WRIST and HAND

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WRIST and HAND




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WRIST and HAND

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The hand and the wrist are the most active and the most intricate parts of the upper extremity. (Magee, David; Orthopedic Physical Assessment 4th Ed)Vulnerable to injury and does not respond well to serious trauma. (Magee, David; Orthopedic Physical Assessment 4th Ed)In addition to being an expressive organ of communication, the hand has a protective role and acts as both a motor and a sensory organ, providing information such as temperature, thickness, texture, depth, and shape as well as the motion of an object. (Magee, David; Orthopedic Physical Assessment 4th Ed)

Wrist and Hand

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BonesJointsMusclesCommon Hand ConditionsAssessment / Special TestsMini Quiz

Topic contents:

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Styloid process of ulna & radius8 carpal bones Proximal row: scaphoid, lunate, triquetrum, pisiform Distal row: trapezium, trapezoid, capitate, hamate5 metacarpals14 phalanges

Bones of the Wrist and Hand

Slide5

Some Lawyers Tender Proposals That They Cannot Handle

The Carpals

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Scaphoid - most frequently fractured carpal bone Lunate – most frequently dislocated carpal bonePisiform – smallest; lies on diff plane; last to ossifyCapitate – largest carpal bone, center of wrist, first to ossifyHamate – with hook like process

The Carpal Bones

Slide7

TRAPEZIUMGreater Multangular(TrapeZOOM)The trapeziUM supports the thUMb

TRAPEZOIDLesser MultangularThe trapezoid’s on the inZOID

How do you remember that the trapezium comes before the trapezoid

?

Slide8

Carpus/Wrist complexDistal Radioulnar Joint (magee)Radiocarpal joints (norkin)Midcarpal jointsIntercarpal JointCarpometacarpal jtsIntermetacarpal jts.Fingers & thumbMetacarpophalangeal Interphalangeal

Joints of the Wrist and Hand

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Distal Radioulnar Jointuniaxial pivotone degree of freedom.RP – 10 degrees supinationCP – 5 degrees supinationCPP – pain at extremes of rotationRadiocarpal Jointbiaxial ellipsoid joint (2 degrees Freedom of Movement)Scaphoid and lunate articulates with radiusLunate and triquetrum articulates with triangular cartilaginous disc (triangular fibrocartilage complex- TFCC)RP – neutral with slight ulnar deviationCP – extensionCPP – flexion and extension equally limited

Joints of the Wrist and Hand

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Midcarpal JointArticulation between proximal and distal carpal rowsCompound sellar joint; Two degrees of freedomRP – neutral or slight flexion with ulnar deviationCP – extension with ulnar deviationCPP – flexion and extension equally limitedIntercarpal JointsThe joints between individual bones of proximal carpal row and joints between individual bones of distal carpal row.RP – neutral or slight flexionCP – extensionCPP – no capsular pattern

Joints of the Wrist and Hand

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Carpometacarpal Joints (CMC)1st CMC – sellar with 3 degrees freedom of movement2nd-5th – plane joints (allow only gliding movements; 2nd and 3rd relatively immobile)RP – Thumb, midway between abduction and adduction, and midway between flexion and extensionFingers, midway between flexion and extensionCP – Thumb, full opposition; Fingers, full flexionCPP – Thumb, abduction, then extensionFingers, equal limitation in all directions

Joints of the Wrist and Hand

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Intermetacarpal Jointshave only a small amount of gliding movement between them and do not include the thumb articulation. They are bound together by palmar, dorsal, and interosseous ligamentsMetacarpal JointsCondyloid joints with 2 degrees of freedomRP - slight flexionCP – full opposition ; fingers full flexionCPP – flexion then extension

Joints of the Wrist and Hand

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Wrist extensorsBrachioradialisECRLECRBExtensor digitorumExtensor carpi ulnarisWrist flexorsPalmaris longusFlexor carpi radialisFlexor carpi ulnarisFlexor digitorum superficialis

Muscles of the Wrist and Hand

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Ulnar abductorsExtensor carpi ulnarisFlexor carpi ulnarisRadial abductorsECRLFlexor carpi radialisAbductor pollicis longusExtensor pollicis brevis

