Hand and Wrist

1
Hand and Wrist

• KSPE 4650
• Leeann Hinton
• Anna Thames
• Joey Thomas

2
Bony Anatomy

• distal radius and ulna
• 8 carpal bones
• 5 metacarpals
• 14 phalanges

3
Bony Anatomy

• Distal radius-
• broadens to form a small ulnar notch on its
  medial surface
• Radial styloid process-
• projects off the anterolateral border

4
Bony Anatomy

• Ulnar head-
• more circular, with the ulnar styloid process
  arising from the medial surface

5
Carpal Bones

• Aligned in two rows
• Proximal row
• Distal row

6
Proximal 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

7
Distal 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

8
Metacarpal Bones

• numbered I-V
• body and two ends
• proximal ends or bases
• distal ends or heads

9
Metacarpal Bones

• bases of the metacarpals
• concave to articulate with the carpal bones
• heads of the metacarpals
• convex to articulate with the proximal phalanges

10
Metacarpal 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

11
Phalanges

• each digit has 3 phalanges, except the thumb (2)
• BASE (proximally)
• BODY (center)
• HEAD (distally)

12
Distal Radioulnar Joint

• formed by the ulnar head and the ulnar notch of
  the radius
• allows 1 of freedom of movement
• pronation/supination

13
Radiocarpal 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

14
Ligaments of Radiocarpal Joint

• Radial collateral ligament (RCL)
• origin- styloid process
• insertion- scaphoid trapezium
• limits ulnar deviation

15
Ligaments of Radiocarpal Joint

• Ulnar collateral ligament (UCL)
• origin- ulnar styloid process
• insertion- triquetrum dorsally pisiform
  palmarly
• limits radial deviation

16
Ligaments 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.

17
Ligaments of Radiocarpal Joint

• Dorsal radiocarpal ligament
• origin- posterior surface of the distal radius
  styloid process
• insertion- lunate triquetrum
• limits wrist flexion

18
Intercarpal Joints

• Interconnecting the carpal bones by small palmar,
  dorsal, and interosseous ligaments.
• very little gliding occurs between the bones

19
Midcarpal 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

20
Carpometacarpal 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

21
Ligaments of Carpometacarpal Joint

• Bones are united by anterior carpometacarpal and
  metacarpal ligaments as well as by the posterior
  and interosseous ligaments.

22
Transverse Carpal Ligament

• encloses the median nerve, FPL, FDP, and FDS on
  the palmer surface of the hand.

23
Metacarpophalangeal 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

24
Ligaments 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

25
Ligaments 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

26
MUSCLES OF THE HAND
27
Pronator 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)

28
Flexor Carpi Radialis

• Proximal Attachment Medial epicondyle of
  humerus
• Distal AttachmentBase of 2nd
• metacarpal bone
• InnervationMedian nerve (C6-C7)
• Main ActionFlexes abducts
• hand (at wrist)

29
Palmaris 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

30
Flexor 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)

31
Flexor 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)

32
Continued 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

33
Flexor 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)

34
Cont Flexor Digitorum Profundus

• Main Action Flexes distal phalanges at distal
  interphalangeal joints of medial four digits
  assists with flexion of hand

35
Flexor 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)

36
MUSCLES OF THE THUMB
37
Pronator 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

38
Brachioradialis

• 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

39
Extensor 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

40
Extensor 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

41
Extensor 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

42
EXTENSOR DIGITORUM
43
Extensor 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

44
Extensor 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

45
Supinator

• 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)

46
Abductor 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

47
Extensor 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
49
Extensor 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

50
Extensor 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

51
THENAR MUSCLES

• Abductor Pollicus Brevis
• Flexor Pollicus Brevis
• Opponens Pollicis

52
Abductor 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

53
Flexor 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

54
Opponens 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

55
Adductor 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

56
ADDUCTOR POLLICUS
57
HYPOTHENAR MUSCLES

• Abductor digiti minimi
• Flexor digiti minimi brevis
• Opponens digiti minimi

58
Abductor 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

59
Flex. 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

60
Opponens 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

61
SHORT MUSCLES

• Lumbricals 1 2
• Lumbricals 3 4
• Dorsal interossei 1-4
• Palmar interossei

62
Lumbricals 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

63
Lumbricals 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

64
Dorsal 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

65
Palmar 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)

66
Cont Palmar Interossei

• Main ActionAdducts digits toward axial line
  assists lumbricals in flexing metacarpophalangeal
  joints extending interphalangeal joints

67
INTEROSSEI
68
Common Injuries of the Wrist and Hand
69

Bony Injuries
70
Wrist 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

71
Metacarpal 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

72
Metacarpal 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

73
Scaphoid 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

74
Lunate 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
76
Wrist 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

77
UCL 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

78
Collateral 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

79
Muscular Injuries
80
Trigger 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

81
Flexor 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

82
Extensor 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

83
Extensor 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

84
Volar 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

85
De 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

86
De 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

87
Other Injuries
88
Injury 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

89
Carpal 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

90
Synovial 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)

91
References

• 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.