3Arches of the Hand Transverse carpal arch Transverse metacarpal arch Longitudina l archNeed arches for functional handIf develop flat hand will not have a functional hand
4Mobility of 4th and 5th CMC Joints Articulations at the 4th and 5th CMC joints allow the “cupping” of the handMobility of 4th and 5th CMC Joints
5Creases of the Hand Distal digital crease Middle digital crease Proximal digital creaseDistal palmar creaseProximal palmar creaseThenar creaseDistal wrist creaseProximal wrist crease
6Volar or Palmar PlatesVolar or Palmar Plates are dense thick discs of fibrocartilage which help to strengthen joint and prevent hyperextensionNote the fibrous digital sheath in top picture (annual pulley)
7Motions at the MP Joints Flexion and ExtensionAxis - LateralPlane - SagittalAbduction and AdductionAxis - Anterior/PosteriorPlane – Frontal
8Motions at the PIP and DIP Joints Flexion and ExtensionAxis - LateralPlane - Sagittal
14Flexor 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.
15Flexor 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
16Annular PulleysHold flexor tendons relatively close to joint (functional insertions)Rupture results in bowstringing with less ROM and strengthTrigger fingerHave 5 Annular PulleysA2 (on Proximal phalanx) and A4 (on middle phalanx) are major pulleys (attach to shafts of phalanges)A1, A3, A5 attach to palmar/volar plates of respective jointsAlso have 3 Cruciate pulleys (between A2 and A3; A3 and A4; A4 and A5) thinner fibers
17Extensor AssemblyOver the proximal phalanx the extensor tendon (from extensor digitorum) divides into a central band and two lateral bandsThe central band inserts at the base of the middle phalanxThe two lateral bands rejoin over the middle phalanx and insert at the base of the distal phalanx
18Extensor assembly is made up of a tendinous system composed of thee distal tendons of attachment of the extensor muscles, lumbricals, interossei, and thenar and hypothenar muscles. Purpose of the assembly is to extend the digits in different positions of finger flexion.Over the proximal phalanx the extensor tendon (from extensor digitorum) divides into a central band and two lateral bandsThe 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.Extensor Mechanism
19Extensor MechanismOver the proximal phalanx the extensor tendon (from extensor digitorum) divides into a central band and two lateral bandsThe central band inserts at the base of the middle phalanxThe two lateral bands rejoin over the middle phalanx and insert at the base of the distal phalanx
20Extensor Mechanism Closed pack position MCP 70 degree sPIP/DI P extensi onHood slides forward here over proximal phalanx. During flexion the lateral bands move volarly.Extensor Mechanism Closed pack position
21Closing HandEarly – FDP and FDS and interossei muscles actively flex the jointsLate – lumbricals still inactive, assembly (hood) moves over proximal phalanx
22Opening Hand Early – extensor digitorum is extending at MCP joint Middle – Intrinsics (lumbricals and interossei) assist extension at the PIP and DIP jointsLate – Assembly (Hood) slides back over MCP joint
23Relationship 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 FingersWhen MP joints are flexed – the collateral ligaments are taut (tight) and prevent AB and ADduction
24Position for Long Term Immobilization Metacarpalphalan geal joints in 60 to 70 degrees of flexionPIP and DIP joints extendedAt MCP joints the collateral ligaments are taut or stretched to prevent shortening and prevent flexion contracturesAt the PIP and DIP joints there is equal tension of collateral ligaments throughout the ROM, hence splinted in extension
25Thumb Movements at CMC Joint Thumb Flexion/Extension (Radial Adduction/Abduction)Axis - Anterior/PosteriorPlane – FrontalThumb Palmar Adduction/AbductionAxis – LateralPlane - Sagittal
27Thumb Movements at CMC Joint Flexion/Extension(Radial AB/Adduction)AB/Adduction(Palmar AB/Adduction)Opposition/Repositio n
28Functional Position of Hand Wrist is in 20 to 30 degrees of extension and slight ulnar deviationFingers in 45 degrees of MCP, 15 degrees of PIP and DIP flexionThumb is in 45 degrees of abduction
29Intrinsic PlusFlexion of MP to 90 degrees and extension at PIP and DIP - or Roof Top PositionInterossei and lumbricals at their shortestCommon in patients with R.A.
30Intrinsic MinusHyperextension of the MP joints and flexion of the PIP joints or “Clawhand”Paralysis of interossei and lumbrical musclesDeformity results from loss of intrinsic muscle action and overaction of the extrinsic extensor muscles on the proximal phalanx of the fingers. Arches of hand disappear and hand becomes “flat”.
