references:
Campbell’s operative orthopaedics 11th edition
Text book of orthopaedics & fractures 5th edition Dr B. Aalami Harandi
Gray’s anatomy 2nd edition
Clinical anatomy Richard S. Snell
1. Clinical Examination
of the Hand and Wrist
• Campbell’s operative orthopaedics 11th edition
• Text book of orthopaedics & fractures 5th edition Dr B. Aalami Harandi
• Gray’s anatomy 2nd edition
• Clinical anatomy Richard S. Snell
2. Anatomy of the wrist
Distal radioulnar joint
Radiocarpal joint
Ulnocarpal joint
8 carpal bones (proximal and distal row and attached
ligaments)
6. Articulations
Radiocarpal joints
Triquetrum and triangular fibrocartilage
Midcarpal articulations
Distal row articulations with the matacarpals
1. Mobility in the thumb
2. Stability in the index and long finger metacarpals
3. Increased mobility in the ring and little finger
7. Triangular fibrocartilage complex
Ulnar collateral ligament
Dorsal and volar radioulnar ligament
Articular disc(Compressed with Pronation and
Extension Compressed with Ulnar deviation)
Meniscal homologue
Extensor carpi ulnaris sheat
Ulnolunate and ulnotriquetral ligament
8. Carpal Ligaments
The major ligaments of the wrist include the
palmar intrinsic ligaments, the volar extrinsic
and the dorsal extrinsic and intrinsic
ligaments
The extrinsic palmar ligaments provide the
majority of the wrist stability
The intrinsic ligaments serve as rotational
restraints, binding the proximal row into a unit of
rotational stability
9. Radiocarpal Joint
Formed by the large articular concave surface of the distal
end of the radius, the scaphoid and lunate of the proximal
carpal row, and the TFCC
10. extensor retinaculum
The extensor retinaculum compartments,
from lateral to medial, contain the tendons of:
Abductor pollicis longus and extensor pollicis
brevis
Extensor carpi radialis longus and brevis
Extensor pollicis longus
Extensor digitorum and indicis
Extensor digiti minimi
Extensor carpi ulnaris
11. The Flexor Retinaculum
Transforms the carpal arch into a tunnel, through
which pass the median nerve and some of the
tendons of the hand
Proximally, the retinaculum attaches to the tubercle of the
scaphoid and the pisiform
Distally it attaches to the hook of the hamate, and the tubercle
of the trapezium
In the condition known as ‘carpal tunnel syndrome’
the median nerve is compressed in this relatively
unyielding space
12. Carpal Tunnel
Serves as a conduit for the median nerve and nine
flexor tendons
The palmar radiocarpal ligament and the palmar ligament
complex form the floor of the canal
The roof of the tunnel is formed by the flexor retinaculum
(transverse carpal ligament)
The ulnar and radial borders are formed by carpal bones
(trapezium and hook of hamate respectively)
Within the tunnel, the median nerve divides into a motor
branch and distal sensory branches
13. Tunnel of Guyon
A depression superficial to the flexor retinaculum,
located between the hook of the hamate and the
pisiform bones
The palmar (volar) carpal ligament, palmaris brevis muscle,
and the palmar aponeurosis form its roof
Its floor is formed by the flexor retinaculum (transverse
carpal ligament), pisohamate ligament, and pisometacarpal
ligament
The tunnel serves as a passage way for the ulnar
nerve and artery into the hand
14. Phalanges
Fourteen in number
Each consist of a base, shaft, and head
Two shallow depressions, which correspond to
the pulley-shaped heads of the adjacent
phalanges, mark the concave proximal bases
Two distinct convex condyles produce the pulley-
shaped configuration of the phalangeal heads
15. Metacarpophalangeal (MCP) Joints
of the 2nd-5th Fingers
The 2nd-5th metacarpals articulate with the
respective proximal phalanges in biaxial joints
The MCP joints allow flexion-extension and
medial-lateral deviation associated with a slight
degree of axial rotation
16. Carpometacarpal Joints
Articulation between the distal borders of the
distal carpal row bones and the bases of the
metacarpals
Stability of the CMC joints is provided by the
palmar and dorsal carpometacarpal and
intermetacarpal ligaments
17. First Carpometacarpal Joint
Functionally the sellar (saddle-shaped) carpometacarpal
(CMC) joint is the most important joint of the thumb
Consists of the articulation between the base of the first
metacarpal and the distal aspect of the trapezium
Motions that can occur at this joint include flexion/extension,
adduction/abduction and opposition (which includes varying
amounts of flexion, internal rotation, and palmar adduction)
18. Metacarpophalangeal Joint of the
Thumb
A hinge joint
Consists of a convex surface on the head of the metacarpal, and
a concave surface on the base of the phalanx
19. Interphalangeal (IP) Joints
Adjacent phalanges articulate in hinge joints that allow motion in
only one plane
The congruency of the IP joint surfaces contributes greatly to
finger joint stability
The proximal IP joint is a hinged joint capable of flexion and extension
The distal IP joint has similar structures but less stability and allows
some hyperextension.
