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WRIST & HAND COMPLEX if hand is amputated: 90% of UE function is gone proximal joints serve the hand o serve as a stable base of support for the hand required ROM for ADLs (for shoulder) o reach perineum: ! 75-90! horizontal abduction ! 30-45!!abduction ! 90! above internal rotation o tuck in shirt ! 50-60! horizontal abduction ! 55-65! abduction ! 90! IR o combing hair ! 30-70! horizontal adduction ! 105-120! abduction ! 90! ER primary function: control length-tension relationships in the multi-articular hand muscles and to allow fine adjustment to grip balance and control most complex joint in the body o many anatomical features biaxial joint: 2 degrees of freedom o motions: flexion/extension & radial (abduction)/ulnar (adduction) deviation Normal ROM o flexion: 0-80! o extension: 0-70! o RD: 0-20! o UD: 0-30! Main source of Stability: Ligaments resting position: neutral c ulnar deviation CPP: full extension c radial deviation Capsular Pattern: Flexion & extension

IMPORTANCE OF 2-JOINT SYSTEM " permits larger ROM " less tendency for structural pinch at extremes of ranges " allowed for flatter multi-joint surfaces that are more capable of withstanding imposed pressures CARPAL BONES # 16 carpal bones # proximal row: scaphoid, lunate, triquetrum, pisiform # distal row: trapezium, trapezoid, capitate, hamate BASE ORDER OF OSSIFICATION # Capitate o largest carpal bone o AKA Os Magnum o at birth/after birth o serve as an axis/fulcrum for radial or ulnar deviation # Hamate o AKA Uncinate o immediately after capitate o palpation: direction of knuckle flexion # Triquetrum o AKA triangular o 2 ! y/o o palpation: ulnar styloid > radial deviation o axis for ROM in flexion & extension o 3rd most commonly fx bone # Lunate o AKA semilunar o 3 ! y/o o most commonly dislocated o Special Test: Murphy Sign o 2nd most commonly fx bone o palpation: same as capitate # Scaphoid o AKA navicular o 5-6 y/o o floor of the anatomical snuff box [fovea radialis] (proximal part) o most commonly fractured bone o palpation: extend thumb/ulnar deviation and palpate scaphoid

JOINTS - Radiocarpal & Midcarpal Joint - Radiocarpal Joint o Articulating Structures ! scaphoid, lunate (Brunstromm) ! scaphoid, lunate, triquetrum (Levangie) o ellipsoid joint o only ellipsoidal joint in the body - Midcarpal Joint o Carpal Bones o pisiform not included: due to orientation & in terms of articulation (on top of triquetrum) o functional joint not an anatomical joint ! no synovium, membrane, or any characteristic of synovial joints

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Cascade Sign: convergence of fingers to scaphoid bone o tenderness in anatomical snuff box signifies scaphoid fracture # Trapezoid o AKA Lesser multangular o 5-6 y/o # Trapezium o AKA greater multangular o 5-6 y/o o floor of anatomical snuff box (distal part) o palpation: just distal to scaphoid & articulates to first metacarpal # Pisiform o 10-12 y/o o only carpal bone c mm attachment o sesamoid bone: formed d/t repetitive contraction of muscles attached o Bikers Palsy: common among bikers ! risk is compressed in handle of bike ! ulnar nerve impingement o prone to dislocation & fx o Fabella: sesamoid bone found in lateral head of gastrocs o AVASCULAR NECROSIS - Kienbocks Disease: lunate - Preissers Disease: scaphoid - Panners Disease: capitulum - Legg-Calve-Perthes Disease: femoral head (in children) - Chandlers Disease: femoral head (in adults) - Kohlers Disease: navicular - Diaz Disease: talus RADIOCARPAL JOINT - articulations: scaphoid, lunate & triquetrum - biconcave: radius - biconvex: carpal bones - proximal joint surface; o lateral radial facet: articulates c scaphoid o medial radial facet: articulates c lunate o TFCC (triangular fibrocartilage complex): articulates c triquetrum - oblique & angled slightly volarly & ulnarly - average inclination of the distal radius: 23! o lateral side of radius: 12mm higher than medial side o observed in the frontal plane - angle of inclination of radius volarly in the saggital plane: 11! o posterior portion of radius is longer than anterior portion of radius TRIANGULAR FIBROCARTILAGE COMPLEX - attached too distal end of radius, ulnar styloid process & triquetrum - Function; o binds radius & ulna o separates distal RU jt & ulna from radiocarpal joint o supports distal RU jt. - Special Test: Supination Lift Test - other structures; o articular disk ! upper portion: volar & dorsal radioulnar ligaments ! lower portion: ECU tendon sheath, collateral ligaments, triquetrum, & 5th MCP, hamate ULNAR (-) vs ULNAR (+) VARIANCE $ Ulnar Negative: ulna is shorter than radius o greater space & thickness of TFCC ! thickness creates abnormal distribution of forces in radiocarpal joint making articular surfaces prone to degeneration ! associated c Kienbocks Disease $ Ulnar Positive: ulna is linger than radius o lesser space & thinner TFCC ! can cause impingement/compression of structures surrounding TFCC LIGAMENTS & CAPSULE - strong but somewhat loose capsule (permitting greater ROM) - reinforced by capsular & intracapsular ligaments - Extrinsic & Intrinsic Ligaments o Extrinsic: connects carpals to radius or ulna o Intrinsic: interconnect carpals, aka Intercarpal/Interosseous INTRINSIC vs EXTRINSIC LIGAMENTS # Stronger: Intrinsic # Nutrition: o intrinsic: from synovium o extrinsic: vascularized tissues # First to Fail: Extrinsic # Better potential for healing: Extrinsic LIGAMENTS - Volar & Dorsal ligaments - Volar Carpal Ligaments o volar radiocarpal o radioscaphocapitate

