Wrist Hand and Fingers

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Wrist Hand and Fingers

• Dr. S. Nishan Silva
• (MBBS)

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Surface Anatomy of Upper Limb

• Carpal Tunnel
• Carpals concave anteriorly
• Carpal ligament covers it
• Contains long tendons, Median nerve
• Inflammation of tendons compression of Median
  nerve
• Anatomical Snuffbox
• Lateral E.pollicis brevis
• Medial E. pollicis longus
• Floor scaphoid, styloid of radius
• Contains Radial Artery (pulse)

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Bones of the Wrist
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Bones of the Wrist
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Ligaments of Wrist (dorsal)
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Triangular FibrocartilageLigament(TFCC)extend
s from ulnar side of distal radius attaches to
ulna _at_ base of ulnar styloid processdisc
provides stability to wristmajor stabilizer of
distal radioulnar joint
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Tendons of Wrist (dorsal)
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Wrist (dorsal)
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(dorsal)
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Hand Anatomy

• Flexor digitorum superficialis (FDS) insert into
  middle phalanx.
• Flexor digitorum profundus (FDP) runs deep to the
  FDS until the level of the MP joint where FDS
  bifurcates.
• FDP inserts at the base of the distal phalanx and
  acts primarily to flex the DIP joint as well as
  all other joints flexed by FDS. (Figure 268-5).

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Ligaments of Wrist (palmar)
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Flexor retinaculum

• It is attached, medially, to the pisiform and
  the hamulus of the hamate bone laterally, to the
  tubercle of the scaphoid, and to the medial part
  of the volar surface and the ridge of
  the trapezium.

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Tendons of Wrist (palmar)
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(palmar)
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(palmar)
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(palmar)
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Bones of the Hand
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Bones of the Hand
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Carpal Tunnel
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Joints of the Upper Extremity

• Radiocarpal joint
• Synovial-condyloid
• Distal radius with proximal row of carpals
• Intercarpal joints
• Synovial-plane
• Carpal-metacarpal (2-5)
• Synovial-plane
• Trapezium-metacarpal 1
• Synovial-saddle
• Metacarpal-phalangeal
• Synovial-condyloid
• Interphalangeal
• Synovial-hinge
• ALL DIARTHROSES

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Carpal Tunnel
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Anatomy Review

• Muscles Tendons
• Extrinsic
• Flexor tendons
• Flexor carpi ulnaris
• Flexor carpi radialis
• Palmaris longus
• Flexor pollicis longus (FPL)
• Flexor digitorum profundis (FDP)
• Flexor digitorum superficialis (FDS)

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Anatomy Review

• Muscles Tendons
• Extrinsic
• Extensor tendons
• Abductor pollicis longus
• Extensor pollicis brevis
• Extensor carpi radialis longus and brevis
• Extensor digitorum
• Extensor digiti minimi
• Extensor carpi ulnaris

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HAND FINGER ANATOMY

• 9 Finger Flexors
• Median nerve
• Transverse carpal ligament
• 5 deep flexors pass through superficialis tendons
  and insert on distal phalanx of each finger and
  thumb
• 4 superficial flexors insert on middle phalanx of
  digits 2-5
• Annular ligaments pulleys (A1-A5)
• PREVENT BOWSTRINGING

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Extrinsic Hand Muscles
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Extensor Indicis

• O
• Dorsal surface lower ½ body of ulna
• Interosseus membrane
• I
• Ulnar side of index finger
• N
• Radial (posterior interosseus)
• F
• MCP and IP Ext of 2nd digit

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Extensor Pollicis Longus

• O
• Posterior 1/3 ulna
• Interosseus membrane
• I
• Posterior surface of base of thumb distal phalanx
• N
• Radial (posterior interosseus)
• F
• CMC, MCP and IP Ext of 1st digit

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Extensor Pollicis Brevis

• O
• Dorsal 2/3 of radius
• I
• Dorsal surface of base of proximal 1st phalanx
• N
• Radial (posterior interosseus)
• F
• CMC MCP Ext of thumb
• CMC ABD of thumb

