Hand

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Hand

• 19 Bones
• 19 Articulations
• 29 Muscles

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Bones of the Hands
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Arches of the Hand

• Transverse carpal arch
• Transverse metacarpal arch
• Longitudinal arch

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Mobility of 4th and 5th CMC Joints
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Creases of the Hand

• Distal digital crease
• Middle digital crease
• Proximal digital crease
• Distal palmar crease
• Proximal palmar crease
• Thenar crease
• Distal wrist crease
• Proximal wrist crease

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Volar or Palmar Plates

• Volar or Palmar Plates are dense thick discs of
  fibrocartilage which help to strengthen joint and
  prevent hyperextension
• Note the fibrous digital sheath in top picture
  (annual pulley)

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Motions at the MP Joints

• Flexion and Extension
• Axis - Lateral
• Plane - Sagittal
• Abduction and Adduction
• Axis - Anterior/Posterior
• Plane Frontal

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Motions at the PIP and DIP Joints

• Flexion and Extension
• Axis - Lateral
• Plane - Sagittal

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Extrinsics

• Muscles originating outside the hand
• Flexor Digitorium Superficialis
• Flexor Digitiorium Profundus
• Flexor Pollicus Longus
• Extensor Digitorum
• Extensor Indicis Proprius
• Extensor Digiti Minimi
• Extensor Pollicus Longus
• Extensor Pollicus Brevis
• Abductor Pollicus Longus

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Intrinsics

• Four Lumbricals
• Three Palmar Interossei
• Four Dorsal Interossei
• Thenar muscles
• Opponens Pollicus
• Abductor Pollicus Brevis
• Adductor Pollicus
• Flexor Pollicus Brevis

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Intrinsics

• Hypothenar muscles
• Opponens Digiti Minimi
• Abductor Digiti Minimi
• Flexor Digiti Minimi Brevis
• Palmaris Brevis

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Flexor Tendons
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Flexor Digitorum SuperficialisTest for Tendon
Integrity

• Therapist holds all fingers except one being
  tested in extension. This isolates the Flexor
  Digitorum Superficialis. If client can flex at
  PIP joint then FDS tendon is intact.

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Flexor Digitorum ProfundusTest for Tendon
Integrity

• Therapist extends all joints of clients finger
  except the DIP. Therapist asks client to flex
  the DIP. If client can, FDP is intact

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Annular Pulleys

• Hold flexor tendons relatively close to joint
  (functional insertions)
• Rupture results in bowstringing with less ROM and
  strength
• Trigger finger

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Extensor Assembly

• Over the proximal phalanx the extensor tendon
  (from extensor digitorum) divides into a central
  band and two lateral bands
• The central band inserts at the base of the
  middle phalanx
• The two lateral bands rejoin over the middle
  phalanx and insert at the base of the distal
  phalanx

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Extensor Mechanism
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Extensor Mechanism
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Extensor MechanismClosed pack position

• MCP 70 degrees
• PIP/DIP extension

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Closing Hand
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Opening Hand
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Relationship of AB Adduction to Flexion and
Extension at MP Joints

• When MP joints are extended the collateral
  ligaments are slack and allow for AB and
  Adduction of Fingers
• When MP joints are flexed the collateral
  ligaments are taut (tight) and prevent AB and
  ADduction

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Position for Long Term Immobilization

• Metacarpalphalangeal joints in 60 to 70 degrees
  of flexion
• PIP and DIP joints extended

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Thumb Movements at CMC Joint

• Thumb Flexion/Extension (Radial
  Adduction/Abduction)
• Axis - Anterior/Posterior
• Plane Frontal
• Thumb Palmar Adduction/Abduction
• Axis Lateral
• Plane - Sagittal

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Thumb Movements
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Thumb Movements at CMC Joint

• Flexion/Extension
• (Radial AB/Adduction)
• AB/Adduction
• (Palmar AB/Adduction)
• Opposition/Reposition

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Functional Position of Hand

• Wrist is in 20 to 30 degrees of extension and
  slight ulnar deviation
• Fingers in 45 degrees of MCP, 15 degrees of PIP
  and DIP flexion
• Thumb is in 45 degrees of abduction

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Intrinsic Plus

• Flexion of MP to 90 degrees and extension at PIP
  and DIP - or Roof Top Position
• Interossei and lumbricals at their shortest
• Common in patients with R.A.

