Magee David Orthopedic Physical Assessment 4 th Ed Vulnerable to injury and does not respond well to serious trauma Magee David Orthopedic Physical Assessment 4 th Ed In addition ID: 912974
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Slide1
WRIST and HAND
Slide2The hand and the wrist are the most active and the most intricate parts of the upper extremity. (Magee, David; Orthopedic Physical Assessment 4
th
Ed)Vulnerable to injury and does not respond well to serious trauma. (Magee, David; Orthopedic Physical Assessment 4
th 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
Slide3BonesJointsMusclesCommon Hand ConditionsAssessment / Special Tests
Mini Quiz
Topic contents:
Slide4Styloid process of ulna & radius8 carpal bones
Proximal row: scaphoid
, lunate, triquetrum
, pisiform Distal row:
trapezium, trapezoid, capitate,
hamate
5 metacarpals14 phalangesBones of the Wrist and Hand
Slide5Some Lawyers Tender Proposals That They Cannot Handle
The Carpals
Slide6Scaphoid -
most frequently fractured carpal bone Lunate – most frequently dislocated carpal bone
Pisiform – smallest; lies on diff plane; last to ossifyCapitate –
largest carpal bone, center of wrist, first to ossifyHamate – with hook like process
The Carpal Bones
Slide7TRAPEZIUMGreater Multangular
(TrapeZOOM)
The trapeziUM
supports the thUMb
TRAPEZOID
Lesser
MultangularThe trapezoid’s on the inZOID
How do you remember that the trapezium comes before the trapezoid
?
Slide8Carpus/Wrist complexDistal
Radioulnar Joint (magee)
Radiocarpal joints (norkin)
Midcarpal jointsIntercarpal
JointCarpometacarpal jts
Intermetacarpal
jts.Fingers & thumbMetacarpophalangeal Interphalangeal
Joints of the Wrist and Hand
Slide9Distal Radioulnar Jointuniaxial
pivotone degree of freedom.
RP – 10 degrees supinationCP – 5 degrees
supinationCPP – pain at extremes of rotation
Radiocarpal 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 deviation
CP – extension
CPP – flexion and extension equally limited
Joints of the Wrist and Hand
Slide10Midcarpal JointArticulation between proximal and distal carpal rows
Compound sellar joint; Two degrees of freedom
RP – neutral or slight flexion with ulnar deviation
CP – extension with ulnar deviation
CPP – flexion and extension equally limitedIntercarpal Joints
The 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 patternJoints of the Wrist and Hand
Slide11Carpometacarpal Joints (CMC)1st CMC –
sellar with 3 degrees freedom of movement2
nd-5th – plane joints (allow only gliding movements; 2nd and 3
rd relatively immobile)RP – Thumb, midway between abduction and adduction, and midway between flexion and extension
Fingers, midway between flexion and extensionCP – Thumb, full opposition; Fingers, full flexion
CPP – Thumb, abduction, then extension
Fingers, equal limitation in all directionsJoints of the Wrist and Hand
Slide12Intermetacarpal 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 freedom
RP - slight flexionCP – full opposition ; fingers full flexion
CPP – flexion then extension
Joints of the Wrist and Hand
Slide13Wrist extensorsBrachioradialis
ECRLECRB
Extensor digitorum
Extensor carpi ulnaris
Wrist flexorsPalmaris
longus
Flexor carpi radialisFlexor carpi ulnarisFlexor digitorum
superficialis
Muscles of the Wrist and Hand
Slide14Ulnar abductorsExtensor carpi
ulnarisFlexor
carpi ulnarisRadial abductors
ECRL
Flexor carpi radialis
Abductor
pollicis longusExtensor pollicis brevisMuscles of the Wrist and Hand
Slide15Extrinsic hand musclesExtensor digitorum
Extensor indicis
propriusExtensor digiti
minimiExtensor
pollicis longusExtensor
pollicis
brevisAbductor pollicis longusFlexor digitorum superficialis
Flexor
digitorum
profundus
Flexor
pollicis
longus
Muscles of the Wrist and Hand
Slide164 lumbricals3
palmar interrosei
4 dorsal interrosei
Thenar muscles: opponens
pollicis, APB adductor
pollicis
, FPBHypothenar muscles: opponens digiti minimi
,
abductor
digiti
minimi
,
flexor
digiti
minimi
brevis
Palmar
brevis
Intrinsic hand muscles
Slide17Slide18Dupuytren’s contractureSwan-neck deformity
Boutonniere deformityMallet fingerJersey finger
Ulnar driftTrigger finger
Claw fingersApe hand deformityBishop’s hand
Wrist drop deformityDe Quervain’s deformity
Common Wrist and Hand Conditions
Slide19Dupuytren’s ContractureDue to the contracture of the
palmar fascia
