forearm, wrist and hand

7/31/2019 Forearm, Wrist and Hand

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FOREARM, WRIST AND

HANDPrepared by: Floriza P. de Leon, PTRP


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Distal Radioulnar Joint

Uniaxial pivot joint that has one degree of freedom

Resting position: 10 supination

Close packed position: 5 supination

Capsular pattern: full ROM with pain at extreme ofrotation


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Radiocarpal (Wrist) Joint

Biaxial ellipsoid joint

Radius articulates with scaphoid and lunate

Distal radius is not straight but is angled toward the ulna

(15-20), and its posterior margin projects more distally toprovide a buttress effect

Lunate and triquetrium also articulate with the triangular

cartilaginous disc and not the ulna. (the disc extends from

the ulnar side of the distal radius and attaches to the ulna

at the base of the ulnar styloid process)

The disc adds stability to the wrist; creates a close

relation between the ulna and carpal bones and binds

together the distal ends of the radius and ulna.


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Radiocarpal (Wrist) Joint

With the disc in place, the radius bears 60% of the load and the

ulna bears 40%. If the disc is removed, the radius transmits

95% of the axial load and the ulna transmits 5%

Therefore, the cartilaginous disc acts as a cushion for the wrist

joint and as a major stabilizer of the distal radioulnar joint; thedisc can be damage by forced extension and pronation

Distal end of radius is concave and the proximal row of carpals

is convex

Has two degrees of freedom Resting position: neutral with slight ulnar deviation

Close packed position: extension

Capsular pattern: flexion and extension equally limited


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Intercarpal Joints

Include the joints between the individual bones of the proximal

row of carpal bones (scaphoid, lunate, and triquetrium) and the

joints between the individual bones of the distal row of carpal

bones (trapezium, trapezoid, capitate and hamate).

Bound together by small intercarpal ligaments (dorsal, palmarand interosseus), which allow only a slight amount of gliding

movement between the bones.

Close packed position: extension

Resting position: neutral or slight flexion Capsular pattern is none

Pisotriquetral joint is considered separately because the

pisiform sits on the triquetrium and does not take a direct part

in the other intercarpal movements


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Midcarpal Joints

Form a compound articulation between the proximal and distalrows of carpal bones with the exception of pisiform

On the medial side, the scaphoid, lunate, and triquetriumarticulate with capitate and hamate, forming a compound sellar(saddle-shaped joint).

On the lateral aspect, the scaphoid articulates with thetrapezoid and trapezium, forming another compound sellar joint

These articulations are bound together by dorsal and palmarligaments; however, there are no interosseus ligamentsbetween the proximal and distal rows

Therefore, greater movement exists at the midcarpal joints thanat the intercarpal joints

Close packed position: extension with ulnar deviation

Resting position: neutral or slight flexion with ulnar deviation

Capsular pattern: equal limitation of flexion and extension


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Carpometacarpal Joint

Sellar joint that has 3 degrees of freedom (thumb)

Plane joint for 2nd to 5th CMC joints

Capsular pattern of CMC jt (thumb): abduction is most limited,followed by extension

Resting position (thumb): midway between the abduction and

adduction and midway between flexion and extension Close packed position (thumb): full opposition

Capsular pattern (2-5): equal limitation in all directions

Bones of are held together by dorsal and palmar ligaments

Thumb articulation has a strong lateral ligament extending from thelateral side of the trapezium to the radial side of the base of the 1st

metacarpal, and the medial four articulations have an interosseusligament similar to that found in the carpal articulation

CMC articulations of fingers allow only gliding movements

CMC articulations of thumb is unique that it allows flexion, extension,abduction, adduction, rotation, and circumduction


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Intermetacarpal Joints

Have only a small amount of gliding movements between

them and do not include the thumb articulation

They are bound together by palmar, dorsal and

interosseus ligaments


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Metacarpophalangeal Joints

Condyloid joints

2nd and 3rd MCP joints tend to be immobile and are the primarystabilizing factor of the hand, whereas the 4th and 5th joints aremore mobile.

Collateral ligaments of these joints are tight on flexion andrelaxed on extension

These articulations are also bound by palmar ligaments anddeep transverse metacarpal ligaments

Has two degrees of freedom

1st CMC has 3 degrees of freedom Close packed position: maximum opposition (thumb);

maximum flexion (fingers)

Resting position: slight flexion

Capsular pattern: more limitation of flexion than extension


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Interphalangeal Joints

Uniaxial hinge joints with one degree of freedom

Close packed position: full extension

Resting position: slight flexion

Capsular pattern: flexion more limited than extension

During flexion, there is some rotation in these joints sothat the pulp of the fingers face more fully the pulp of thethumb

Cascade sign if the MCP jts and PIP jts of the fingers

are flexed, they converge toward the scaphoid tubercle If one or more fingers do not converge, it usually indicates

trauma to the digits that has altered their normalalignment


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Patient History

Lunate dislocation fall on the outstretched hand

Dislocation of fingers extension of fingers

Galleazzi fx fracture of the radius and dislocation of the distal end ofthe ulna

Wrist is commonly injured by weight bearing, by rotation stress

combined with ulnar deviation, by twisting, and by impact loading If flexor tendons (which are round, have synovial sheaths, and have a

longer excursion that the extensor tendons) are injured, they respondmuch more slowly to treatment than do extensor tendons (which areflat or ovoid)

