The Wrist and Hand Chapter 19

Structure and Function of the wrist and hand Figure 19.1 illustrates bones of the wrist and hand complex.

Joints of the Wrist Characteristics and Arthrokinematics Radiocarpal joint Midcarpal joint Box 19.1 summarizes Arthrokinematics of the Wrist and Hand Joints.

Joints of the Hand Characteristics and Arthrokinematics Carpometacarpal joints of digits 2 through 5 Carpometacarpal joint of the thumb (digit 1) Metacarpophalangeal joints of digits 2 through 5 Interphalangeal joints and MCP joint of the thumb

Hand Function Muscles of the Wrist and Hand Length-tension relationships Extensor mechanism Control of the unloaded (free) hand Grips and Prehension Patterns Power grips Precision patterns Combined grips Table 19.1 outlines Muscles of the Wrist and Hand. Figure 19.2 illustrates the extrinsic and intrinsic muscles of the wrist and hand. Figure 19.3 illustrates anatomical structures of the extensor mechanism.

Major Nerves Subject to Pressure and Trauma at the Wrist and Hand Nerve Disorders in the Wrist Median nerve Ulnar nerve Referred Pain and Sensory Patterns

management of wrist and hand disorders and surgeries Table 19.2 summarizes Wrist and Hand Pathologies/Surgical Procedures and Preferred Practice Patterns.

Joint Hypomobility: Nonoperative Management Common Joint Pathologies and Associated Impairments Rheumatoid arthritis Osteoarthritis and post-traumatic arthrosis Postimmobilization hypomobility Common Activity Limitations and Participation Restrictions

Joint Hypomobility: Nonoperative Management (cont'd) Management: Protection Phase Control pain and protect joints Patient education Pain management Splinting Activity modification Maintain joint and tendon mobility and muscle integrity Passive, assistive, or active ROM Tendon-gliding exercises Multiple-angle muscle setting exercises Box 19.2 summarizes Joint Protection in the Wrist and Hand.

Joint Hypomobility: Nonoperative Management (cont'd) Management: Controlled Motion and Return to Function Phases Increase joint play and accessory motions Joint mobilization techniques Unlocking a subluxated ulnomeniscal-triquetral joint Improve joint tracking and pain-free motion MWM of the wrist MWM of the MCP and IP joints of the digits

Joint Hypomobility: Nonoperative Management (cont'd) Management: Controlled Motion and Return to Function Phases (cont’d) Improve mobility, strength, and function Neuromuscular control and strength Functional activities Conditioning exercises Joint protection

Wrist Arthroplasty Indications for Surgery Procedures Implant designs, materials, and fixation Operative overview Joint Surgery and Postoperative Management Box 19.3 summarizes Surgical Intervention for RA or DJD of the Wrist and Hand. Box 19.4 contains Contraindications to Arthroplasty of the Wrist or Digits.

Wrist Arthroplasty (cont'd) Postoperative Management Immobilization Exercise Maximum and moderate protection phases Minimum protection/return to functionphase Outcomes Pain relief Wrist and forearm ROM, strength, and function Complications Joint Surgery and Postoperative Management Box 19.5 contains Precautions After Wrist Arthroplasty.

Metacarpophalangeal Implant Arthroplasty Indications for Surgery Procedures Implant design, materials, and fixation Operative overview Joint Surgery and Postoperative Management

Metacarpophalangeal Implant Arthroplasty (cont'd) Postoperative Management Immobilization Exercise Maximum protection phase Moderate and minimum protection phases Outcomes Pain relief and patient satisfaction ROM and hand function Complications Joint Surgery and Postoperative Management

Proximal Interphalangeal Implant Arthroplasty Indications for Surgery Procedure Implant design, materials, and fixation Operative overview Joint Surgery and Postoperative Management Table 19.3 compares Surgical Approaches for PIP Joint Arthroplasty.

Proximal Interphalangeal Implant Arthroplasty (cont'd) Postoperative Management Immobilization Exercise Maximum and moderate protection phases Boutonnière deformity Swan-neck deformity Minimum protection/return to function phase Outcomes Complications Joint Surgery and Postoperative Management Table 19.4 outlines Position of Immobilization After PIP Arthroplasty.

Carpometacarpal Arthroplasty of the Thumb Indications for Surgery Procedure Background and surgical options Operative overview Tendon interpositional arthroplasty Surface replacement arthroplasty Joint Surgery and Postoperative Management

Carpometacarpal Arthroplasty of the Thumb (cont'd) Postoperative Management Immobilization Exercise Maximum protection phase Moderate and minimum protection phases Outcomes Pain relief and patient satisfaction ROM and hand function Complications Joint Surgery and Postoperative Management Box 19.8 contains Precautions After CMC Arthroplasty of the Thumb.