Muscles of the Wrist and Hand

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Extrinsic hand musclesExtensor digitorumExtensor indicis propriusExtensor digiti minimiExtensor pollicis longusExtensor pollicis brevisAbductor pollicis longusFlexor digitorum superficialisFlexor digitorum profundusFlexor pollicis longus

Muscles of the Wrist and Hand

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4 lumbricals3 palmar interrosei4 dorsal interroseiThenar muscles: opponens pollicis, APB adductor pollicis, FPBHypothenar muscles: opponens digiti minimi, abductor digiti minimi, flexor digiti minimi brevisPalmar brevis

Intrinsic hand muscles

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Dupuytren’s contractureSwan-neck deformityBoutonniere deformityMallet fingerJersey fingerUlnar driftTrigger fingerClaw fingersApe hand deformityBishop’s handWrist drop deformityDe Quervain’s deformity

Common Wrist and Hand Conditions

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Dupuytren’s ContractureDue to the contracture of the palmar fasciaCommon among menUsually seen in the 50- to 70- age groupFixed flexion deformity of the MCP & PIP jointsUsually seen in the ring or little finger

Common Wrist and Hand Conditions

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Swan-Neck DeformityResult of contracture of the intrinsic muscles Often seen after trauma or in patients with RAFlexion of the MCP & DIP joints & extension of the PIP joint

Common Wrist and Hand Conditions

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Boutonniere DeformityResult of the rupture of the central tendinous slip of the extensor hoodMost common after trauma or in RAExtension of the MCP & DIP joints & flexion of the PIP joint

Common Wrist and Hand Conditions

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Mallet FingerResult of the rupture or avulsion of the extensor tendon where it inserts in the distal phalanx of the fingerDistal phalanx rests in a flexed position

Common Wrist and Hand Conditions

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Jersey FingerCaused by rupture of the flexor digitorum profundus tendonCommon among football playersOccurs most often in the ring fingerInability to flex the affected DIP joint which becomes apparent when the patient is asked to make a fistPositive sweater finger sign

Common Wrist and Hand Conditions

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Ulnar DriftDue to weakening of the capsuloligamentous structures of the MCP joints & the accompanying bowstring effect if the extensor communis tendons Commonly seen in patients with RAUlnar deviation of the digits

Common Wrist and Hand Conditions

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Claw FingersIntrinsic minus handLoss of intrinsic muscle action & the overaction of the extrinsic muscles on the proximal phalanx of the fingersCombined median & ulnar nerve palsyMCP joints are hyperextended & the PIP & DIP joints are flexed

Common Wrist and Hand Conditions

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Ape Hand DeformityMedian nerve palsyWasting of the thenar eminence of the handInability to oppose or flex the thumb

Common Wrist and Hand Conditions

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Bishop’s Hand or Benediction Hand DeformityUlnar nerve palsyWasting of the hypothenar muscles of the hand, the interossei muscles, & the two lumbrical musclesFlexion of the 4th & 5th fingers

Common Wrist and Hand Conditions

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Wrist Drop DeformityRadial nerve palsyParalysis of the extensor muscles of the wrist

Common Wrist and Hand Conditions

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De Quervain’s SyndromeSeen in patients who perform activities requiring forceful gripping with radial deviation of the wrist, or repetitive use of the thumbInsidious onset of pain & tenderness over the dorsal radial aspect of the wristPositive Finkelstein’s test

Common Wrist and Hand Conditions

Slide30

Wrist and Hand

Special tests for tendon and muscle pathology

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FINKELSTEIN -- PASSIVE PROCEDURE - Pt MAKES A FIST WITH THUMB INSIDE THE FINGERS - THE PT WILL STABILIZED THE FOREARM AND DEVIATES THE WRIST TOWARDS ULNAR SIDE POSITIVE - PAIN OVER THE ABPL AND EPB INDICATION - DE QUERVEINS / HOFFMAN’S DSE COMMON - ROWERS

SPECIAL TEST FOR WRIST AND HAND

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SWEATER FINGER / JERSEY TEST PROCEDURE - THE Pt WILL FLEXED ALL THE MCP JOINTS POSITIVE - IF THE DIP WILL NOT FLEX INDICATION - FDP RUPTURE

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Bunnel-Littler Test

Tests for …

Tightness or contracture in the joint capsule of the PIP joint.

Position

Sitting with MCP joint held in extension.

Stimulus

Move PIP joint into flexion.