Surgical no mans land region between the distal palmar crease

and the midportion of the middle phalanx of the fingers; damage tothe flexor tendons in this area that requires surgical repair usuallyleads to the formation of the adhesive bands that restrict gliding. Inaddition, the tendons may become ischemic, being replaced by scartissue. Because of this, the prognosis after surgery in this area ispoor


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Observation

Skin creases occur because of movement at the various joints

Note of any muscle wasting on the thenar eminence (median nerve),1st dorsal interosseus mm (C7 nerve root), or hypothenar eminence(ulnar nerve) that may be indicative of nerve or nerve root injury

Note of any localized swelling

In the wrist and hand, effusion and synovial thickening are mostevident on the dorsal and radial aspects

Swelling of MCP and IP jts are most obvious on the dorsal aspects

Dominant hand tends to be larger than the non dominant

Any vasomotor, sudomotor, pilomotor, and trophic changes should be

recorded; indicative of PNI, PVD, DM, reynauds dse, or reflexneurovascular syndromes such as shoulder-hand syndrome orsudecks atrophy

Note any hypertrophy; may be indicative ofpagets dse,neurofibromatosis, AV fistula


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Observation

Presence ofheberdens orbouchards nodes

Heberdens nodes appear on the dorsal surface of the DIP jtsand are associated with OA

Bouchards nodes are on the dorsal surface of the PIP joints;associated with gastrectasis and rheumatoid arthritis

Any ulcerations may indicate neurological or circulatoryproblems

Any alteration in the color of the limb with changes in positionmay indicate a circulatory problem

Ulnar drift may be seen in RA

Spoon-shaped nails are often result of fungal infection, anemia,iron deficiency, long term DM, local injury, developmentalabnormality, chemical irritants or psoriasis.

Clubbed nails associated with COPD, congenital heart defects,or cor pulmonale


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Common Hand Deformities

Swan-neck deformity Involves only the fingers.

There is flexion of the MCP and DIP.

There is hyperextension of the PIP jt.

Result of contracture of intrinsic mm and is often seen in RA

Boutonniere deformity Extension of the MCP and DIP and flexion of PIP jt Result of the rupture of the central tendinous slip of the extensor hood

Most common after trauma or in RA

Ulnar drift Commonly seen in patients with RA but can occur with other conditions

Results in ulnar deviation of the digits due to weakening of the capsuloligamentous

structures of the MCP jts and the accompanying bowstring effect of the extensorcommunis tendons

Extensor plus deformity Caused by adhesions or shortening of the extensor communis tendon proximal to

the MCP jt

Results in inability to simultaneously flex the MCP and PIP jts, although they may beflexed individually


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Common Hand Deformities Claw fingers

Results from loss of intrinsic mm action and the overaction of the extrinsic (long) extensor mmon the proximal phalanx of the fingers.

MCP jts are hyperextended, and the proximal and distal IP jts are flexed.

If intrinsic function is lost, the hand is called intrinsic minus hand

Normal cupping of the hand is lost, both the longitudinal and transverse arches of the handdisappear.

There is intrinsic mm wasting Often caused by a combined median and ulnar nerve palsy

Trigger finger Aka digital tenovaginitis stenosans

Result of a thickening of the flexor tendon sheath which causes sticking of the tendon when thepatient attempts to flex the finger

A low grade inflammation of the proximal fold of the flexor tendon leads to swelling andconstriction (stenosis) in the digital flexor tendon.

When px attempts to flex the finger, the tendon sticks, and the finger lets go, often with a snap Usually occurs in middle aged women

Trigger thumb usually occurs in young children; condition usually occurs in the third or fourthfinger.

Often associated with RA and tends to be worse in the morning


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Common Hand Deformities

Ape hand deformity

Wasting of the thenar eminence of the hand occurs as a result of the

median nerve palsy

Thumb falls back in line with the fingers as a result of the pull of the

extensor mm Px is unable to oppose or flex the thumb

Bishops hand or Benediction hand deformity

Wasting of the hypothenar mm of the hand, the interossei mm, and the

2 medial lumbrical mm

Occurs because of the ulnar nerve palsy Flexion of the 4th and 5th fingers is the most obvious resulting change

Drop-wrist deformity

Extensor mm of the wrist are paralyzed as a result of the radial nerve

palsy, and the wrist and fingers cannot be extended


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Types of Grip

Power Grip Requires fine control and gives greater flexor asymmetry to the hand

Used whenever strength or force is the primary consideration

Digits maintain the object against the palm

Thumb may or may not be involved, and the extrinsic mm are moreimportant

For a power grip to be formed, fingers are flexed and the wrist in ulnardeviation and slightly extended

Hook grasp in which all or the second and third fingers are used as a hookcontrolled by the FA flexors and extensors; involve the IP and MCP jts(thumb not involved)

Cylinder grasp type of palmar prehension, thumb is used, and the entirehand wraps around an object

Fist grasp/digital palmar prehension - hand moves around a narrow object

Spherical grasp type of palmar prehension, in which there is moreopposition and the hand moves around the sphere


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Precision or prehension grip

An activity limited mainly to the MCP joints and involves primarily

the radial side of the hand

Used whenever accuracy and precision are required

Radial digits (index and long fingers) provide control by working inconcert with the thumb to form a dynamic tripod for precision

handling

There is pulp to pulp contact between the thumb and fingers, and

the thumb opposes the fingers.

Intrinsic mm are more important

Types of pinch grip

Three point chuck, three fingered, or digital prehension, in which palmar

pinch, or subterminal opposition, is achieved; precision grip with power

forearm, wrist and hand

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