MUSCULOSKELETAL EXAMINATION OF THE ELBOW, FOREARM, WRIST AND HAND (P2)

PART 2: WRIST and HAND (ANATOMY review S&O)

What is the resting/recovery position of the hand?

slight extension, slight flexion of MCP, flexion and abduction of thumb

Note: This is the preferred position when casting the hand to prevent contractures

True or False:

Tendons are in most efficient position to contract and perform function while in close packed position (no active or passive insufficiencies)

True or False:

Tendons are in most efficient position to contract and perform function while in RESTING / RECOVERY position (no active or passive insufficiencies)

ARCHES OF THE HAND:

Proximal Transverse Arch

Distal Transverse Arch

Longitudinal Arch

This arch should be more stable than distal transverse arch

• Contains carpal tunnel, distal row of carpal bones, capitate (central keystone), CMC jt. of thumb 

Proximal Transverse Arch

Why should the Proximal Transverse Arch be more stable than the Distal Transverse Arch

So that the distal structures can have more mobility without sacrificing instability

“THE BODY NEEDS ALTERNATING JOINT STABILITY AND MOBILITY IN THE JOINTS FOR PROPER BODY FUNCTIONING”

What is the keystone for your proximal transverse arch of the hand

Capitate

What are the keystones for your Distal and Longitudinal arch of the hand

Keystone: 2nd and 3rd MCP

State if the structure is for stability or mobility:

Shoulder:

Elbow:

RC joint:

Proximal Transverse arch:

Distal Transverse arch:

State if the structure is for stability or mobility:

Shoulder: Mobility

Elbow: Stability

RC joint: Mobility

Proximal Transverse arch: Stability

Distal Transverse arch: Mobility

What are considered the stable segments of the hand?

Distal row of carpals & 2nd and 3rd Metacarpal

Hypermobility of these = compromised stability

CARPAL BONES

Proximal (lateral to medial)

• Scaphoid, Lunate, Triquetrum, Pisiform

Distal (lateral to medial)

• Trapezium, Trapezoid, Capitate, Hamate

“Skibidi lovers try positions that they cant handle”

Joint responsible for rotation Pronation, radial and ulnar deviation, supination (reclec)

• uniaxial pivot (1 DoF) (magee)

DISTAL RADIOULNAR JOINT

note that even if the radius is the main mover of the jt. the ulna is not stationary

Distal Radioulnar Joint

Resting position:

Close packed position:

Capsular pattern:

Distal Radioulnar Joint

Resting position: 10° of supination

Close packed position: 5° of supination

Capsular pattern: Full range of motion, pain at extremes of rotation

Biaxial ellipsoid joint (2 DoF)

• responsible for wrist Flex-ext, radial and ulnar deviation

RADIOCARPAL JOINT

Radiocarpal (Wrist) Joint

Resting position:

Close packed:

Capsular pattern:

Radiocarpal (Wrist) Joint

Resting position: Neutral with slight ulnar deviation

Close packed: Extension with radial deviation

Capsular pattern: Flexion and extension equally limited (works with midcarpal joints)

How many degrees is the radius angled to the ulna at the Radiocarpal jt.?

15° to 20°

posterior margin also projects more distally to provide a “buttress effect.”

True or False:

The stability of the carpals (wrist) is primarily maintained by a complex configuration of ligaments and bones. The ligaments stabilizing the scaphoid, lunate, and trapezium are the most important.

False:

The stability of the carpals (wrist) is primarily maintained by a complex configuration of ligaments and bones. The ligaments stabilizing the scaphoid, lunate, and triquetrum are the most important.

True or False

Of these ligaments, the radioscapholunate ligament, the scapholunate and the lunotriquetral ligaments are the most important intrinsic ligaments and are the ligaments least commonly disrupted.

False:

Of these ligaments, the radioscapholunate ligament, the scapholunate and the lunotriquetral ligaments are the most important intrinsic ligaments and are the ligaments most commonly disrupted

Highly important ligament in keeping the stability of proximal carpal bones on the radiocarpal joint

• Acts as sling for the scaphoid

• This ligament; along with the radiolunate ligament; allows for the rotation of the scaphoid

• Stabilizes scaphoid at extremes of motion

Radioscapholunate Ligament

Radioscapholunate Ligament is most commonly injured in what type of injury?