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radioscapholunate (scapholunate interosseous ligament): primary stabilizer of scaphoid o radioulnate (radiolunotriquetral/lunotriquetral) : primary stabilizer lunate Dorsal Carpal Ligaments o Dorsal Radiocarpal Ligament: primary stabilizer of the back of the hand o Dorsal Intercarpal Ligament Graysons & Clelands Ligaments o fix skin to bone of fingers along the lateral & medial side o important in grasping objects o damaged flexor tendon contour of palmar surface o thenar & hypothenar eminence: should be bulky o guttering: thinning of hand muscles ! possible nerve injury 3 arches; o longitudinal: phalanges to Carpal Bones o 2 transverse ! proximal [oblique] {only mobile} (carpal bones) & distal transverse (mc heads) hills & valleys o bulges & depressions o hills: neurovascular bundles o valleys: areas where flexor tendons attaches knuckles nails o coloration may indicate blood supply dysfunction or liver dysfunction

MOTIONS AT THE WRIST # combination of active & passive structures # FCU: muscle that attaches to the carpal bone # radius, proximal carpal row, distal carpal row # 3-segment linkage # proximal carpal row: INTERCALATED SEGMENT o movement in between fixed segments # proximal carpal row needs stabilization # scaphoid shows the greatest motion # convex: carpal bone; concave: radius $ Wrist Extension from full flexion o distal carpal row glides on the proximal row o scaphoid & distal row move o carpals move as a unit on the radius $ Radial/Ulnar Deviation o unique reciprocal motion of the proximal carpal row $ Flexion 85! (AAOS= 80!) o radiocarpal joint: 50! o midcarpal joint: 35! $ Extension 85! (AAOS= 70! o radiocarpal joint: 35! o midcarpal joint: 50! $ Radial Deviation o radiocarpal ! o midcarpal ! $ Ulnar Deviation o radiocarpal 2/3 o midcarpal 1/3 INSPECTION OF THE HAND - complete number of fingers - attitude of the hand o position assumed by hand at rest

Arches - importance; o gripping activities o increases surface area of the hand o increase the sensory contact of hand - maintain arch of hand o transverse carpal ligament o intercarpal ligament o deep transverse metacarpal ligament - increase upon contraction of FCU & intrinsic muscles *palmaris brevis: facilitates cupping of the hand Beaus Line - degeneration of cells of the nails - depression seen in the nails PALMAR CREASES {Hoppenfeld} - proximal/distal interphalangeal crease - palmar digital crease - proximal/distal palmar crease - thenar crease - wrist crease Boundaries of Surgical NO MANS LAND - no surgery should be done in this area due to decrease in healing d/t poor vascularization MUSCLES OF THE WRIST COMPLEX - posterior: wrist extensors (radial nerve)