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Abductor Pollicis Longus

• O
• Posterior distal 2/3 of ulna
• Posterior middle 1/3 of radius
• Interosseus membrane
• I
• Radial side of base of 1st metacarpal
• N
• Radial (posterior interosseus)
• F
• CMC ABD Ext of thumb

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Flexor Pollicis Longus

• O
• Anterior middle ½ of radius
• Interosseus membrane
• I
• Palmar surface of base of distal 1st phalanx
• N
• Median (anterior interosseus)
• F
• IP Flexion of thumb

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Extensor Digiti Minimi

• O
• Lateral epicondyle of humerus
• I
• Extensor expansion of 5th digit
• N
• Radial (posteior interosseus)
• F
• MCP and IP extension of 5th digit

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Flexor Digitorum Superficialis

• O
• Medial epicondyle of humerus
• Middle ½ anterior radius
• I
• Four tendons separating into two parts that
  insert into sides of bases of middle 2-5
  phalanxes
• N
• Median
• F
• MCP flexion digits 2-5
• PIP flexion digits 2-5

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Flexor Digitorum Profundus

• O
• Anteriomedial surface of ulna
• Interosseus membrane
• I
• Four tendons inserting into distal phalanges of
  digits 2-5
• N
• Median 2-3 digits
• Ulna 4-5 digits
• F
• DIP flexion of 2-5 digits

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Intrinsic Hand Muscles

• Thenar Eminance

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Abductor Pollicis Brevis

• O
• Scaphoid tuberosity
• Trapezium ridge
• Transverse carpal ligament
• I
• Lateral base of proximal 1st phalanx
• N
• Median
• F
• CMC MCP ABD of thumb

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Flexor Pollicis Brevis

• O
• Superficial head trapezium
• Deep head trapezoid, capitate and palmar
  ligaments of distal carpal bones
• I
• Base of prximal 1st phalanx on radial side
• Extensor expansion
• N
• Superficial median
• Deep Ulnar
• F
• CMC MCP Flexion of thumb

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Opponens Pollicis

• O
• Trapezium
• Transverse Carpal Ligament
• I
• Radial side of 1st metacarpal shaft
• N
• Median
• F
• Opposition

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Intrinsic Hand Muscles

• Hypothenar Eminence

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Abductor Digiti Minimi

• O
• Pisiform
• I
• Ulnar side base of 5th proximal phalanx
• N
• Ulnar
• F
• MCP ABD of 5th digit

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Opponen Digiti Minimi

• O
• Hook of hamate
• Transverse carpal ligament
• I
• Ulnar border of entire 5th metacarpal bone
• N
• Ulnar
• F
• MCP flexion rotation of 5th digit

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Flexor Digiti Minimi

• O
• Hamate bone
• Transverse carpal ligament
• I
• Ulnar side of proximal 5th phalanx
• N
• Ulnar
• F
• MCP Flexion of 5th digit

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Other Intrinsic Hand Muscles
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Adductor Pollicis

• O
• Oblique Head
• Capitate bone
• Bases of 2-3 metacarpals
• Transverse Head
• Proximal 2/3 of palmar surface of 3rd metacarpal
• I
• Ulnar side of base of 1st proximal phalanx
• N
• Ulnar
• F
• CMC ADD of thumb

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Palmar Interossei

• O
• 1st ulnar side base of 1st metacarpal bone
• 2nd ulnar side of 2nd MC bone
• 3rd radial side of 4th MC bone
• 4th radia side of 5th MC bone
• I
• Extensor expansion of 2,4 and 5th digits
• N
• Ulnar
• F
• ADD of 1st, 2nd, 4th and 5th digits toward
  midline of hand

