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WRIST and HAND The hand and the wrist are the most active and the most intricate parts WRIST and HAND The hand and the wrist are the most active and the most intricate parts

WRIST and HAND The hand and the wrist are the most active and the most intricate parts - PowerPoint Presentation

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WRIST and HAND The hand and the wrist are the most active and the most intricate parts - PPT Presentation

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

hand wrist joints amp wrist hand amp joints common flexion ulnar conditions joint carpal finger nerve muscles thumb test

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Slide1

WRIST and HAND

Slide2

The 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

Slide3

BonesJointsMusclesCommon Hand ConditionsAssessment / Special Tests

Mini Quiz

Topic contents:

Slide4

Styloid 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

Slide5

Some Lawyers Tender Proposals That They Cannot Handle

The Carpals

Slide6

Scaphoid -

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

Slide7

TRAPEZIUMGreater 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

?

Slide8

Carpus/Wrist complexDistal

Radioulnar Joint (magee)

Radiocarpal joints (norkin)

Midcarpal jointsIntercarpal

JointCarpometacarpal jts

Intermetacarpal

jts.Fingers & thumbMetacarpophalangeal Interphalangeal

Joints of the Wrist and Hand

Slide9

Distal 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

Slide10

Midcarpal 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

Slide11

Carpometacarpal 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

Slide12

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 freedom

RP - slight flexionCP – full opposition ; fingers full flexion

CPP – flexion then extension

Joints of the Wrist and Hand

Slide13

Wrist extensorsBrachioradialis

ECRLECRB

Extensor digitorum

Extensor carpi ulnaris

Wrist flexorsPalmaris

longus

Flexor carpi radialisFlexor carpi ulnarisFlexor digitorum

superficialis

Muscles of the Wrist and Hand

Slide14

Ulnar abductorsExtensor carpi

ulnarisFlexor

carpi ulnarisRadial abductors

ECRL

Flexor carpi radialis

Abductor

pollicis longusExtensor pollicis brevisMuscles of the Wrist and Hand

Slide15

Extrinsic 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

Slide16

4 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

Slide17

Slide18

Dupuytren’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

Slide19

Dupuytren’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

Slide20

Swan-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

Slide21

Boutonniere 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

Slide22

Mallet 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

Slide23

Jersey 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

Slide24

Ulnar 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

Slide25

Claw 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

Slide26

Ape Hand DeformityMedian nerve palsyWasting of the

thenar eminence of the handInability to oppose or flex the thumb

Common Wrist and Hand Conditions

Slide27

Bishop’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

Slide28

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

Common Wrist and Hand Conditions

Slide29

De 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

Slide30

Wrist and HandSpecial tests for tendon and muscle pathology

Slide31

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

Slide32

SWEATER FINGER / JERSEY TEST PROCEDURE

- THE Pt WILL FLEXED ALL THE MCP JOINTS POSITIVE - IF THE DIP WILL NOT FLEX

INDICATION - FDP RUPTURE

Slide33

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 HandTests for neurologic dysfunction

Slide35

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.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

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 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