Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine...
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Transcript of Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine...
![Page 1: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/1.jpg)
chapter
21
Wrist and Hand
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Importance of the Hand
• The hand is extremely complex and requires fine balance of all structures to function properly.
• Finger and hand injuries can be among the most devastating if not well cared for because we use our hands daily for hundreds of activities.
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Complexity of the Hand
• 29 bones• 30+ tendinous insertions• Complex neurological system• 25% of the body’s pacinian corpuscles’ sensory
endings are in the hands• 9 muscles in thumb; 7 in index finger• #1 and #2: dexterity activities• #3, #4, and #5: grasping activities
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Figure 21.1
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Skeletal Structure
• Structures must maintain flexibility and strength to maintain adaptability.
• Wrist joint: Concave radius joins with convex proximal carpal row.
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Wrist Motions
• Flexion • Extension• Abduction: radial deviation or radial flexion• Adduction: ulnar deviation or ulnar flexion• Combined motions: circumduction
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Joints
• Intercarpal joints: held in place by ligaments• Carpometacarpal joints: permit flexion,
extension, abduction, adduction of metacarpals (MC)
• Thumb, 4th, 5th MC: rotate to provide opposition
• Metacarpophalangeal (MCP), interphalangeal (IP; proximal, distal [PIP, DIP]) joints: convex proximal segment, concave distal segment of each joint
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Fascia of the Hand
• Palmar fascia– Superficial = extension of transverse carpal ligament
and palmaris longus tendon; goes to fingers– Deep = floor from thenar to hypothenar; serves to
cushion and protect hand and maintain hand’s concavity
• Dorsal fascia: in two layers but less dense
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Figure 21.2a
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Figure 21.2b
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Tendon Sheaths and Pulleys
• Extensor tendon sheaths are limited to the wrist area (extensor retinaculum at wrist).
• An elaborate pulley system holds finger flexor tendons in place.
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Tendons and Muscles
• 20 extrinsic.• 19 intrinsic (#4 to #1, #3 to #5).• Extensor tendons are attached to proximal
phalanx by sagittal bands on volar plate.• Beyond MCP joints, extensor tendons split into
three segments: one attaches at middle phalanx and two converge and attach at distal phalanx.
(continued)
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Figure 21.3a
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Dorsal Soft-Tissue Zones
• I and II: mallet or swan neck deformities
• III and IV: boutonniere deformity
• V and VI: adhesions of tendons and extensor hood
• VII: adhesions of synovial sheaths, retinaculum• See figure 21.3b.
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Figure 21.3b
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Tendons and Muscles
• Flexor digitorum sublimis (FDS) splits and attaches at middle phalanx to flex PIP joint.
• Flexor digitorum profundus (FDP) attaches to distal phalanx and flexes DIP joint.
• FDS tendons have separate muscle bellies; FDP does not, so distal finger movement cannot be isolated.
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Figure 21.4a
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Palmar Surface of the Hand Zones
• I: Ruptures; poor tendon gliding, contracture, repair failures
• II: Adhesions of tendons and sheaths
• III: Intrinsic muscle adhesions
• IV: Tendon adhesions
• V: Tendon sheath adhesions• See figure 21.4b
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Figure 21.4b
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Tendons and Muscles
• Extrinsic muscles: gross motor activity• Intrinsic muscles: fine motor activity• Lumbricals originate on flexor tendons in palm
and insert on extensor tendons to flex MCPs and extend IPs.
• Dorsal and palmar interossei muscles are responsible for finger abduction and adduction.
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Skin of Hand
• Volar surface– Thick– Underlying fascial
attachments– Inelastic– Hairless– Ridges for grasping
• Dorsal surface– Elastic– Mobile– Thinner– Loose– Pliable– Must stretch 1 in. for
fingers to close
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Edema in Hand
• Frequently accumulates in dorsum.• Can lead to contractures.• Excessive swelling on dorsum can cause hand
arches to collapse anteriorly and adduct the thumb.
• Finger range of motion (ROM) can be impaired.• Edema causes reduced mobility and function of
the hand in short term and in long term if fibrous formations occur.
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Treating Hand Edema
• Must reduce early edema• Measured by circumferential gauge or string
wrapped around finger• Use of elevation, ice, compression, other
modalities• See figure 21.5
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Figure 21.5
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Tendon Excursion
• Inhibition of normal tendon gliding can inhibit normal hand function.
