Post on 10-Apr-2015
Orthopaedic AssessmentsLectures 23 & 24
The Wrist & The Wrist & HandHand
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 10° of supination• Close Pack Pos'n 5° of supination• Capsular Pattern pain at extreme of
rotation
Wrist & Hand – Applied Anatomy
Radiocarpal (Wrist) Joint
• Resting Pos'n neutral with slight ulnar deviation
• Close Pack Pos'n extension• Capsular Pattern 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 neutral or slight flexion
• Close Pack Pos'n extension• Capsular Pattern 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 neutral or slight flexion with ulnar deviation
• Close Pack Pos'n extension with slight ulnar deviation
• Capsular Pattern 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 full opposition
• Capsular Pattern abduction, then extension
Wrist & Hand – Applied Anatomy
Carpometacarpal Joints (FINGERS)
• Resting Pos'n midway b/w flexion and extension
• Close Pack Pos'n full flexion• Capsular Pattern 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 slight flexion• Close Pack Pos'n THUMB: full
opposition FINGERS: full flexion
• Capsular Pattern flexion, then extension
Wrist & Hand – Applied Anatomy
Metacarpophalangeal Joints
• 2nd & 3rd metacarpophalangeal joints are generally immobile and are the primary stabilizing factor of the hand
Wrist & Hand – Applied Anatomy
Interphalangeal Joints
• Resting Pos'n slight flexion• Close Pack Pos'n full flexion• Capsular Pattern 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
EXAMINATIONEXAMINATION
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 ofWRIST AND HAND
Wrist & Hand – Examination
ACTIVE ROM• Pronation (forearm) 80° - 90°• Supination (forearm) 90°• Wrist abduction 15°
–Radial deviation• Wrist adduction 30° - 45°
–Ulnar deviation• Wrist flexion 80° - 90°• Wrist extension 70° - 90°
Wrist & Hand – Examination
ACTIVE ROM (cont'd)• Finger flexion
–MCP 85° - 90°–PIP 100°–DIP 80° - 90°
• Finger extension–MCP 30° - 45°–PIP 0°–DIP 20°
Wrist & Hand – Examination
ACTIVE ROM (cont'd)• Finger abduction 20° - 30°• Finger adduction 0°• Thumb flexion
–CMC 45° - 50°–MCP 50° - 55°–IP 85° - 90°
• Thumb extension–MCP 0°–IP 0° - 5°
Wrist & Hand – Examination
ACTIVE ROM (cont'd)• Thumb abduction 60° - 70°• Thumb adduction 30°• Opposition of the thumb and 5th digit (tip-
to-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 tissue stretch• Supination tissue stretch• Radial deviation bone-to-bone• Ulnar deviation bone-to-bone• Wrist flexion tissue stretch• Wrist extension tissue stretch• Finger flexion tissue stretch• Finger extension tissue stretch
Wrist & Hand – Examination
PASSIVE ROM (cont'd)• Finger abduction tissue stretch• Thumb flexion tissue stretch• Thumb extension tissue stretch• Thumb abduction tissue stretch• Thumb adduction tissue approximat'n• Opposition tissue stretch
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
• Middle (3rd) finger – strongest–Important for power and precision
• Little (5th) 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 PIPINDICATES: 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 TestsALLEN'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
POSITIVE: head of 3rd MC is level with that of 2nd and 4th MC
INDICATES: dislocation of the lunate