Wrist & Hand

Orthopaedic Assessments Lectures 23 & 24

The Wrist & Hand

Agenda – Introduction – Applied anatomy – Patient History – Observation – Examination • Active movements • Passive movements • Isometric – Special tests

Wrist & Hand - Introduction

• Most active and intricate parts of the upper limb • Vulnerable to injury • Respond poorly to severe trauma • Mobility is enhanced by movements of the shoulder and elbow

Wrist & Hand - Introduction

• Functions – Communication – Protection – Motor and sensory organ • Important to remember that when examining the hand/wrist, they do not work in isolation from the elbow and shoulder

Wrist & Hand – Applied Anatomy

• 29 bones • 19 intrinsic muscles • 20 extrinsic muscles • Many articulations

Triangular Cartilaginous Disc • O: ulnar side of distal radius • I: ulna at styloid process • Adds stability – Close relation b/w ulna and carpal bones – Stabilizes long bones

Wrist & Hand – Applied Anatomy

Distal Radioulnar Joint

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern

10° of supination 5° of supination pain at extreme of rotation

Wrist & Hand – Applied Anatomy

Radiocarpal (Wrist) Joint

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern

neutral with slight ulnar deviation extension flexion and extension equally limited

Wrist & Hand – Applied Anatomy

Radiocarpal (Wrist) Joint

• Radius articulates with the scaphoid and lunate • Lunate and triquetrium articulate with the TFCC

Wrist & Hand – Applied Anatomy

Intercarpal Joints

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern

neutral or slight flexion extension none

Wrist & Hand – Applied Anatomy

Intercarpal Joints

• Includes the joints of b/w the individual bones of the proximal row of carpal bones (scaphoid, lunate, triquetrium) and the joints b/w the individual bones of the distal row of carpal bones (trapezium, trapezoid, capitate, hamate)

Wrist & Hand – Applied Anatomy

Wrist & Hand – Applied Anatomy

Midcarpal Joints

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern

neutral or slight flexion with ulnar deviation extension with slight ulnar deviation equal limitation of flexion and extension

Wrist & Hand – Applied Anatomy

Midcarpal Joints

• Form a compound articulation b/w the proximal and distal rows of carpal bones – ie. Grouping of bones • MEDIALLY: scaphoid, lunate & triquetrium articulate with capitate & hamate • LATERALLY: scaphoid articulates with trapezoid and trapezium

MEDIAL GROUP

LATERAL GROUP

Wrist & Hand – Applied Anatomy

Carpometacarpal Joints (THUMB)

• Resting Pos'n

midway b/w abduction and adduction, and midway b/w flexion and extension

• Close Pack Pos'n • Capsular Pattern

full opposition abduction, then extension

Wrist & Hand – Applied Anatomy

Carpometacarpal Joints (FINGERS)

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern `

midway b/w flexion and extension full flexion equal limitation in all directions

Wrist & Hand – Applied Anatomy

Carpometacarpal Joints

• Fingers 2-5, only gliding movements are allowed for • At the thumb, movement into 6 directions are allowed for: – Flexion, extension, abduction, adduction, rotation and circumduction

Wrist & Hand – Applied Anatomy

Metacarpophalangeal Joints

• Resting Pos'n • Close Pack Pos'n

• Capsular Pattern

slight flexion THUMB: full opposition FINGERS: full flexion flexion, then extension

Wrist & Hand – Applied Anatomy

Metacarpophalangeal Joints nd

rd

• 2 & 3 metacarpophalangeal joints are generally immobile and are the primary stabilizing factor of the hand

Wrist & Hand – Applied Anatomy

Interphalangeal Joints

• Resting Pos'n • Close Pack Pos'n • Capsular Pattern

slight flexion full flexion flexion, then extension

Wrist & Hand – Applied Anatomy

• During flexion of the fingers, they converge towards the scaphoid tubercle – “cascade sign”

Wrist & Hand – Patient History

•Review relevant section in Magee

Wrist & Hand – Patient Observation

• Views from palmar and dorsal aspect • Normal bony and soft tissue contours –Include forearm • Willingness to move or ability to move hand • Finger flexion – normally when fingers and wrist are at rest in neutral, the fingers become more progressively flexed as you move from the radial to ulnar side

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Ulcerations: neurological or circulatory problems –Look for alteration in colour of limb; may indicate circulatory problem • Wounds / scarring – may interfere with finger mobility and control

Wrist & Hand – Patient Observation

• Nails: –“clubbed” nails may point to cardiac or respiratory dysfunction –“spoon-shaped” nails are often the result of fungal infection, anemia, iron deficiency, chronic diabetes, local injury, psoriasis, developmental abnormality, chemical irritation

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Duputryen's Contracture • the connective tissue under the skin of your palm contracts and toughens (thickens) over time

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Ganglions & Cysts – Benign, fluid-filled capsules – Occur adjacent to joints and tendons – Cause: unknown • One school of thought is FRICTION

