Hand

1. Hand 19 Bones 19 Articulations 29 Muscles

2. Bones of the Hands

3. Arches of the Hand • Transverse carpal arch • Transverse metacarpal arch • Longitudinal arch

4. Mobility of 4th and 5th CMC Joints

5. Creases of the Hand • Distal digital crease • Middle digital crease • Proximal digital crease • Distal palmar crease • Proximal palmar crease • Thenar crease • Distal wrist crease • Proximal wrist crease

6. Volar or Palmar Plates • Volar or Palmar Plates are dense thick discs of fibrocartilage which help to strengthen joint and prevent hyperextension • Note the fibrous digital sheath in top picture (annual pulley)

7. Flexion and Extension • Axis - Lateral • Plane - Sagittal • Abduction and Adduction • Axis - Anterior/Posterior • Plane – Frontal Motions at the MP Joints

8. Flexion and Extension • Axis - Lateral • Plane - Sagittal Motions at the PIP and DIP Joints

9. Muscles originating outside the hand • Flexor Digitorium Superficialis • Flexor Digitiorium Profundus • Flexor Pollicus Longus • Extensor Digitorum • Extensor Indicis Proprius • Extensor Digiti Minimi • Extensor Pollicus Longus • Extensor Pollicus Brevis • Abductor Pollicus Longus Extrinsics

10. Four Lumbricals • Three Palmar Interossei • Four Dorsal Interossei • Thenar muscles • Opponens Pollicus • Abductor Pollicus Brevis • Adductor Pollicus • Flexor Pollicus Brevis Intrinsics

11. Hypothenar muscles • Opponens Digiti Minimi • Abductor Digiti Minimi • Flexor Digiti Minimi Brevis • Palmaris Brevis Intrinsics

12. Flexor Tendons

14. Flexor Digitorum SuperficialisTest for Tendon Integrity • Therapist holds all fingers except one being tested in extension. This isolates the Flexor Digitorum Superficialis. If client can flex at PIP joint then FDS tendon is intact.

15. Flexor Digitorum ProfundusTest for Tendon Integrity • Therapist extends all joints of client’s finger except the DIP. Therapist asks client to flex the DIP. If client can, FDP is intact

16. Annular Pulleys • Hold flexor tendons relatively close to joint (functional insertions) • Rupture results in bowstringing with less ROM and strength • Trigger finger

17. Over the proximal phalanx the extensor tendon (from extensor digitorum) divides into a central band and two lateral bands • The central band inserts at the base of the middle phalanx • The two lateral bands rejoin over the middle phalanx and insert at the base of the distal phalanx Extensor Assembly

18. Extensor Mechanism

19. Extensor Mechanism

20. MCP 70 degrees PIP/DIP extension Extensor MechanismClosed pack position

21. Closing Hand

22. Opening Hand

23. Relationship of AB & Adduction to Flexion and Extension at MP Joints • When MP joints are extended – the collateral ligaments are slack and allow for AB and Adduction of Fingers • When MP joints are flexed – the collateral ligaments are taut (tight) and prevent AB and ADduction

24. Position for Long Term Immobilization • Metacarpalphalangeal joints in 60 to 70 degrees of flexion • PIP and DIP joints extended

25. Thumb Flexion/Extension (Radial Adduction/Abduction) • Axis - Anterior/Posterior • Plane – Frontal • Thumb Palmar Adduction/Abduction • Axis – Lateral • Plane - Sagittal Thumb Movements at CMC Joint

26. Thumb Movements

27. Thumb Movements at CMC Joint • Flexion/Extension • (Radial AB/Adduction) • AB/Adduction • (Palmar AB/Adduction) • Opposition/Reposition

28. Functional Position of Hand • Wrist is in 20 to 30 degrees of extension and slight ulnar deviation • Fingers in 45 degrees of MCP, 15 degrees of PIP and DIP flexion • Thumb is in 45 degrees of abduction

29. Intrinsic Plus • Flexion of MP to 90 degrees and extension at PIP and DIP - or Roof Top Position • Interossei and lumbricals at their shortest • Common in patients with R.A.

30. Intrinsic Minus • Hyperextension of the MP joints and flexion of the PIP joints or “Clawhand” • Paralysis of interossei and lumbrical muscles

31. Intrinsic=(Lumbricals and interosseus =table top) • Extrinsic=ED, FDS, FDP) = Hook Intrinsic and extrinsicplus hand

32. Intrinsic Plus and Minus

33. Power grip • Spherical • Cylindrical • Precision grip • Power (key) pinch • Lateral pinch • Precision pinch • Hook grip Types of Prehension

34. Power grip • Spherical • Cylindrical • Precision grip • Power (key) pinch • Lateral pinch • Precision pinch • Hook grip Match

35. Common hand disorders

36. Intrinsic Tightness • Nerve injuries • Ulnar Nerve Injury • Median Nerve Injury • Carpal Tunnel Syndrome • Radial Nerve Injury • Tendon injuries • Mallet Finger • Swan Neck Deformity • Boutonniere Deformity • Zig Zag Deformities • DeQuervain’s Disease • Fascia • