent with degree of
sprain
79Muscular Injuries
80Trigger Finger
- Chronic onset
- From repetitive trauma to flex. tendon sheath
- Thickening of the tendon results in a catching or
snapping as it passes through the sheath during
flexion
- Sheath becomes more stenotic as condition
continues and finger may require assistance to
return to extension - Signs and symptoms of tenosynovitis present
- Usually seen in 3rd 4th digits
81Flexor Tendon AvulsionJersey Finger
- Acute onset
- From sudden forced extension
- Affects the flexor digitorum profundus
- Immediate pain, swelling, and pt. tenderness
exist on distal palmar phalanx - Complete rupture will reveal inability to flex
the DIP joint - Incomplete rupture will reveal weakness with
flexion of the DIP joint
82Extensor Tendon AvulsionMallet Finger
- Acute onset
- From sudden forced flexion of the distal extensor
tendon - Immediate pain, swelling, and pt. tenderness on
the distal dorsal phalanx - Complete rupture will reveal inability to extend
the DIP joint - Bony avulsion often occurs but surgery
intervention can be prevented if splinted early
83Extensor Tendon RuptureBoutonneire Deformity
- Acute onset
- From forced flexion of the PIP joint
- Pain, swelling, and pt. tenderness present at the
PIP joint and the tendons insertion - Disruption leads to central slip of the tendons
lateral bands causing permanet ext. of DIP joint
and flex, of the PIP joint
84Volar Plate Rupture
- Acute onset
- From forced hyperextension of the PIP joint
- Pain, swelling, and pt. tenderness present over
palmar aspect thumb
- Swan Neck Deformity- disruption of distal
attachment causing permanent hyperextension - Pseudoboutenniere Deformity-
- disruption of proximal attachment causing a
flexion contracture
85De Quervains Syndrome
- Chronic onset
- From repetitive stress involving ulnar dev.
- Pain and swelling present over the radial styloid
process, thenar eminence, extensor pollicus
brevis, and abductor pollicus longus
86De Quervains Syndrome (cont.)
- AROM painful with radial ulnar deviation of the
wrist as well as flexion adduction of the thumb - PROM painful with ulnar deviation of the wrist as
well as flexion adduction of the thumb - RROM painful with radial deviation of the wrist
as well as extension abduction of the thumb - Positive Finkelsteins test
87Other Injuries
88Injury to the Triangular Fibrocartilage
- Acute onset
- From forced hyperextension creating a compressive
force - No swelling is immediately present but pain and
pt. tenderness appear along the medial half of
the wrist distal to the ulna - APROM limited in extension
- Easily confused with UCL sprain or the wrist but
symptoms of fibrocartilage injury will persist
longer than would a sprain
89Carpal Tunnel Syndrome
- Chronic onset
- From repetitive flexion and extension of the
wrist - Parasthesia and pain run along the wrist, hand,
and fingers following the distribution of the
median nerve
- AROM may be limited due to stiffness
- PROM may increase symptoms with full flexion and
extension - RROM reveals decreased strength of abd. pollicus
brevis - Positive Tinels sign
- Positive Phalens test
90Synovial CystWrist Ganglion
- Chronic onset
- Occurs following a sprain or strain
- Due to a weakened synovial sheath allowing fluid
to escape
- Observable mass present
- May or may not be painful and limit ROM (usually
depends on location in wrist)
91References
- http//www.e-hand.com
- http//www.gwc.maricopa.edu/class/bio201/muscle/mu
stut - http//www.linkpublishing.com/tableofcontents1.htm
Exercise13 - http//www.meddean.luc.edu/lumen/MedEd/GrossAnatom
y/GA.html - http//vh.org/Providers/Testbooks/AnatomicVariants
/Images/0036.html - Moore, K. and Dalley, A. Clinically Oriented
Anatomy, 4th Ed, 1999. Lippincott Williams
Wilkins Philadelphia.