20. Palmar Aponeurosis
A dense fibrous structure continuous with the
palmaris longus tendon and fascia covering the
thenar and hypothenar muscles
Dupuytren’s contracture is a fibrotic condition of
the palmar aponeurosis that results in nodule
formation or scarring of the aponeurosis, and
which may ultimately cause finger flexion
contractures
21. Extensor Hood
A complex tendon, which covers the dorsal
aspect of the digits is formed from a combination
of the tendons of insertion from extensor
digitorum, extensor indicis, and extensor digiti
minimi
Creates a ‘cable’ system that provides a
mechanism for extending the MCP and IP joints,
and allows the lumbrical, and possibly
interosseous muscles, to assist in the flexion of
the MCP joints
22. Synovial Sheaths
Long narrow balloons filled with synovial fluid, which wrap around
a tendon so that one part of the balloon wall (visceral layer) is
directly on the tendon, while the other part of the balloon wall
(parietal layer) is separate
23. Flexor Pulleys
Annular (A) and cruciate (C) pulleys restrain the
flexor tendons to the metacarpals and phalanges
and contribute to fibro-osseous tunnels through
which the tendons travel
A1 from the MP joint and volar plate
A2 from the proximal phalanx
A3 from the PIP joint volar plate
A4 from the middle phalanx
A5 from the DIP joint volar plate
24. Muscles of the Hand
Short muscles of the thumb
Abductor pollicis brevis (APB)
Flexor pollicis brevis (FPB)
Opponens pollicis (OP)
Adductor pollicis (AP)
25. Muscles of the Hand
Short muscles of the 5th digit
Abductor digiti minimi (ADM)
Flexor digiti minimi (FDM)
Opponens digit minimi (ODM)
26. Muscles of the hand
Interosseous muscles of the hand
Three palmar interossei. Each functions to adduct the digit, to which it
is attached, toward the middle digit
Four dorsal interossei. Each functions to abduct the index, middle and
ring fingers from the mid-line of the hand
27. Muscles of the hand
Lumbricales
Function to perform the motion of IP joint extension with the MCP joint
held in extension
Can assist in MCP flexion
28. Anatomic Snuff Box
A depression on the dorsal surface of the hand
at the base of the thumb, just distal to the radius
Formed by the tendons of the APL and EPB,
while the ulnar border is formed by the tendon of
the EPL
Along the floor of the snuffbox is the deep
branch of the radial artery and the tendinous
insertion of the ECRL. Underneath these
structures, the scaphoid and trapezium bones
are found
29. Neurology
The three peripheral nerves that supply the skin and muscles of
the wrist and hand include the median, ulnar, and radial nerve
30. Vasculature of the wrist and hand
The brachial artery bifurcates at the elbow into radial and ulnar
branches, which are the main arterial branches to the hand
Vascular arches of the hand
Dorsal arches
Palmar arches
31. Biomechanics
The wrist contains several segments whose combined
movements create a total range of motion that is greater than
the sum of its individual parts
32. Pronation
Approximately 90° of forearm pronation is available
During pronation, the concave ulnar notch of the radius glides around
the peripheral surface of the relatively fixed convex ulnar head
Pronation is limited by the bony impaction between the radius and the
ulna
33. Supination
Approximately 85-90° of forearm supination is available
Supination is limited by the interosseous membrane, and the bony
impaction between the ulnar notch of the radius, and the ulnar styloid
process
34. Wrist flexion and extension
The movements of flexion and extension of the wrist are shared
among the radiocarpal articulation, and the intercarpal
articulation, in varying proportions
35. Wrist flexion and extension
During wrist flexion, most of the motion occurs in
the midcarpal joint (60% or 40° versus 40% or
30° at the radiocarpal joint), and is associated
with slight ulnar deviation and supination of the
forearm
During wrist extension, most of the motion
occurs at the radiocarpal joint (66.5% or 40°
versus 33.5% or 20° at the midcarpal joint), and
is associated with slight radial deviation and
pronation of the forearm
36. Radial Deviation
Radial deviation occurs primarily between the proximal and distal
rows of the carpal bones
The motion of radial deviation is limited by impact of the scaphoid
onto the radial styloid, and ulnar collateral ligament
37. Ulnar deviation
Ulnar deviation occurs primarily at the radiocarpal joint
Ulnar deviation is limited by the radial collateral ligament
38. The hand
The hand accounts for about 90% of upper
limb function
The thumb is involved in 40-50% of hand function
The index finger is involved in about 20% of hand
function
The middle finger, which accounts for about 20%
of all hand function, is the strongest finger, and is
important for both precision and power functions
39. Thumb motions
Within the first CMC joint, the longitudinal
diameter of the articular surface of the trapezium
is generally concave from a palmar to dorsal
direction
The transverse diameter is generally convex
along a medial to lateral direction
The proximal articular surface of the first
metacarpal is reciprocally shaped to that of the
trapezium
40. Thumb flexion and extension
Thumb flexion and extension occur around an anterior-posterior
axis in the frontal plane that is perpendicular to the sagittal plane
of finger flexion and extension
In this plane, the metacarpal surface is concave, and the
trapezium surface is convex
41. Thumb abduction and adduction
Thumb abduction and adduction occur around a medial-lateral
axis in the sagittal plane, that is perpendicular to the frontal plane
of finger abduction and adduction
During thumb abduction and adduction, the convex metacarpal
surface moves on the concave trapezium
42. A number of grips have been
recognized:
Fist grip
Cylindrical grip
Ball grip
Hook grip
Ring grip
Pincer grip
Pliers grip
43. history
What is the cause of pain?
