Studied by 48 people
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
Note 
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