1. 19 Bones 19 Articulations 29 Muscles
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
Need arches for functional hand
If develop flat hand will not have a functional hand

4. Mobility of 4th and 5th CMC Joints
Articulations at the 4th and 5th CMC joints allow the “cupping” of the hand
Mobility of 4th and 5th 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
Extensor Digitorum - Radial
Extensor Indicis Proprius - Radial
Extensor Digiti Minimi - Radial
Extensor Pollicus Longus - Radial
Extensor Pollicus Brevis - Radial
Abductor Pollicus Longus - Radial
Flexor Digitorium Superficialis - Median
Flexor Digitiorium Profundus - Median/on radial side;; Ulnar/Ulnar side
Flexor Pollicus Longus - Median

10. Intrinsics Four Lumbricals Three Palmar Interossei
Four Dorsal Interossei
Thenar muscles
Opponens Pollicus
Abductor Pollicus Brevis
Adductor Pollicus
Flexor Pollicus Brevis
Four Lumbricals Radial two – Median; Ulnar two - Ulnar
Three Palmar Interossei - Ulnar
Four Dorsal Interossei - Ulnar
Thenar muscles
Opponens Pollicus - Median
Abductor Pollicus Brevis - Median
Adductor Pollicus - Ulnar
Flexor Pollicus Brevis – Superficial (median); Deep (Ulnar)

11. Intrinsics Hypothenar muscles Palmaris Brevis Opponens Digiti Minimi
Abductor Digiti Minimi
Flexor Digiti Minimi Brevis
Palmaris Brevis
All Ulnar Nerve
Hypothenar muscles
Opponens Digiti Minimi
Abductor Digiti Minimi
Flexor Digiti Minimi Brevis
Palmaris Brevis

12. Flexor Tendons

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
Have 5 Annular Pulleys
A2 (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 joints
Also have 3 Cruciate pulleys (between A2 and A3; A3 and A4; A4 and A5) thinner fibers

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 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 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.
Extensor Mechanism

19. Extensor Mechanism
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

20. Extensor Mechanism Closed pack position
MCP 70 degree s
PIP/DI P extensi on
Hood slides forward here over proximal phalanx. During flexion the lateral bands move volarly.
Extensor Mechanism Closed pack position

21. Closing Hand
Early – FDP and FDS and interossei muscles actively flex the joints
Late – lumbricals still inactive, assembly (hood) moves over proximal phalanx

22. Opening Hand Early – extensor digitorum is extending at MCP joint
Middle – Intrinsics (lumbricals and interossei) assist extension at the PIP and DIP joints
Late – Assembly (Hood) slides back over MCP joint

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
At MCP joints the collateral ligaments are taut or stretched to prevent shortening and prevent flexion contractures
At the PIP and DIP joints there is equal tension of collateral ligaments throughout the ROM, hence splinted in extension

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
Deformity 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”.

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

32. Intrinsic Plus and Minus

33. Types of Prehension Power grip Precision grip Power (key) pinch
Spherical
Cylindrical
Precision grip
Power (key) pinch
Lateral pinch
Precision pinch
Hook grip
Power grip - hammer
Spherical
Cylindrical
Precision grip – holding an egg; holding a baseball
Power (key) pinch
Lateral pinch
Precision pinch – tip to tip; pulp to pulp
Hook grip - suitcase
Types of Prehension

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

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
Mallet Finger - Tear of the extensor tendon from the attachment on the distal phalanx
Swan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contract
Boutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIP
Zig Zag Deformities from Rheumatoid Arthritis
DeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tenderness
Dupuytren’s Contracture - fibrous contracture of the palmar fascia
Problems of the Hand

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
Loss of musculocutaneous = profound weakness of forearm flexion, extension and supination
Statically – forearm is pronated and extended

42. http://video. google. com/videosearch
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Tenodesis- C6

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
Median Nerve Injury

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
Median Nerve = C5-C6, Medial and Lateral cords

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)
Most wrist and extrinsics muscles originating in the area of the medial epicondyle

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. Wasting 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 thumb
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)
In forearm = all flexor compartment EXCEPT FCU, ulnar half of FDP = Ulnar
A 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 useless
Median Nerve Injury (ape or pope)

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)
Ulnar nerve- points of entrapment

52. Ulnar nerve injury More severe deformity with low injury
High injury also loose FDP so fingers are less flexed
FCU and Ulnar half of FDP
Cutaneous branch
The muscles paralyzed are the flexor carpi ulnaris, medial half of the flexor digitorum profundus, medial two lumbricals, all interossei and the adductor pollicis
Injury 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

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)
Muscles innervated by the Ulnar nerve

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

55. Froment’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)

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
Posterior compartment of the arm
Superficial branch = Cutaneous only
Radial Nerve- Points of entrapment

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
Most wrist and extrinsics muscles originating in the area of the lateral epicondyle

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.
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 drop
Radial Nerve Injury = Wrist drop or Saturday night palsy

60. Radial Tunnel Syndrome
Test = Resisted supination and resisted middle finger extension
Confused with Lateral Epicondyilits
5 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

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
Radial Nerve Injury

62. Wrist 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)

63. Mallet Finger
Mallet Finger - Tear of the extensor tendon from the attachment on the distal phalanx
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
Swan Neck Deformity - MCP joint subluxes volarly and PIP extends as intrinsics contract

66. Boutonniere Deformity
Boutonniere Deformity - Central extensor slip and lateral bands migrate volarly; extends MCP (and DIP) and flexes PIP
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.

68. Zig Zag Deformities of the Fingers

69. Zig 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.

70. Tenosynovitis of thumb “tendons at the radial styloid process
abductor pollicus longus
extensor pollicus brevis
Maybe a swelling in the area, tenderness
DeQuervain’s Disease -tendinitis of thumb abductors at the radial styloid process abductor pollicus longus and extensor pollicus brevis - maybe a swelling in the area, tenderness
DeQuervain’s Disease

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
Fibrous contracture of the palmar fascia
Most common in ring and little fingers