Tendon Rupture Associated With RA Background and Indications for Surgery Procedures Tendon transfer Tendon graft reconstruction Tendon anastomosis (side-to-side tenorrhaphy) Direct end-to-end repair Joint Surgery and Postoperative Management

Tendon Rupture Associated With RA (cont'd) Postoperative management Immobilization Exercise Maximum protection phase Moderate and minimum protection phases Outcomes Joint Surgery and Postoperative Management Box 19.9 contains Precautions After Extensor Tendon Transfers or Reconstruction in the Rheumatoid Hand.

Repetitive Trauma Syndromes/ Overuse Syndromes Tendinopathy Etiology of symptoms Common structural and functional impairments Common activity limitations and participation restrictions Management Protection phase Controlled motion and return to function phases

Simple Sprain Nonoperative Management Common functional and structural impairments Common activity limitations and participation restrictions Management Traumatic Lesions in the Wrist and Hand

Lacerated Flexor Tendons of the Hand Background and Indications for Surgery Procedures Types and timing of operative procedures Immediate primary repair Delayed primary repair Secondary repair Late reconstruction Staged repair Traumatic Lesions in the Wrist and Hand Figure 19.12 illustrates Flexor Tendon Zones. Box 19.10 describes Flexor Tendon Zones: Anatomical Landmarks.

Lacerated Flexor Tendons of the Hand (cont'd) Procedures (cont’d) Operative overview Surgical approach Suturing technique Closure Traumatic Lesions in the Wrist and Hand

Lacerated Flexor Tendons of the Hand (cont'd) Postoperative Management General considerations Approaches to postoperative management Immobilization Duration Type or method Position Traumatic Lesions in the Wrist and Hand Box 19.14 contains Indications for Use of Prolonged Immobilization and Delayed Motion After Flexor Tendon Repair.

Lacerated Flexor Tendons of the Hand (cont'd) Postoperative Management (cont’d) Exercise Early controlled motion approaches Passive motion Active motion Maximum protection phase Moderate protection phase Minimum protection/return to function phase Delayed motion approach Outcomes Traumatic Lesions in the Wrist and Hand Figure 19.14 illustrates splinting and exercise for early active motion postflexor tendon repair.

Lacerated Extensor Tendons of the Hand Background and Indications for Surgery Procedures Types of repair and reconstruction Operative overview Zone III/IV primary repair Traumatic Lesions in the Wrist and Hand Figure 19.15 illustrates extensor tendon zones. Box 19.17 outlines Extensor Tendon Zones: Anatomic Landmarks.

Lacerated Extensor Tendons of the Hand (cont'd) Postoperative Management Immobilization Duration Types Exercise Early controlled active motion approach Use of customized static volar splints Delayed mobilization approach Outcomes Traumatic Lesions in the Wrist and Hand Box 19.19 summarizes Special Considerations for Exercise After Extensor Tendon Repair and Extended Immobilization.

Exercise interventions for the wrist and hand

Tendon-Gliding and Tendon-Blocking Exercises Place-and-Hold Exercises Flexor Tendon-Gliding Exercises Hook (claw) fist position Full fist Straight fist (sublimis fist) Thumb flexion Techniques for Musculotendinous Mobility Figure 19.17 illustrates the five finger positions used for flexor tendon-gliding exercises.

Tendon-Gliding and Tendon-Blocking Exercises (cont'd) Flexor Tendon-Blocking Exercises Isolated MCP flexion (lumbricales and palmar interossei) PIP flexion (flexor digitorum superficialis) DIP flexion (flexor digitorum profundus) Full fist Techniques for Musculotendinous Mobility Figure 19.18 illustrates flexor tendon-blocking exercises.

Tendon-Gliding and Tendon-Blocking Exercises (cont'd) Exercises to Reduce Extensor Lag Isolated MCP extension Isolated PIP and DIP extension Terminal range extension of IP joints Extensor Tendon-Gliding Exercises Techniques for Musculotendinous Mobility

Scar Tissue Mobilization for Tendon Adhesions To Mobilize the Long Finger Flexor Tendons To Mobilize the Extensor Tendons and the Extensor Mechanism Techniques for Musculotendinous Mobility

Exercise Techniques to Increase Flexibility and Range of Motion General Stretching Techniques To increase wrist extension To increase wrist flexion To increase flexion or extension of individual joints of the fingers or thumb

Exercise Techniques to Increase Flexibility and Range of Motion (cont'd) Stretching Techniques for the Intrinsic and Multijoint Muscles Self-stretching the lumbricales and interossei muscles Self-stretching the interossei muscles Self-stretching the adductor pollicis Manual stretching of the extrinsic muscles Self-stretching the flexor digitorum profundus and superficialis Self-stretching the extensor digitorum communis

Exercise to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement Techniques to Strengthen Muscles of the Wrist and Hand To strengthen wrist musculature To strengthen weak intrinsic musculature To strengthen weak extrinsic musculature Mechanical resistance techniques for combined intrinsic and extrinsic muscle function

Exercise to Develop and Improve Muscle Performance, Neuromuscular Control, and Coordinated Movement (cont'd) Dexterity and Functional Activities Fine finger dexterity Functional activities

Independent Learning Activities Critical Thinking and Discussion Laboratory Practice Case Studies