FOOSH injuries

Especially in an extended & pronated wrist w/ ulnar deviation & intercarpal supination

Second most commonly injured ligament of the proximal carpal bones

Luno-triquetral ligament (Causes luno-triquetral instability)
MOI: wrist extension, radial deviation, intercarpal supination

Which ligament of the wrist gets injured via FOOSH with wrist extension, radial deviation, intercarpal supination?

Luno-triquetral ligament

this carpal bone acts as a strut transmitting movements of the distal carpal row to the proximal carpal row

Scaphoid

The scaphoid, lunate, and triquetrum are described as a /an _____________ segment

The scaphoid, lunate, and triquetrum are described as an Intercalated segment

What the ligament which is the primary stabilizer of the scapholunate joint?

Scapholunate interosseous ligament

True or False:

if the Scapholunate interosseous ligament injured (3° sprain), the result is dynamic instability and static instability, which only occurs when secondary ligamentous supports are also injured.

False:

if the Scapholunate interosseous ligament injured (3° sprain), the result is dynamic instability but NOT static instability, which only occurs when secondary ligamentous supports are also injured.

Cartilage that serves as a cushion for the triquetrum as it articulates with ulna

Bears weight of the triquetrum at side of ulna

TFCC (Triangular fibrocartilage complex)

made up of the:

• ulnolunate and ulnotriquetral ligament,

• extensor carpi ulnaris tendon and its sheath,

• ulnar capsule

• anterior and posterior radioulnar ligaments,

• ulnomeniscal homolog

• triangular fibrocartilaginous disc

Which type of wrists have a thicker TFCC?

Ulnar negative wrists.

wrists with short ulna

In the ulnar neutral wrist, the axial load across the TFCC is about how many percent?

18%

The anterior part of the TFCC is tight on __________ and prevents posterior displacement of the ulna

The anterior part of the TFCC is tight on pronation and prevents posterior displacement of the ulna

the posterior part is tight on supination and prevents _________ displacement of the ulna.

the posterior part is tight on supination and prevents anterior displacement of the ulna.

During WB of the wrist, how much weight is distributed to the radius and TFCC of the ulna

60% of weight is borne on the radius

40% of weight is borne on ulna; mostly on TFCC

MOI of TFCC Compression Injury (most common) (reclec)

FOOSH + Ulnar deviation

MOI of TFCC Strain (reclec)

FOOSH + Radial deviation

MOST COMMON MOI of TFCC (Magee)

Forced extension and pronation

True or False:

The palmar ligaments are much stronger than the dorsal ligaments.

True

joints between the individual bones of the proximal row of carpal bones

intercarpal joints

Intercarpal Joints

Resting position:

Close packed position:

Capsular pattern:

Intercarpal Joints

Resting position: Neutral or slight flexion

Close packed position: Extension

Capsular pattern: None

True or false:

The pisotriquetral joint is not considered part of the intercarpal joints.

True

the pisiform sits on the triquetrum and does not take a direct part in the other intercarpal movements.

The only muscle to insert into any of the wrist carpals

Flexor carpi ulnaris

True or false:

Carpal motion is primarily determined by passive forces.

True

The compound articulation between the proximal and distal rows of carpal bones with the exception of the pisiform bone is called what jt.

Midcarpal joints

Midcarpal Joints

Resting position:

Close packed position:

Capsular pattern:

Midcarpal Joints

Resting position: Neutral or slight flexion with ulnar deviation

Close packed position: Extension with ulnar deviation

Capsular pattern: Equal limitation of flexion and extension (works with radiocarpal joints)

True or False:

Greater movement exists at the midcarpal joints than between the individual bones of the two rows of the intercarpal joints.