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Dorsal Interossei

• O
• 1st lateral head ulnar side of 1st metacarpal
  bone
• 1st medial head radial side of 2nd metacarpal
  bone
• 2nd, 3rd, 4th space between metacarpal bones
• I
• 1st radial side 2nd proximal phalanx
• 2nd radial side of 3rd
• 3rd ilnar side of 3rd
• 4th ulnar side of 4th
• N
• Ulnar
• F
• ABD of 2nd, 3rd, and 5th finger from midline

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Lumbricales

• O
• Tendons of FDP
• I
• Extensor expansion on dorsal aspect of each
  digits radial side
• N
• 1 and 2 median
• 3 and 4 ulnar
• F
• MCP flexion 2-5 digits
• DIP PIP ext 2-5 digits

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Palmaris Brevis

• O
• Flexor retinaculum
• I
• Palmar surface skin on ulnar side of hand
• N
• Ulnar
• F
• Wrinkles skin of hand on ulnar side

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Intrinsic Muscles of Hand
pg 297
Palmar Interossei
Lumbricals
Dorsal Interossei
3rd
ABduction
ADDuction
2nd
4th
1st
Interossei help the lumbricals to extend IP
joints and flex MC-P joints
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Movements
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Joints

• Wrist joint
• 70 to 90 degrees of flexion
• 65 to 85 degrees of extension
• 15 to 25 degrees of abduction
• 25 to 40 degrees of adduction

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Joints

• Each finger has 3 joints
• Metacarpophalangeal (MCP) joints
• Proximal interphalangeal (PIP) joints
• Distal interphalangeal (DIP) joints

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Joints

• Thumb has 2 joints
• Metacarpophalangeal (MCP) joint
• Full extension into 40 to 90 degrees of flexion

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Joints

• Thumb has 2 joints
• Interphalangeal (IP) joint
• Flex 80 to 90 degrees

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Joints

• Thumb has 2 joints
• Carpometacarpal (CMC) joint of thumb
• Unique saddle-type joint
• 50 to 70 degrees of abduction
• Flex 15 to 45 degrees extend 0 to 20 degrees

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ThumbMovements
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Movements

• Wrist
• Flexion extension
• Abduction adduction
• Fingers
• Flex extend
• MCP joints also abduct adduct

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Movements

• Opposition
• movement of thumb across palmar aspect to oppose
  any or all of the phalanges
• Reposition
• movement of thumb as it returns to anatomical
  position from opposition with hand and/or fingers

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Anatomy Review

• Muscles Tendons
• Extrinsic
• Extension of MP
• Flex of IP
• Intrinsic
• Abduct and adduct fingers
• Flexion of MP
• Extension of IP

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Hand Grips

• Grasps
• Power grip is when an object needs to be held
  forcefully and then moved by more proximal
  muscles.
• Precision Grip is when an object is manipulated
  with fingers

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Hand Grips

• Power grips
• Cylindrical grip is fingers flexed around an
  object. Thumb on one side fingers on other, like
  gripping a hammer or racquet.
• Spherical grip is fingers and thumb are together
  around an
• object. Like grabbing
• an apple or doorknob.

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Hand Grips

• Power Grip
• Hook grip involves the second through fifth
  fingers flexed around an object in a hooklike
  manner. Thumb is extended and not involved at
  all. Only possible grip for
• someone with no thumb or
• median nerve ability.

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Hand Grips

• Precision Grips-
• Pad to pad
• Pinch grip is the thumb and one finger gripping
• Three jaw chuck is holding a pencil, three
  fingers and thumb.

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Hand Grips

• Precision Grips
• Tip to Tip grip
• Pincer grip is tip of thumb against tip of a
  finger, like to pick up a coin. Difficult with
  long fingernails

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Hand Grips

• Precision Grips
• Lumbrical grip or plate grip has the MCP and PIP
  joint flexed and the DIP extended. The thumb
  opposes and this grip is used to hold something
  horizontal like a plate. Lumbricals is used they
  flex the MCP joint.