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Intrinsic Minus

• Hyperextension of the MP joints and flexion of
  the PIP joints or Clawhand
• Paralysis of interossei and lumbrical muscles

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Intrinsic and extrinsicplus hand

• Intrinsic(Lumbricals and interosseus table top)
• ExtrinsicED, FDS, FDP) Hook

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Intrinsic Plus and Minus
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Types of Prehension

• Power grip
• Spherical
• Cylindrical
• Precision grip
• Power (key) pinch
• Lateral pinch
• Precision pinch
• Hook grip

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Match

• Power grip
• Spherical
• Cylindrical
• Precision grip
• Power (key) pinch
• Lateral pinch
• Precision pinch
• Hook grip

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• Common
• hand disorders

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Problems of the Hand

• Intrinsic Tightness
• Nerve injuries
• Ulnar Nerve Injury
• Median Nerve Injury
• Carpal Tunnel Syndrome
• Radial Nerve Injury

• Tendon injuries
• Mallet Finger
• Swan Neck Deformity
• Boutonniere Deformity
• Zig Zag Deformities
• DeQuervains Disease
• Fascia
• Dupuytrens Contracture

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Bunnell-Lister Test for Intrinsic Tightness

• MCP joint held in slight extension while examiner
  moves the PIP joint into flexion if cant be
  flexed, intrinsic or joint capsule tightness
• Place MCP joint in a few degrees of flexion to
  relax intrinsics if joint can now flex, then it
  was intrinsic tightness
• If when MCP joint placed in flexion still cant
  flex PIP then it is a joint capsule tightness
  or contracture.

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Bunnell-Lister Test for Intrinsic Tightness Step
1

• MCP joint held in slight extension will therapist
  moves the PIP joint into flexion if cant be
  flexed, intrinsic or joint capsule tightness

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Bunnell-Lister Test for Intrinsic Tightness Step
2

• Place MCP joint in a few degrees of flexion to
  relax intrinsics if joint can now flex, then it
  was intrinsic tightness

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Bunnell-Lister Test for Intrinsic Tightness Step
3

• If when MCP joint placed in flexion still cant
  flex PIP then it is a joint capsule tightness
  or contracture

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Musculotaneous nerve (C5, C6 Continuation of
the lateral cord)Points of entrapment

• 1.) Coracoid process (may be injured during
  surgery)
• 2.) Coracobrachialis muscle
• 3.) Distal lateral arm as it goes through
  investing fascia
• 4.) Lateral Forearm Vulnerable to blunt trauma

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Median Nerve Injury

• Unable to oppose thumb
• Unable to make a complete fist
• Atrophy of thenar eminence
• Weak wrist flexion
• Weak pronation of the forearm

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Median Nerve C5-C6, Medial and Lateral cords

• 1.) Ligament of struthers/supracondylar process
  (medial ridge)
• 2.) Bicipital aponeurosis
• 3.) Between 2 heads of pronator teres (Pronator
  syndrome)
• 4.) Sublimis Bridge (FDS borders)
• 5.) AIN (Anterior interosseous nerve branch)- may
  also be entrapped by pronator
• 6.) Carpal Tunnel- between flexor tendons and
  transverse carpal ligament
• 7.) Metacarpal tunnel between metacarpal
  ligaments and MCPs

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Muscles Innervated by the Median Nerve

• Flexor Carpi Radialis
• Palmaris Longus
• Flexor Digitorum Superficialis
• Radial Half of Flexor Digitorum Profundus
• Two Radial Lumbricals
• Flexor Pollicus Longus
• Superficial portion of Flexor Pollicus Brevis
• Opponens Pollicus
• Abductor Pollicus Brevis (may have ulnar
  innervation)

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Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome Tinels Sign

• Tinels Sign When therapist taps over the
  carpal tunnel, the client will feel parasthesias
  or tingling distally

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Phalens Test

• Therapist flexes clients wrists manually and
  holds together for one minute. Positive test
  elicits tingling in thumb, index finger, and
  middle and lateral half of the ring finger and is
  indicative of Carpal Tunnel Syndrome.