31Intrinsic and extrinsic plus hand Intrinsic=(Lumb ricals and interosseus =table top)Extrinsic=ED, FDS, FDP) = HookIntrinsic and extrinsic plus hand
33Types of Prehension Power grip Precision grip Power (key) pinch SphericalCylindricalPrecision gripPower (key) pinchLateral pinchPrecision pinchHook gripPower grip - hammerSphericalCylindricalPrecision grip – holding an egg; holding a baseballPower (key) pinchLateral pinchPrecision pinch – tip to tip; pulp to pulpHook grip - suitcaseTypes of Prehension
34Match Power grip Precision grip Power (key) pinch Precision pinch SphericalCylindricalPrecision gripPower (key) pinchLateral pinchPrecision pinchHook gripMatch
36Problems of the Hand Intrinsic Tightness Nerve injuries Ulnar Nerve InjuryMedian Nerve InjuryCarpal Tunnel SyndromeRadial Nerve InjuryTendon injuriesMallet FingerSwan Neck DeformityBoutonniere DeformityZig Zag DeformitiesDeQuervain’s DiseaseFasciaDupuytren’s ContractureMallet Finger - Tear of the extensor tendon from the attachment on the distal phalanxSwan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contractBoutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIPZig Zag Deformities from Rheumatoid ArthritisDeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tendernessDupuytren’s Contracture - fibrous contracture of the palmar fasciaProblems of the Hand
37Bunnell-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 tightnessPlace MCP joint in a few degrees of flexion to relax intrinsics – if joint can now flex, then it was intrinsic tightnessIf when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture.
38Bunnell-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
39Bunnell-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
40Bunnell-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
41Musculotaneous nerve (C5, C6 – Continuation of the lateral cord) Points of entrapment 1.) Coracoid process (may be injured during surgery)2.) Coracobrachialis muscle3.) Distal lateral arm as it goes through investing fascia4.) Lateral Forearm – Vulnerable to blunt traumaLoss of musculocutaneous = profound weakness of forearm flexion, extension and supinationStatically – forearm is pronated and extended
43Median Nerve Injury Unable to oppose thumb Unable to make a complete fistAtrophy of thenar eminenceWeak wrist flexionWeak pronation of the forearmMedian Nerve Injury
44Median 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’sMedian Nerve = C5-C6, Medial and Lateral cords
45Muscles Innervated by the Median Nerve Flexor Carpi RadialisPalmaris LongusFlexor Digitorum SuperficialisRadial Half of Flexor Digitorum ProfundusTwo Radial LumbricalsFlexor Pollicus LongusSuperficial portion of Flexor Pollicus BrevisOpponens PollicusAbductor Pollicus Brevis (may have ulnar innervation)Most wrist and extrinsics muscles originating in the area of the medial epicondyle
47Carpal Tunnel Syndrome – Tinel’s Sign Tinel’s Sign – When therapist taps over the carpal tunnel, the client will feel parasthesias or tingling distally
48Phalen’s TestTherapist 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.
49Wasting of thenar eminence Wasting of thenar eminence. Thumb falls back into line with fingers as a result of pull of extensor muscles. Unable to oppose or flex thumbApe Hand Deformity
50Median Nerve Injury (ape or pope) Low injury = Thumb, index, middle. Loss of 2 lateral lumbricalsIndex and middle have noticeable claw,Thumb is rotated and flexed and in same plane as fingers, looses opposition (ape)In forearm = all flexor compartment EXCEPT FCU, ulnar half of FDP = UlnarA median nerve palsy due to a wound on the palmar aspect of the wrist. This is causing wasting and paralysis of the thenar muscles.High injury can only pronate to midpoint =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 uselessMedian Nerve Injury (ape or pope)
51Ulnar 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)Ulnar nerve- points of entrapment
52Ulnar nerve injury More severe deformity with low injury High injury also loose FDP so fingers are less flexedFCU and Ulnar half of FDPCutaneous branchThe muscles paralyzed are the flexor carpi ulnaris, medial half of the flexor digitorum profundus, medial two lumbricals, all interossei and the adductor pollicisInjury to the nerve at or above the elbow results in paralysis of the medial half of the flexor digitorum profundus with the loss of flexion of the distal phalanges of the medial two digits. Flexion of the wrist joint will produce abduction due to the paralysis of the flexor carpi ulnaris. The hypothenar eminence muscles will be paralysed and the eminence may be wasted. Since the interossei are paralysed the patient will not be able to hold a sheet of paper between the fingers - loss of abduction and adduction. Adduction of the thumb is lost due to paralysis of the adductor pollicis muscle. The patient gets around this loss by strongly contracting the flexor pollicis longus to bring the terminal phalanx of the thumb against the index finger. The fourth and fifth MCP joints are hyperextended due to the loss of the lumbricals and interossei , while the interphalangeal joints of the same digits are flexed. The picture is that of a 'claw hand'. The sensory loss is to the palm and both palmar and dorsal aspects of the medial one and one-half digits. Injury to the nerve at the wirst spares the flexor carpi ulnaris and the flexor digitorum profundus so that wrist flexion is normal and the fourth and fifth interphalangeal nerves are even more flexed into a claw hand.Ulnar nerve injury