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Nerve Innervation (dorsal)
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Nerve Innervation (palmar)
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Intrinsic Muscles of Hand
Muscle
Nerve

• Pinky (little finger)
• All digiti minimi Ulnar (Flexor, Abductor,
  Opponens)
• Thumb
• Abductor pollicis brevis Median
• Flexor pollicis brevis Median
• Opponens pollicis Median
• Adductor pollicis Ulnar
• Other Intrinsic Muscles
• Palmar Dorsal Interossei Ulnar
• Lumbricals Median, Ulnar

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Hand Anatomy

• Blood supply (BS)
• Hand and digits has dual (BS) with contributions
  from the radial and ulnar arteries.

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Hand Anatomy

• Blood supply (BS)
• Proximal portions of the hand (BS) come from the
  deep and superficial arches on the palmar and
  dorsal side.
• BS of the fingers is distributed by the digital
  arteries that arises from the superficial palmer
  arch.

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Hand Anatomy - Blood supply
The Allen's test.
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Digital Allen Test (arterial compromise)

• The examiner instructs pt. to rapidly open and
  close the hand 15 times
• As soon as the athlete finishes the final
  repetition, the examiner places his or her thumb
  over the pts radial artery and index finger over
  the pts ulnar artery
• If pts hand remains cyanotic until after the
  examiner removes the pressure, then the test is
  positive for poor, impaired, and/or depressed
  perfusion (circulation) through the distal
  extremities

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Brachial Plexus innervation
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Innervation by Posterior Cord

• Radial Nerve (largest branch)
• Course Through arm, around humerus, around
  lateral epicondyle, then divides
• Innervates all posterior muscles of arm and
  forearm
• Triceps brachii, anconeus, supinator,
  brachioradialis
• Divides in forearm
• Superficial skin of arm and dorsolateral
  surface of hand
• Deep extensor muscles of forearm (eg E. carpi
  radialis L B)
• Damage to Radial Nerve wristdrop
• Inability to extend the hand, st inability to
  fully extend forearm

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Innervation by Posterior Cord (continued)

• Axillary Nerve (runs w/ caudal humeral circumflex
  a.)
• Innervates
• Deltoid and Teres minor (motor inn)
• Capsule of shoulder, skin of shoulder (sensory
  inn)
• Subscapular Nerve branches of C5 C6 rami
• Innervates Subscapularis, Teres major
• Thoracodorsal Nerve (runs w/thoracodorsal av)
• Innervates Latissimus dorsi

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Innervation by Lateral Cord

• Musculocutaneous
• Course branches to arm, distal to elbow becomes
  cutaneous for lateral forearm skin
• Innervates
• Biceps brachii, brachialis, coracobrachialis
  (motor inn)
• Skin distal to elbow (sensory)
• Suprascapular (runs w/suprascapular av) C5, C6
• Innervates Supraspinatus, Infraspinatus

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Innervation by both Lateral and Medial Cords

• Median
• Course middle of brachial plexus, does not
  branch in arm, distal to elbow provides many
  branches to most forearm flexors, passes through
  carpal tunnel to hand to lateral palmar
  intrinsics
• Innervates most muscles of anterior forearm
  (motor inn)
• (eg) most flexors, some intrinsics (thumb)
• Innervates skin of lateral 2/3 hand on palm
  side, dorsum of fingers 23 (sensory inn)
• Nerve Damage Ape Hand
• Inability to Oppose Thumb

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Clinicals
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Wrist drop - Radial
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Ulnar claw hand
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Testing Ulna nerve
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Median Claw Hand
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Carpal Tunnel Syndrome

• Entrapment of the median nerve
• Phalens and Tinels Test
• 2 point discrimination
• Symptoms
• Aching in hand and arm
• Nocturnal or AM paresthesias
• Shaking to obtain relief

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Carpal tunnel Syndrome
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Carpal tunnel Syndrome
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Colles Fracture

• Most common fracture in Osteoporotic bones
• Extra-Articular 1 inch of distal Radius
• Results from a fall on dorsi flexed wrist
• Typical deformity Dinner Fork
• Deformity is Impaction, dorsal displacement
  and angulation, radial displacement and
  angulation and avulsion of ulnar styloid process
• Management is usually conservative MUA and
  forearm POP

