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Hand 19 Bones 19 Articulations 29 Muscles. Bones of the Hands.

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Presentation on theme: "Hand 19 Bones 19 Articulations 29 Muscles. Bones of the Hands."— Presentation transcript:

1 Hand 19 Bones 19 Articulations 29 Muscles

2 Bones of the Hands

3 Arches of the Hand Transverse carpal arch Transverse metacarpal arch Longitudina l arch

4 Mobility of 4 th and 5 th CMC Joints

5 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

6 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)

7 Motions at the MP Joints Flexion and Extension ◦Axis - Lateral ◦Plane - Sagittal Abduction and Adduction ◦Axis - Anterior/Posterior ◦Plane – Frontal

8 Motions at the PIP and DIP Joints Flexion and Extension ◦Axis - Lateral ◦Plane - Sagittal

9 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

10 Intrinsics Four Lumbricals Three Palmar Interossei Four Dorsal Interossei Thenar muscles ◦Opponens Pollicus ◦Abductor Pollicus Brevis ◦Adductor Pollicus ◦Flexor Pollicus Brevis

11 Intrinsics Hypothenar muscles ◦Opponens Digiti Minimi ◦Abductor Digiti Minimi ◦Flexor Digiti Minimi Brevis Palmaris Brevis

12 Flexor Tendons

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14 Flexor Digitorum Superficialis Test 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.

15 Flexor Digitorum Profundus Test for Tendon Integrity Therapist extends all joints of client’s finger except the DIP. Therapist asks client to flex the DIP. If client can, FDP is intact

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

17 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

18 Extensor Mechanism

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20 Extensor Mechanism Closed pack position MCP 70 degree s PIP/DI P extensi on

21 Closing Hand

22 Opening Hand

23 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

24 Position for Long Term Immobilization Metacarpalphalan geal joints in 60 to 70 degrees of flexion PIP and DIP joints extended

25 Thumb Movements at CMC Joint Thumb Flexion/Extension (Radial Adduction/Abduction) ◦Axis - Anterior/Posterior ◦Plane – Frontal Thumb Palmar Adduction/Abduction ◦Axis – Lateral ◦Plane - Sagittal

26 Thumb Movements

27 Thumb Movements at CMC Joint Flexion/Extension ◦(Radial AB/Adduction) AB/Adduction ◦(Palmar AB/Adduction) Opposition/Repositio n

28 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

29 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.

30 Intrinsic Minus Hyperextension of the MP joints and flexion of the PIP joints or “Clawhand” Paralysis of interossei and lumbrical muscles

31 Intrinsic and extrinsic plus hand Intrinsic=(Lumb ricals and interosseus =table top) Extrinsic=ED, FDS, FDP) = Hook

32 Intrinsic Plus and Minus

33 Types of Prehension Power grip ◦Spherical ◦Cylindrical Precision grip Power (key) pinch ◦Lateral pinch Precision pinch Hook grip

34 Match Power grip ◦Spherical ◦Cylindrical Precision grip Power (key) pinch ◦Lateral pinch Precision pinch Hook grip

35 Common hand disorders

36 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 ◦DeQuervain’s Disease Fascia ◦Dupuytren’s Contracture

37 Bunnell-Lister Test for Intrinsic Tightness MCP joint held in slight extension while examiner moves the PIP joint into flexion – if can’t 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 can’t flex PIP – then it is a joint capsule tightness or contracture.

38 Bunnell-Lister Test for Intrinsic Tightness: Step 1 MCP joint held in slight extension will therapist moves the PIP joint into flexion – if can’t be flexed, intrinsic or joint capsule tightness

39 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

40 Bunnell-Lister Test for Intrinsic Tightness: Step 3 If when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture

41 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

42 Tenodesis- C6 -8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0

43 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

44 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 MCP’s

45 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)

46 Carpal Tunnel Syndrome

47 Carpal Tunnel Syndrome – Tinel’s Sign Tinel’s Sign – When therapist taps over the carpal tunnel, the client will feel parasthesias or tingling distally

48 Phalen’s Test Therapist flexes client’s 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.

49 Ape Hand Deformity

50 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 don’t have the force of the long flexors. (pope) Hand is virtually useless

51 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.) Guyon’s canal – against piso-hamate ligament, from chronic compression (bike rider)

52 Ulnar nerve injury More severe deformity with low injury High injury also loose FDP so fingers are less flexed

53 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)

54 Ulnar Nerve Injury Flexion Deformity of the 4 th and 5 th 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”

55 Froment’s Sign Therapist has client hold paper with a lateral pinch

56 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.

57 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

58 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

59 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.

60 Radial Tunnel Syndrome

61 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

62 Wrist Drop (Radial Nerve Injury)

63 Mallet Finger Tear of the extensor tendon from the attachment on the distal phalanx

64 Swan Neck Deformity MCP joint subluxes volarly and PIP extends as intrinsics contract. Is a result of contracture of the intrinsics

65

66 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.

67

68 Zig Zag Deformities of the Fingers

69 Zig Zag Deformity of the Thumb

70 DeQuervain’s Disease Tenosynovitis of thumb “tendons at the radial styloid process ◦ abductor pollicus longus ◦extensor pollicus brevis Maybe a swelling in the area, tenderness

71 Anatomical Snuff Box Abductor pollicus longus Extensor pollicus brevis

72 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.

73 Palmar Aponeurosis Fascia in the palm of hand

74 Dupuytren’s Contracture Fibrous contracture of the palmar fascia

75


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