– Not cancerous, nor will they spread

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Thenar / Hypothenar Atrophy – Thenar: median n. – Hypothenar: ulnar n. – First dorsal interosseous muscle: C7 nerve root

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Osteoarthritis –Aka: degenerative arthritis –Abnormal wearing of cartilage of joints –Loss of synovial fluid –Heberden's Nodes: bony nodes at the DIP (dorsal surface) • Early sign of OA

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Rheumatoid Arthritis –Chronic, systemic autoimmune disorder that causes the immune system to attack one's own joints –Can be very disabling and painful –Problems with other organs of the body can occur – Bouchard's Nodes: bony nodes at the PIPs – Ulnar drift

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Boutonniere Deformity –Extension of the metacarpophalangeal and DIP joints, flexion of the PIP joint –Rupture of the extensor tendon over joint •Trauma, RA

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Swan-Neck Deformity –Flexion of the metacarpophalangeal and DIP joints, extension at the PIP –Usually due to contracture of the intrinsic muscles •Trauma, RA

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Claw Fingers –Loss of intrinsic muscle action and the overaction of extrinsic (long) extensor muscles on the proximal phalanx of the fingers –MCP joints are hyperextended; PIPs and DIPs are flexed –Normal cupping of hand is lost –Combination of median and ulnar nerve palsy

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Trigger Finger –Thickening of the flexor tendon sheath causing sticking of the tendon when the patient attempts to flex the finger –Inflammation leads to swelling and tendon stenosis –Finger will snap

Wrist & Hand – Patient Observation

• Ape Hand Deformity –Median nerve palsy causing atrophy of the thenar eminence –Thumb falls in line with the fingers as a result of the pull of the extensor muscles –Person unable to oppose or flex the thumb

Wrist & Hand – Patient Observation

• Drop-Wrist Deformity –Radial nerve palsy leading to inability of extensor muscles to function • Wrist and fingers cannot be extended

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Mallet Finger Deformity –Rupture or avulsion of the extensor tendon where it inserts into the distal phalanx of the finger –Distal phalanx rests in a flexed position

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

• Raynaud's Disease –Cold, painful hands –Idiopathic vascular disorder characterized by attacks of pallor and cyanosis of the extremities often brought about by cold or emotion

Wrist & Hand – Patient Observation

Wrist & Hand – Patient Observation

EXAMINATION

Wrist & Hand – Examination

• Wrist and hand have both a fixed and a mobile segment • Fixed Segment: distal row of carpal bones (trapezium, trapezoid, capitate, hamate) and the 2nd and 3rd MC bones – Provides stability to the hand and wrist without sacrificing mobility – Not a rigid segment; there is movement, but less so then the mobile segment

• Mobile Segment: five phalanges and the 1st, 4th and 5th MC bones

FIXED SEGMENT of WRIST AND HAND

Wrist & Hand – Examination

ACTIVE ROM • Pronation (forearm) • Supination (forearm) • Wrist abduction –Radial deviation • Wrist adduction –Ulnar deviation • Wrist flexion • Wrist extension

80° - 90° 90° 15° 30° - 45° 80° - 90° 70° - 90°

Wrist & Hand – Examination

ACTIVE ROM (cont'd) • Finger flexion –MCP –PIP –DIP • Finger extension –MCP –PIP –DIP

85° - 90° 100° 80° - 90° 30° - 45° 0° 20°

Wrist & Hand – Examination

ACTIVE ROM (cont'd) • Finger abduction • Finger adduction • Thumb flexion –CMC –MCP –IP • Thumb extension –MCP –IP

20° - 30° 0° 45° - 50° 50° - 55° 85° - 90° 0° 0° - 5°

Wrist & Hand – Examination

ACTIVE ROM (cont'd) 60° - 70° • Thumb abduction 30° • Thumb adduction • Opposition of the thumb and 5th digit (tipto-tip) • Combined movements (if necessary) • Repetitive movements (if necessary) • Sustained movements (if necessary)

Wrist & Hand – Examination

THUMB ABDUCTION & ADDUCTION

THUMB FLEXION & EXTENSION

Wrist & Hand – Examination

PASSIVE ROM • Pronation • Supination • Radial deviation • Ulnar deviation • Wrist flexion • Wrist extension • Finger flexion • Finger extension

tissue stretch tissue stretch bone-to-bone bone-to-bone tissue stretch tissue stretch tissue stretch tissue stretch

Wrist & Hand – Examination

PASSIVE ROM (cont'd) tissue stretch • Finger abduction tissue stretch • Thumb flexion tissue stretch • Thumb extension tissue stretch • Thumb abduction tissue approximat'n • Thumb adduction tissue stretch • Opposition

Wrist & Hand – Examination

ISOMETRIC RESISTED ROM • Pronation • Supination • Radial deviation • Ulnar deviation • Wrist flexion • Wrist extension • Finger flexion • Finger extension

Wrist & Hand – Examination

ISOMETRIC RESISTED ROM (cont'd) • Finger abduction • Finger adduction • Thumb flexion • Thumb extension • Thumb abduction • Thumb adduction • Opposition