True:

The midcarpal joint is supported by dorsal an palmar ligaments

The individual bones of the distal row are bound together by strong interosseous ligaments

CMC joint (Thumb)

Resting position: midway between abduction and adduction, and midway between flexion and extension

Close packed position: full opposition

Capsular Pattern: abduction, extension

CMC joint (Fingers)

Resting position: midway between flexion and extension

Close packed position: full flexion

Capsular Pattern: equal limitation in all directions

Which metacarpal joints are the primary stabilizing joints of the hand?

2nd and 3rd metacarpal

Which metacarpal joints allow the hand to adapt to different shaped objects while grasping

4th and 5th metacarpal

Metacarpophalangeal Joints

Resting position: Slight flexion

Close packed position: Thumb, full opposition Fingers, full flexion

Capsular pattern: Flexion, extension

Interphalangeal Joints

Resting position: Slight flexion

Close packed position: Full extension

Capsular pattern: Flexion, extension

If the metacarpophalangeal joints and the proximal interphalangeal joints of the fingers are flexed, they converge toward the scaphoid tubercle, what sign is this called?

Cascade sign

If one or more fingers do not converge, it usually indicates trauma

arthritic changes are most commonly seen in patients who are older than how many years of age?

40 years of age

Kienbock’s disease is more likely to be seen in males between _________ years of age.

20 and 40 years

MOI for Lunate dislocation, colles fx, scaphoid fx, injury to TFCC

FOOSH

MOI: FOOSH; Dinner fork fracture

Colle’s Fracture

FOOSH with flexed wrist

Smith’s Fracture

Rotational torsion stress fx with FOOSH

Montaggia or Galeazzi

Compressive overload of ulnar head to lunate and triquetrum; pain in pronated arm

Ulnocarpal Impaction

Injury to ulnar artery d/t repetitive blunt trauma to hypothenar eminence

Hypothenar Hammer Syndrome

Injury to UCL between 1st MCP and proximal phalanx of the thumb 

Skier’s Thumb

DEFORMITIES OF THE HANDS

Heberden’s/ Bouchard Nodes

Ulnar drift (MCP, PIP, DIP)

Dupuytren’s Contracture

Spoon-shaped nails

Clubbing of DIP

Benediction Sign

Swan Neck

Claw hand/Ape hand

Syndactyly/ Polydactyly

Drop wrist/Radial nerve palsy

Claw hand

Nodes in the PIP jt.

Bouchard’s Nodes (Seen in RA)

*letter A

Nodes in the DIP jt.

Heberden’s Nodes (Seen in RA)

*letter B

Ulnar Deviation of the MCP DIP and PIP with concomitant radial deviation of the metacarpals

Tendons of the extensors are bowstringing leading to grip insufficiencies

Ulnar Drift / Bowstringing effect (Seen in late stage RA)

Deformities we just have to take note of for now:

Clubbing of DIP

• Indication of respiratory conditions, infection

Spoon-shaped Nails

• Entails fungal, anaemic, DM, local injuries 

  and many other conditions

Sign where 4th and 5th digit does not raise when you ask patient to open their hand:

(+) Benediction sign

• wasting of interossei muscles and 2 medial lumbrical muscles

• Contractures on volar surface

Rupture of central slip of extensor hood

Boutonniere Deformity (present dt trauma or ulnar drift)

Hand deformity present in median nerve compromise regardless of site of compression

Ape Hand deformity

Hand deformity present in Radial nerve affectation regardless of side of compression; inability to extend wrist

Drop wrist/Radial nerve palsy

“Kobe deformity” - S’Charles (Bro wtf T_T)

Contracture of anterior fascia of the MCP, DIP

Genetic and progressive

Differs from the benediction sign because there is a significant cord-like structure

Dupuytren’s Contracture 

Hand deformity in combined median and ulnar nerve palsy

MCP Hyperextension, PIP & DIP flexion

Intrinsic minus

Claw hand deformity

Hand deformity present in RA together with ulnar drift, bowstringing effect with a dislocated CMC, hyperextended MCP and flexed DIP

Accompanied by avulsion or rupture of the ligaments of the CMC joint

Zigzag deformity

Hyperextension of PIP dt rupture of volar plate or RA

Swan Neck Deformity

Do we measure each hand join ROM individually?