Common among menUsually seen in the 50- to 70- age group
Fixed flexion deformity of the MCP & PIP joints
Usually seen in the ring or little finger
Common Wrist and Hand Conditions
Slide20Swan-Neck DeformityResult of contracture of the intrinsic muscles Often seen after trauma or in patients with RA
Flexion of the MCP & DIP joints & extension of the PIP joint
Common Wrist and Hand Conditions
Slide21Boutonniere DeformityResult of the rupture of the central tendinous slip of the extensor hood
Most common after trauma or in RAExtension of the MCP & DIP joints & flexion of the PIP joint
Common Wrist and Hand Conditions
Slide22Mallet FingerResult of the rupture or avulsion of the extensor tendon where it inserts in the distal phalanx of the finger
Distal phalanx rests in a flexed position
Common Wrist and Hand Conditions
Slide23Jersey FingerCaused by rupture of the flexor digitorum
profundus tendonCommon among football players
Occurs most often in the ring fingerInability to flex the affected DIP joint which becomes apparent when the patient is asked to make a fist
Positive sweater finger sign
Common Wrist and Hand Conditions
Slide24Ulnar Drift
Due to weakening of the capsuloligamentous
structures of the MCP joints & the accompanying bowstring effect if the extensor communis tendons Commonly seen in patients with RA
Ulnar deviation of the digits
Common
Wrist and Hand
Conditions
Slide25Claw FingersIntrinsic minus hand
Loss of intrinsic muscle action & the overaction of the extrinsic muscles on the proximal phalanx of the fingers
Combined median & ulnar nerve palsyMCP joints are
hyperextended & the PIP & DIP joints are flexed
Common Wrist and Hand Conditions
Slide26Ape Hand DeformityMedian nerve palsyWasting of the
thenar eminence of the handInability to oppose or flex the thumb
Common Wrist and Hand Conditions
Slide27Bishop’s Hand or Benediction Hand DeformityUlnar nerve palsy
Wasting of the hypothenar muscles of the hand, the
interossei muscles, & the two lumbrical muscles
Flexion of the 4th & 5th fingers
Common Wrist and Hand Conditions
Slide28Wrist Drop DeformityRadial nerve palsyParalysis of the extensor muscles of the wrist
Common Wrist and Hand Conditions
Slide29De Quervain’s Syndrome
Seen 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 wrist
Positive Finkelstein’s test
Common Wrist and Hand Conditions
Slide30Wrist and HandSpecial tests for tendon and muscle pathology
Slide31FINKELSTEIN -- 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
Slide32SWEATER FINGER / JERSEY TEST PROCEDURE
- THE Pt WILL FLEXED ALL THE MCP JOINTS POSITIVE - IF THE DIP WILL NOT FLEX
INDICATION - FDP RUPTURE
Slide33Bunnel-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.
Slide34Wrist and HandTests for neurologic dysfunction
Slide35Tinel’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.
Slide36PHALEN’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
Slide374. 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
Slide38OK 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
Slide396. 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
Slide407. WRINKLE / SHRIVEL TEST PROCEDURE
- Pt FINGER PLACE IN WARM WATER FOR 5 TO 20 MINS. POSITIVE
- NO WRINKLING OF PULP INDICATIVE - DENERVATION
Slide41Allen 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.
Slide42Proximal Row of carpal bones all except:1.Scaphoid2.Lunate3.Trapezium
4.TriquetralA 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 fracture2.Lunate dislocation3. Barton’s fracture
4.Scaphoid fractureThe most common nerve involvement is dislocation of lunate
is Median nerveAnterior
interosseus
Posterior interosseousMedian nerveBennet’s fracture is fracture dislocation of base of metacarpal:1.4th2. 3
rd
3.2
nd
4.1
st
Slide43A 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 hyperextensionSurgical repair of the flexor tendon
Buddy strappingIn hand surgery which area is called no mans land:
Proximal phalanxDistal phalanx
WristBetween distal phalanx crease and proximal phalanx.
True regarding mallet finger is:
Avulsion of tendon at the base of the middle phalanxAvulsion of extensor tendon at the base of the distal phalanxFracture of distal phalanxFracture of proximal phalanxFroment sign is positive in:1.Ulnar nerve injury
2. Radial nerve injury
3. Median nerve injury
4.
Erbs
palsy