Wrist & Hand – Examination

FUCTIONAL • Thumb is the most important digit –Relation to other digits, forces it can bear, mobility • Index finger is the second most important digit –Musculature, strength, interaction with the thumb

Wrist & Hand – Examination

FUCTIONAL rd

• Middle (3 ) finger – strongest –Important for power and precision th • Little (5 ) finger – enhances power grip, affects the capacity of the hand, holds objects against the hypothenar eminence • Ring (4th) finger – least functional of the fingers

Wrist & Hand – Examination

FUCTIONAL • In terms of loss: – Thumb: 40-50% of hand function – Index finger: 20% of hand function – Middle finger: 20% of hand function – Ring finger: 10% of hand function – Little finger: 10% of hand function

Wrist & Hand – Examination

FUCTIONAL

• In terms of loss: – The entire hand: 90% loss of upper limb function!!!

Wrist & Hand – Examination

FUCTIONAL - GRIP • Power Grip – Primary function of the ulnar side of hand – Used whenever strength or force is the primary consideration • Precision Grip – Limited mainly to the MCP joints and involves primarily the radial side of the hand – Accuracy and precision

Wrist & Hand – Special Tests

SPECIAL TESTS • Tendons & Muscles – Finkelstein's Test – Bunnel-Littler Test • Neurological – Tinel's Sign at the wrist – Phalen's Test – Reverse Phalen's Test – Froment's

– Circulatory • Allen's Test – Instability Tests (ligamentous) • Shuck Test • Thumb Ulnar Collateral Ligament instability Test – Other • Murphy's Sign (Skyline Sign)

Wrist & Hand – Special Tests

FINKELSTEIN TEST (1) Client: makes fist with thumb in fist (2) Therapist: stabilizes the forearm and ulnar deviates the wrist POSITIVE: pain over abductor pollicis longus and extensor brevis tendons INDICATES: de Quervain's tenosynovitis in the thumb * can cause discomfort in normal individuals, so compare bilaterally and consider whether the client's symptoms are reproduced

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

BUNNEL-LITTLER TEST (1) Therapist: holds MCP of test finger in slight extension (2) Therapist: moves PIP (of same finger) into flexion POSITIVE: inability to flex the PIP INDICATES: tight intrinsic muscles or contracture of the joint capsule (ie. arthritide)

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

TINEL'S SIGN (at the wrist) (1) Therapist: tap over the carpal tunnel at the wrist POSITIVE: tingling or paraesthesia into the thumb, index finger, middle and lateral half of ring finger (median nerve distribution) INDICATES: carpal tunnel syndrome

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

PHALEN'S TEST (1) Client or Therapist: maximally flex wrists and hold them together for 1 minute POSITIVE: tingling or paraesthesia in the median nerve distribution INDICATES: carpal tunnel syndrome

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

REVERSE PHALEN'S TEST (1) Client or Therapist: maximally extend wrists and hold them together (2) Therapist: apply direct pressure over the carpal tunnel for 1 minute POSITIVE: tingling or paraesthesia in the median nerve distribution INDICATES: carpal tunnel syndrome

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

FROMENT'S SIGN (1) Client: attempts to grasp a piece of paper b/ w the thumb and index finger (2) Therapist: pull paper away POSITIVE: (a) terminal phalanx of thumb flexes; (b) MCP joint of thumb hyperextends INDICATES: (a) paralysis of abductor pollicis muscle; (b) Jeanne's Sign – Both positives are indicative of median nerve paralysis

Wrist & Hand – Special Tests

Wrist & Hand – Special Tests

ALLEN'S TEST (1) Client: ask to open and close the hand several times as quickly as possible and then squeeze the hand tightly (2) Therapist: compress the radial and ulnar arteries by placing thumb and index finger over them (3) Client: open hand (4) Therapist: release pressure over one artery then the other POSITIVE: ----INDICATES: patency of the radial and ulnar arteries and determines which artery provides the major blood supply to the hand

Wrist & Hand – Special Tests

SHUCK TEST (1) Therapist: hold client's wrist in flexion (2) Therapist: resist isometric extension of the fingers POSITIVE: pain (dorsum of wrist) INDICATES: scaphoid, radiocarpal OR midcarpal instability/inflammation

Wrist & Hand – Special Tests

THUMB ULNAR COLLATERAL LIGAMENT INSTABILITY TEST (1) Therapist: stabilize client's hand and take thumb into extension with the other (2) while holding the thumb in extension, apply a valgus stress to the MCP joint of thumb POSITIVE: valgus movement greater than 35° INDICATES: damage to ulnar collateral ligament (and collateral ligaments); Gamekeeper's thumb; Skier's thumb

Wrist & Hand – Special Tests

MURPHY'S SIGN (SKYLINE SIGN) (1) Client: make a fist and hold arm straight out rd

POSITIVE: head of 3 MC is level nd th with that of 2 and 4 MC INDICATES: dislocation of the lunate