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anterior: flexors (median nerve) provides a stable base for the hand wrist flexors o palmaris longus, FCR, FCU (primary wrist flexors) o FDS, FDP, FPL (secondary wrist flexions) ! most of functions occur at the digits Flexor Retinaculum o function: prevent bowstringing of flexor tendons o Transverse Carpal Ligament: distal portion/extension of flexor retinaculum ! responsible for formation of carpal tunnel ! attached to pisiform and hamate (medial side) ! scaphoid (lateral part) o stabilized by palmaris longus and FCU {on top of flexor retinaculum to maintain and stabilize} o contents (10; ! Median Nerve ! 4 tendon of FDS ! 4 tendons FDP ! FPL ! FCR {part of flexor retinaculum but not part of the carpal tunnel} o ECRB Tennis Elbow 3 EPL ulnar border of anatomical snuff box Tunnel 4 ! EIP ! EDC ! Hex Sign Tunnel 5 ! EDM Tunnel 6 ! ECU ! ! Tunnel ! !

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Anatomical Snuff Box # EPL, APL, EPB (boundaries) Tennis Elbow # ECRL, ECRB, Brachioradialis SPECIFIC MUSCLE ACTIONS # Palmaris Longus o pure wrist flexor o can be used for tendon grafts # FCU o able to exert the greatest tension of all wrist muscles o long moment arm given by attachment to pisiform o effective flexor and ulnar deviator than FCR # FDS o flex the wrist if the fingers are flexed o d/t passive insufficiency, crosses less joints, it is superficial o functions as a wrist flexor than FDP # FPL o can produce radial deviation o 2 headed muscle ! smaller head: Gantzers Muscle # ECRB o strongest wrist extensor o attached to 3rd MCP o second reason: most common tendon affected by lateral epicondylitis # ECRL o can be an elbow flexor at 0-90! elbow flexion o d/t attachment in lateral supracondylar ridge of humerus o inserts to second metacarpal o strong radial deviator of the wrist # ECU o wrist extensor is affected by forearm position o it can also flex the wrist

TUNNEL OF GUYON - Ulnar Nerve: nerve that passes the tunnel - pisohamate ligament: ligament that forms the tunnel of guyon Carpal Tunnel Syndrome - paresthesia on lat. 3 finger, " 4th finger palmarly, up to proximal phalanx posteriorly lateral 3rd. - thenar eminence atrophy Wrist extensors o ECRL, ECRB, ECU (primary wrist extensors) o EDC, EIP, EDM, EPL, EPB, APL (secondary wrist extensors) Mobile Wad of Henle o brachioradialis, ECRL, ECRB Extensor Retinaculum o form tunnels Tunnels o Tunnel 1 ! APL ! EPB ! De Quervains o Tunnel 2 ! ECRL

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# EDM & EIP o common function with EDC # EDC o pure wrist extensor o can extend wrist if fingers are extended o d/t passive insufficiency # APL & EPB o can perform radial deviation HAND COMPLEX 5 digits= 4 fingers, 1 thumb each has an MCP fingers have PIP & DIP jts if thumb is amputated= 40-50% of hand function is gone if index finger/middle finger: 20% if 4th/5th finger: 10% o has 2 sesamoid bones; ulnar & radial sides ! attachment of intrinsic muscles & ligaments

ROM # # # # #

MCP jt flexion/extension: 90! PIP jt flexion/extension: 100! DIP jt flexion/extension: 90! Thumb CMC jt flexion/extension: 20! /15! Thumb MCP jt. Flexion/Extension: 20!

CMC JOINT OF THE FINGERS - distal carpal row of base of 2nd-5th MCP - deep transverse metacarpal ligament; o stability of CMC jt - Proximal Transverse Carpal Arch o maintained by deep transverse metacarpal ligament - greatest motion found in the 5th finger o for individual to be able to grasp objects CMC JOINT OF THE THUMB - formed by; o trapezium & base of 1st metacarpal - saddle or sellar - has very loose and very thick jt capsule - has 3 degrees of freedom - flexion/extension: motion parallel to palm - abduction/adduction: motion perpendicular to palm o related to orientation of trapezium, that effectively rotates volar surface of thumb medially. - Common to OA MCP JOINT - formed by o concave: head of metacarpal o convex: base proximal phalanx - condyloid jt - 2 degrees of freedom - Thumb MCP o condyloid jt.