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Ape Hand Deformity
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Median Nerve Injury (ape or pope)

• Low injury Thumb, index, middle. Loss of 2
  lateral lumbricals
• Index and middle have noticeable claw,
• Thumb is rotated and flexed and in same plane as
  fingers, looses opposition (ape)

• High injury Only FCU and ulnar half of FDP are
  spared. Similar claw but not as pronounced
  because dont have the force of the long flexors.
  (pope)
• Hand is virtually useless

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Ulnar nerve- points of entrapment

• 1.) Arcade of Struthers (as goes into posterior
  compartment through medial septum)
• 2.) Posterior to medial epicondyle (on bony
  floor)
• 3.) Cubital tunnel between FCU and medial
  collateral ligament (cubital tunnel syndrome)
• 4.) Guyons canal against piso-hamate ligament,
  from chronic compression (bike rider)

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Ulnar nerve injury

• More severe deformity with low injury
• High injury also loose FDP so fingers are less
  flexed

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Muscles innervated by the Ulnar nerve

• Flexor carpi ulnaris
• Medial half of the flexor digitorum profundus
• Medial two lumbricals,
• Interossei (4 dorsal and 4 palmar)
• Adductor pollicis

• Abductor digiti minimi
• Opponnens digiti minimi
• Flexor digiti minimi
• Flexor policis brevis (also has median
  innervation)

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Ulnar Nerve Injury

• Flexion Deformity of the 4th and 5th fingers (due
  to paralysis of the lumbricals)
• Atrophy of hypothenar eminence
• Atrophy of interrossei
• Atrophy of thumb web space
• Difficulty holding a paper between thumb and
  index finger
• Claw Hand

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Froments Sign

• Therapist has client hold paper with a lateral
  pinch

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Cubital Tunnel Syndrome

• Surgery consists of
• a.) "decompression", (removal of the roof or one
  wall of the tunnel
• OR
• b.) "transposition" which moves the ulna nerve
  out of the cubital tunnel to another place.

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Radial Nerve- Points of entrapment

• Spiral Groove with fracture, (Saturday night
  palsy- when compressed between bone and hard
  surface)
• Lateral intermuscular septum
• Radial Tunnel
• Superficial branch- (posterior interosseous
  nerve) vulnerable to external forces, and as it
  branches through fascia

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Muscles Innervated by the Radial Nerve

• Extensor Carpi Radialis Longus
• Extensor Carpi Radialis Brevis
• Extensor Carpi Ulnaris
• Extensor Digitorum
• Extensor Indicis Proprius
• Extensor Pollicus Longus
• Extensor Pollicus Brevis
• Abductor Pollicus Longus

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Radial Nerve Injury Wrist drop or Saturday
night palsy

• In Axilla- loss of elbow extensors and extensors
  of the wrist and digits resulting in wrist drop.
• There is a sensory loss to a narrow strip of skin
  on the back of the forearm and on the dorsum of
  the hand and lateral three and one half digits.

• Spiral Groove The branches to the triceps are
  spared in this injury so that extension of the
  elbow is possible.
• The long extensors of the forearm are paralyzed
  and this will result in a "wrist drop". There is
  a small loss of sensation over the dorsal surface
  of the hand and the dorsla sufaces of the roots
  of the lateral three fingers.

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Radial Tunnel Syndrome
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Radial Nerve Injury

• Wrist drop
• Lack of MP extension
• Lack of thumb IP extension
• Lack of thumb abduction
• Grip affected due to lack of wrist extension

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Wrist Drop (Radial Nerve Injury)
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Mallet Finger

• Tear of the extensor tendon from the attachment
  on the distal phalanx

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Swan Neck Deformity

• MCP joint subluxes volarly and PIP extends as
  intrinsics contract.
• Is a result of contracture of the intrinsics

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Boutonniere Deformity

• Deformity is a result of a rupture of the central
  tendinous slip of the extensor hood
• Central extensor slip and lateral bands migrate
  volarly extends MCP (and DIP) and flexes PIP.

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Zig Zag Deformities of the Fingers
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Zig Zag Deformity of the Thumb
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DeQuervains Disease

• Tenosynovitis of thumb tendons at the radial
  styloid process
• abductor pollicus longus
• extensor pollicus brevis
• Maybe a swelling in the area, tenderness

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Anatomical Snuff Box

• Abductor pollicus longus
• Extensor pollicus brevis
• Extensor pollicus brevis

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Finkelstein Test

• Client makes a fist with thumb inside the fist.
  Therapist stabilizes forearm and ulnarly
  deviates wrist. Positive sign is pain over the
  abductor pollicus and extensor pollicus brevis.

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Palmar Aponeurosis

• Fascia in the palm of hand

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Dupuytrens Contracture

• Fibrous contracture of the palmar fascia

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