(+) Response

PIP joint does not move into flexion. If MCP is flexed & PIP does move into more flexion, then intrinsic muscle tightness.

Slide34

Wrist and Hand

Tests for neurologic dysfunction

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Tinel’s Sign at the Wrist

Tests for …

Median nerve.

Position

Sitting with forearm supination.

Stimulus

Tap over pt.’s volar carpal ligament with fingertip.

(+) Response

Pain or paresthesia distal to the wrist.

Slide36

PHALEN’S PROCEDURE - THE EXAMINER WILL FLEXED THE WRIST MAXIMALLY AND HOLD THE POSITION FOR 1 MIN POSITIVE - PARESTHESIA / TINGLING SENSATION ON THUMB, INDEX, MIDDLE AND HALF OF THE RING FINGER INDICATION - CARPAL TUNNEL SYNDROME - MEDIAN NERVE IMPINGEMENT

Slide37

4. REVERSE PHALEN’S / PRAYERS TEST - SAME AS PHALEN’S TEST

CARPAL TUNNEL SYNDROME

ATROPHY OF THENAR

- LONG TERM

COMPRESSION

NO SENSORY LOSS

+ PARESTHESIA

PAIN AT NIGHT

PT MANAGEMENT

REST AND AROMES

Slide38

OK SIGN USE - TEST THE INTEGRITY OF THE AIN - PQ, FPL AND FDP PROCEDURE - ASK THE PATIENT TO MAKE AN OK SIGN POSITIVE - IF PULP TO PULP / INDICATION - AIN SYNDROME PATHOLOGY KILOH – NEVIN SYNDROME

NO SENSORY SYMPTOMS

Slide39

6. FROMENT’S TEST PROCEDURE - Pt GRASP THE PIECE OF PAPER BETWEEN THE THUMB AND INDEX THE PT WILL PULL THE PAPER POSITIVE - FLXION OF THE DIP OF THUMB INDICATION - ADDUCTOR POLLICIS AFFECTATION

Slide40

7. WRINKLE / SHRIVEL TEST PROCEDURE - Pt FINGER PLACE IN WARM WATER FOR 5 TO 20 MINS. POSITIVE - NO WRINKLING OF PULP INDICATIVE - DENERVATION

Slide41

Allen Test for Radial & Ulnar Nerve Patency

Tests for …

Patency of the radial &

ulnar

arteries

Position

Sitting with forearm free to move, elbow bent with fingers pointing up toward the ceiling.

Stimulus

Compress the radial &

ulnar

arteries at the wrist, one thumb on the

ulnar

artery & the other on the radial artery. Pt. should open & close fist quickly. PT then releases the pressure on the one artery & observes the filling pattern of the vessels in the palm. Do the same for the other artery.

(+) Response

Blanching remains in the palm after pressure is released from the artery. Can also be used to test individual fingers.

Slide42

Proximal Row of carpal bones all except:

1.Scaphoid

2.Lunate

3.Trapezium

4.Triquetral

A patient reported with a history of fall on an outstretched hand, complains of pain in the anatomical snuffbox and clinically no deformities

visible.The

diagnosis is:

1.Colles fracture

2.Lunate dislocation

3. Barton’s fracture

4.Scaphoid fracture

The most common nerve involvement is dislocation of

lunate

is

Median nerve

Anterior

interosseus

Posterior

interosseous

Median nerve

Bennet’s

fracture is fracture dislocation of base of metacarpal:

1.4

th

2.

3

rd

3.2

nd

4.1

st

Slide43

A 30 year old man involved in a fight, injured his middle finger and noticed slight flexion of DIP joint. X rays were normal . The most appropriate management at this stage is:

Ignore

Splint the finger in hyperextension

Surgical repair of the flexor tendon

Buddy strapping

In hand surgery which area is called no mans land:

Proximal phalanx

Distal phalanx

Wrist

Between distal phalanx crease and proximal phalanx.

True regarding mallet finger is:

Avulsion of tendon at the base of the middle phalanx

Avulsion of extensor tendon at the base of the distal phalanx

Fracture of distal phalanx

Fracture of proximal phalanx

Froment

sign is positive in:

1.Ulnar nerve injury

2. Radial nerve injury

3. Median nerve injury

4.

Erbs

palsy


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