• Repaired extensor tendon excursion should be limited to 5 mm during healing; exact degrees of motion vary from finger to finger.
• There are implications for splinting and motion limitations.
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Power Grips
• Power grips = 20% 9 (see figure 21.55)– Fist– Hook– Cylinder– Spherical
• Ulnar hand is used. Thumb opposes other fingers.
• Fingers flex and rotate and move into ulnar deviation. Fingers point toward thenar eminence.
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Figure 21.6a
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Figure 21.6b
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Figure 21.6c
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Figure 21.6d
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Prehensile Grips
• Intricate tasks = 80% of time– Digital prehension pinch– Lateral prehension pinch– Tip-to-tip pinch
• Fingers: flexed and abducted at MCP• Radial digits used
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Figure 21.7a
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Figure 21.7b
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Figure 21.7c
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Splinting
• Purposes: prevent damage or maintain or improve balance; based on three-point pressure system
• Static splints: no moving parts; used to prevent movement, support and protect hand, maintain motion
• Dynamic splints: used to gain motion or guide or assist movement
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Figure 21.8
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Splint Precautions
• Avoid friction and pressure: Fit should be firm yet comfortable.
• Check periodically for skin breakdown or redness; pad as needed.
• Additional padding may change force of splint.• Adjust as needed as patient’s condition
changes.• Take care over bony prominences.
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Figure 21.10
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Soft-Tissue Mobilization
• Trigger points:– Extensor carpi radialis longus (ECRL), extensor
carpi radialis brevis (ECRB), ECR (rarely has active trigger points)
– Flexor carpi radialis (FCR), flexor carpi ulnaris (FCU)– Adductor pollicis
• Palmar fascia release
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Figure 21.12a1
![Page 41: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/41.jpg)
Figure 21.12a2
![Page 42: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/42.jpg)
Figure 21.12a3
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Figure 21.12b
![Page 44: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/44.jpg)
Figure 21.12c
![Page 45: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/45.jpg)
Figure 21.13a
![Page 46: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/46.jpg)
Figure 21.13b
![Page 47: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/47.jpg)
Figure 21.13c
![Page 48: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/48.jpg)
Figure 21.13d
![Page 49: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/49.jpg)
Figure 21.13e
![Page 50: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/50.jpg)
Figure 21.13f
![Page 51: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/51.jpg)
Figure 21.14a
![Page 52: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/52.jpg)
Figure 21.14b
![Page 53: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/53.jpg)
Figure 21.14c
![Page 54: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/54.jpg)
Figure 21.14d
![Page 55: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/55.jpg)
Figure 21.14e
![Page 56: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/56.jpg)
Figure 21.16
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Capsular Patterns
• Wrist: – Flexion = extension.– Pronation = supination.
• Fingers: Flexion limits > extension limits.• Thumb: Abduction limits > adduction limits.
![Page 58: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/58.jpg)
Joint Mobilization
• Distal radioulnar joint– Anteroposterior (AP)– Posteroanterior (AP)
glides
• Wrist joint– Traction– Dorsal glide– Volar glide– Radial glide– Ulnar glide
• Carpometacarpal joints– Traction– Glides
• MCP and IP joints– Traction– Rotations– PA glides– AP glides– Lateral glides
![Page 59: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/59.jpg)
Figure 21.17
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Figure 21.18
![Page 61: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/61.jpg)
Figure 21.19
![Page 62: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/62.jpg)
Figure 21.20
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Figure 21.21
![Page 64: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/64.jpg)
Figure 21.22
![Page 65: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/65.jpg)
Figure 21.23
![Page 66: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/66.jpg)
Figure 21.24
![Page 67: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/67.jpg)
Figure 21.25
![Page 68: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/68.jpg)
Figure 21.26
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Figure 21.27
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Figure 21.28
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Figure 21.29
![Page 72: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/72.jpg)
Figure 21.30
![Page 73: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/73.jpg)
Figure 21.31
![Page 74: Chapter 21 Wrist and Hand. Importance of the Hand The hand is extremely complex and requires fine balance of all structures to function properly. Finger.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cc55503460f9498ed49/html5/thumbnails/74.jpg)
Figure 21.32