If the case warrants it (just say Rheumatoid Arthritis bruh)

Range of motion where you test different grips.

Functional ROM

True or false:

Difficulty in grips / Inability to perform a grip can be documented under MMT.

FALSE:

Difficulty in grips / Inability to perform a grip can be documented under ROM.

Key myotomes for MMT Testing:

• C5 =_____________

• C6 = _____________

• C7 = _____________

• C8 = _____________

• T1 = _____________

• C5 = Elbow Flexors

• C6 = Wrist Extensors

• C7 = Elbow Extensors

• C8 = Finger flexors (DP of the little finger)

• T1 = Finger abductors

If with hand/finger problem, test muscle for each finger

This type of MMT test assesses the muscle in an advantageous position, with the lowest score being 4/5.

Break Test

Note : Document at what degree of motion you tested the muscle

True or False:

Always test for grade 3/5 strength at the beginning of your MMT assessment

True:

3→5→4→2→1

How many trials do we do for the Grip and Pinch Strength Assessment?

3 trials

What is the normal strength difference between dominant and non dominant hand?

N = 5-10%

Correlation of pain and strength: MMT guide

• Strong & Painless = ?

• Strong & Painful = ?

• Weak & Painless = ?

• Weak & Painful =?

• Strong & Painless = Normal

• Strong & Painful = Minor lesion of contractile tissues

• Weak & Painless = Neurologic , nerve affectation

• Weak & Painful =Major lesion (fx)

Patterns of Inert Tissue Lesions: ROM guide

• Pain free & full ROM = ?

• Pain and limited motion in every direction = ?

• Pain and excessive or limited ROM in some directions = ?

• Pain free & limited ROM =?

• Pain free & full ROM = Normal

• Pain and limited motion in every direction = Capsular problem (Inflammation or congestion of joint capsule)

• Pain and excessive or limited ROM in some directions = specific structures cause limited rom (If AROM is diminished think contractile and if PROM is diminished think inert structures)

• Pain free & limited ROM = Capsular Inert or Passive structure problem

Which type of grips are Physical Therapists more concerned of?

Power grips

Which type of grips are Occupational Therapists more concerned of?

Precision grips

A loss of thumb function decreases the function of its hand by how many percent?

40-50%

A loss of index and middle finger function decreases the function of its hand by how many percent?

20% each

A loss of ring and little finger function decreases the function of its hand by how many percent?

10% each

Loss of function of the whole hand diminishes arm function by how many percent?

90%

Take note of all percentages they will appear in the boards

Assessment that finds the % sensory deficit as to what senses on what areas (distribution of peripheral nerves or dermatomes)

Indicate the devices used during testing 

Sensory Testing

For normal functional wrist movement, an individual should have:

• ____ flexion

• ____ extension

• ____ radial deviation

• ____ ulnar deviation

For normal functional wrist movement, an individual should have:

• 40° flexion

• 40° extension

• 15° radial deviation

• 20° ulnar deviation

Superficial Sensations of sensory testing

Light touch, Pressure, Pin prick & temperature

Dermatomes (flippy)

Sensory nerve distribution (flipparooo)

Which aspect of the hand is supplied by the median nerve?

Which aspect of the hand is supplied by the ulnar nerve?

Which aspect of the hand is supplied by the Radial nerve?

More specific test to test for sensory disturbance of the hand used for diabetic, arthritic conditions or neurologic compromise

More common for diabetic conditions

The gold standard for sensory assessment of the hand

Semmes-Weinstein monofilament test AKA Von Frey test

Sense of the hand is tested with monofilaments till the thinnest monofilament sensed

Normal size of thinnest monofilament sensed during the Von Frey test for normal light touch.

2.44-2.83 (unit will be updated once clarified with sir)

Monofilament number range for Diminished light touch

3.22-4.56 (unit will be updated once clarified with sir)

Monofilament number range for Minimal light touch

4.74-6.10

Monofilament number range for intact sensation but no localization sensibility

6.10-6.65

Test for Two point discrimination of the hand

Measures minimum distance detected as 2 points

Weber’s or Moberg’s Test

Tools used are the caliper and discriminator