Mechanism of injury?
Previous history?
Location, duration and intensity of pain?
Creptitus, numbness, distortion in temperature?
Sounds or sensations?
Technique changes?
Weakness or fatigue?
What provides relief?
44. Observation
The clinician inspects for lacerations, surgical
scars, masses, localized swelling, or erythema
Scars should be examined for degree of
adherence, degree of maturation, hypertrophy
(excess collagen within boundary of wound), and
keloid (excess collagen that no longer conforms
to wound boundaries)
The location and type of edema should be noted
45. Examination
AROM, then PROM with over pressure
The gross motions of wrist, hand, finger and thumb flexion,
extension, and radial and ulnar deviation are tested, first actively
and then passively
Any loss of motion compared with the contralateral,
asymptomatic wrist and hand should be noted
46. Palpation
Palpation of the muscles, tendon, insertions, ligaments, capsules,
bones of the wrist and hand should occur as indicated, and be
compared with the uninvolved side
47. Pain provocation tests
These tests are used to determine the cause of a painful or
dysfunctional motion by systematically testing each of the
articulations to see whether the maneuvers reproduce the
patient’s symptoms
48. Strength testing
Isometric tests are carried out in the extreme
range, and if positive, in the neutral range
These isometric tests must include the interossei
and lumbricales
The straight plane motions of wrist flexion,
extension, ulnar and radial deviation are tested
initially
Pain with any of these tests requires a more
thorough examination of the individual muscles
49. Examination
Functional Assessment
The functional range of motion for the hand is the range in which
the hand can perform most of its grip and other functional
activities
A number of assessment tools are available
50. Examination
Passive Physiological Mobility Testing
In each of the tests, the clinician
notes the quantity of motion as well
as the joint reaction (end feel).
The tests are always repeated on,
and compared to, the same joint in
the opposite extremity
51. Passive Accessory Mobility Tests
In each of the tests, the clinician notes the quantity of accessory
joint motion as well as the joint reaction
The tests are always repeated on, and compared to, the same
joint in the opposite extremity
52. Ligament Stability
A number of tests are available to evaluate the ligamentous
stability of the forearm, wrist, hand and finger joints
54. Examination
Sensibility Testing
The assessment of sensibility of the hand is an important
component of every hand examination because sensation is
essential for precision movements and object manipulation
Two types of sensibility are assessed
Protective
Functional
55. Examination
Special tests
Carpal Shake test
Sit to Stand test
Ulnar Impaction test
Finkelstein’s test
Flexor digitorum superficialis (FDS) test
Flexor digitorum profundus test
Extensor Hood rupture test
Froment’s sign
Murphy’s sign
56. Examination
Diagnostic testing
Diagnostic testing of the forearm, wrist and hand
is limited to plain radiographs for most patients
Bony tenderness with a history of trauma or a
suspicion of bone or joint disruption indicates a
need for radiographs
Standard projections for the wrist are the
posteroanterior, lateral, and oblique
For the patient with a suspicion of a scaphoid
injury, a scaphoid view should be added
74. ROM
Distal Radioulnar joint
Supination and Pronation – 80-90o
Ulna moves posteriorly and laterally with pronation
Radiocarpal joint (and Ulnocarpal joint)
Flexion (80-90o) and Extension (75-85o)
Radial (20o) and Ulnar (35o) Deviation
Intercarpal joints
Gliding
75.
76. palpation
Bony and Soft Tissue Palpation
Are they where they should be?
Do they feel like they should feel?
Circulatory and Neurological Evaluation
Hands should be felt for temperature
Cold hands indicate decreased circulation
Take pulse – radial artery
Pinching fingernails can also help detect circulatory problems
(capillary refill)
Hand’s neurological functioning should also be tested
(sensation and motor functioning)