SOFT TISSUE SUPPORTS * jts are incongruent c each other ! volar plate, collateral ligaments, deep transverse metacarpal ligaments ! Volar Plate o increases congruency of MCP jt. o provides stability of MCP jt. o prevents hyperextension o protects volar surface of the hand o prevents compression of long finger flexors ! Collateral Ligaments o limits side to side movements of MCP o provides stabilization for gripping o accessory collateral ligament: extension of ligament ! supports volar plate ! Deep Transverse MCP Ligament o limits spreading of fingers o permits flexible metacarpal arch o Types of Prehension ! Powerful Grip ! Precisional Grip POWER GRIP - Hook Grip - Cylinder Grip - Fist Grip - Spherical Grip PRECISION GRIP - Chuck or Three-Fingered Pinch (digital prehension) - Lateral or Key Pinch (lateral prehension) - Tip Pinch (tip-to-tip prehension) GRIP/PINCH STRENGTH: Dynamometer - no normal/ standard value for grip and pinch strength - 5-10lbs greater strength of dominant than nondominant

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HAND MUSCULATURE - Extrinsic o Flexors ! FDS, FDP {dually innervated: median & ulnar nerve}, FPL o Extensors ! EDC, EIP, EDM, EPL, EPB, APL - Intrinsic ! Thenar {AFO} Pollicis median nerve ! Hypothenar {AFO} Digiti Minimi ulnar nerve ! Lumbricals {dually innervated} ! Interossei {dually innervated} ! Palmaris Brevis ulnar nerve o Proximal Attachments: mostly attach to metacarpals - Adductor Pollicis o Froments Sign o checking integrity of the muscle EXTRINSIC FLEXORS # FDS, FDP, FPL # Actions: o FDS: flex PIP, MCP & Wrist o FPPL: flex MCP & IP of thumb # FDP more active; FDS contracts if greater force is needed # At the level of MCP: FDS is more active o more superficial & crosses lesser joints # At the level of PIP: FDP is more active o Campers Chiasma: splitting of the FDS tendon in the middle phalanx phalanx. RUPTURED FDP - sweater finger sign/jersey finger o ask pt to make a fist and the DIP does not flex. = possible sign of FDP. FLEXOR MECHANISM - how flexor tendons produce tension at the digits # flexor retinaculum, deep transverse mcp ligament, annular & cruciate pulleys # forms tunnels; (+) bursa # prevents bow stringing of tendons # increases efficiency of contractions of finger flexors # infection may travel through tendon sheaths # trigger finger o stenosing tenovaginitis EXTRINSIC EXTENSORS - EDC, EIP, EDM - forearm to extensor retinaculum At the MCP level: EDC merges c extensor mechanism EDC combines c EIP & EDM Junctura Tendinae o connects the tendons of each digit

EXTENSOR MECHANISM # AKA extensor expansion, apparatus, ext aponeurosis, retinaculum, ext mechanism, dorsal hood # termination of almost all digital extensors & intrinsic muscles o palmaris brevis o opponens pollicis o hypothenar muscles # Primary mm: EDC, interossei & lumbricals # Anatomical Features # EDC crosses MCP joint & inserts to base of prox phalanx # will give off 3 bands (3 lateral: 1 central) # lateral band/ sip: continue to rejoin over the middle phalanx & inserts to base of distal phalanx # central band/slip: inserts to base of middle phalanx # interossei: attaches to base of proximal & middle phalanx, volar plate & lateral bands # lumbricals: inserts to lateral slip Central Slip: Bouttonier Lateral Band: Swan Neck Deformity HAND CLOSURE/ OPENING # Light Hand Closure o unresisted o FDP # Forceful hand closure o resisted o FDS, FDP & interossei # Light Hand Opening o ED # Forceful hand opening o lumbricals, EDC SPECIFIC ACTIONS OF MUSCLES - EDC o MCP jt hyperextension o IP flexion - Lumbricals o MCP flex o IP extension - FDP o IP flexion - FDS o PIP flexion - Interossei o abd/add of hand

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FPL o o thenar o o o only flexor of thumb IP adductor of the adducted thumb mm unresisted opposition MCP flex CMC abd

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