53Muscles innervated by the Ulnar nerve Flexor carpi ulnarisMedial half of the flexor digitorum profundusMedial two lumbricals,Interossei (4 dorsal and 4 palmar)Adductor pollicisAbductor digiti minimiOpponnens digiti minimiFlexor digiti minimiFlexor policis brevis (also has median innervation)Muscles innervated by the Ulnar nerve
54Flexion Deformity of the 4th and 5th fingers (due to paralysis of the lumbricals) Atrophy of hypothenar eminenceAtrophy of interrosseiAtrophy of thumb web spaceDifficulty holding a paper between thumb and index finger“Claw Hand”Ulnar Nerve Injury
55Froment’s Sign Therapist has client hold paper with a lateral pinch Can’t hold paper in “lateral pinch”.If ulnar nerve injury (maybe cubital tunnel), can’t hold, IP joint will flex. (As interossei won’t hold)
56Cubital 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.
57Radial Nerve- Points of entrapment Spiral Groove – with fracture, (Saturday night palsy- when compressed between bone and hard surface)Lateral intermuscular septumRadial TunnelSuperficial branch- (posterior interosseous nerve) – vulnerable to external forces, and as it branches through fasciaPosterior compartment of the armSuperficial branch = Cutaneous onlyRadial Nerve- Points of entrapment
58Muscles Innervated by the Radial Nerve Extensor Carpi Radialis LongusExtensor Carpi Radialis BrevisExtensor Carpi UlnarisExtensor DigitorumExtensor Indicis PropriusExtensor Pollicus LongusExtensor Pollicus BrevisAbductor Pollicus LongusMost wrist and extrinsics muscles originating in the area of the lateral epicondyle
59Radial 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.The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair, and now presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints. With the hand supinated (palm up) and the extensors aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will dropRadial Nerve Injury = Wrist drop or Saturday night palsy
60Radial Tunnel Syndrome Test = Resisted supination and resisted middle finger extensionConfused with Lateral Epicondyilits5 points of compression= Fibrous bands, vascular leash, ECRB, Supinator, At proximal or distal edge.The goal of surgery for radial tunnel syndrome is to relieve any abnormal pressure on the nerve where it passes through the radial tunnel. The surgeon begins by making an incision along the outside of the elbow and down the forearm, near the spot where the radial nerve goes under the supinator muscle.Soft tissues are gently moved aside so the surgeon can check the places where the radial nerve may be getting squeezed within the radial tunnel. The nerve can be pinched in many spots, so it is important to check all the areas that may be causing problems. Any parts of the tunnel that are pinching the nerve are cut. This expands the tunnel and relieves pressure on the nerve. At the end of the procedure, the skin is stitched together.Radial Tunnel Syndrome
61Radial Nerve Injury Wrist drop Lack of MP extension Lack of thumb IP extensionLack of thumb abductionGrip affected due to lack of wrist extensionRadial Nerve Injury
62Wrist Drop (Radial Nerve Injury) Extensor muscles of the wrist are paralyzed as a result of radial nerve palsy. Wrist and fingers can not be extended.Wrist Drop (Radial Nerve Injury)
63Mallet FingerMallet Finger - Tear of the extensor tendon from the attachment on the distal phalanxTear of the extensor tendon from the attachment on the distal phalanx
64Swan Neck DeformityMCP joint subluxes volarly and PIP extends as intrinsics contract.Is a result of contracture of the intrinsicsSwan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contract
66Boutonniere Deformity Boutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIPDeformity is a result of a rupture of the central tendinous slip of the extensor hoodCentral extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIP.
69Zig Zag Deformity of the Thumb Chronic synovitis – periarticular tissue strength is reduced resulting in destruction of mechanical integrity of joint (deformities) from the various forces acting on the joint.
70Tenosynovitis of thumb “tendons at the radial styloid process abductor pollicus longusextensor pollicus brevisMaybe a swelling in the area, tendernessDeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tendernessDeQuervain’s Disease
72Finkelstein TestClient 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.