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Colles Fracture
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Scaphoid Fractures

• tenuous blood supply
• high incidence of avascular necrosis in waist and
  proximal fractures
• often require bone grafting

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Scaphoid Fracture Pathoanatomy

• Blood supplied from distal pole
• In children, 87 involve distal pole
• In adults, 80 involve waist

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Scaphoid Bone Fractures Treatment by compression
Screw Fixation
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Trigger Finger

• Stenosing flexor tenosynovitis
• Painful snap or lock
• Palpate nodule as digit flexed and extended

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Boutonniere Deformity

• Tear or stretch of the central extensor tendon at
  PIP
• Note unopposed flexion at PIP
• Extension at DIP
• Trauma or inflammatory arthritis

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Swan Neck Deformity

• Contraction of intrinsic muscles (trauma, RA)
• NOTE Extension at PIP

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Mallet Finger

• Hyperflexion injury
• Ruptured terminal extensor mechanism at DIP
• Incomplete extension of DIP joint or extensor lag
• Treatment
• stack splint

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Dorsal Muscle Wasting
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Dorsal Muscle Wasting
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Rheumatoid arthritis
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Rheumatoid arthritis
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Summary
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Muscles that move the arm (humerus) Pectoralis
major Flexes, adducts and rotates arm
medially. Latissimus dorsi Extends,
adducts, and rotates arm medially draws arm
downward and backward. Deltoid
Abducts, flexes, extends, and medially and
laterally rotates arm. Subscapularis
Rotates arm medially. Supraspinatus
Assists deltoid muscle in abducting
arm. Infraspinatus Rotates arm
laterally adducts arm. Teres major
Extends arm assists in adduction and medial
rotation of arm. Teres minor
Rotates arm laterally extends and adducts
arm. Coracobrachialis Flexes and adducts
arm.
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Muscles that move the forearm (radius and
ulna) Biceps brachii Flexes and
supinates forearm flexes arm. Brachialis
Flexes forearm. Brachioradialis
Flexes forearm semisupinates and semipronates
forearm. Triceps brachii Extends
forearm extends arm. Anconeus
Extends forearm. Pronator teres
Pronates forearm and hand and flexes
forearm. Pronator quadratus Pronates forearm
and hand. Supinator Supinates
forearm and hand.
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Muscles that move the wrist, hand, and
fingers Flexor carpi radialis
Flexes and abducts wrist. Palmaris longus
Flexes wrist. Flexor carpi
ulnaris Flexes and adducts
wrist. Flexor digitorum superficialis Flexes
middle phalanges of each
finger. Flexor
digitorum profundus Flexes distal phalanges
of each
finger. Flexor pollicis longus
Flexes thumb. Extensor carpi
radialis longus Extends and abducts
wrist. Extensor carpi radialis brevis Extends
and abducts wrist. Extensor digitorum
Extends phalanges. Extensor digiti minimi
Extends little finger. Extensor
carpi ulnaris Extends and adducts
wrist. Abductor pollicis longus
Extends thumb abducts wrist. Extensor pollicis
brevis Extends thumb abducts
wrist. Extensor indicis
Extends index finger.
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Muscles that move the fingers
Abductor pollicis brevis Abducts thumb.
Flexor pollicis brevis Flexes and
adducts thumb. Opponens pollicis
Draws thumb across palm to meet little finger

(opposition). Adductor pollicis
Adducts thumb. Abductor digiti minimi
Abducts little finger. Flexor digiti
minimi Flexes little finger.
Opponens digiti minimi Draws little
finger across palm to meet thumb. Lumbricals
Extends interphalangeal
joints and flexes
metacarpophalangeal
joints. Dorsal interossei
Abducts fingers from middle finger flexes

metacarpophalangeal joints and extends

interphalangeal joints. Palmar interossei
Adducts fingers toward middle finger
flexes
metacarpophalangeal joints and
extends
interphalangeal joints.
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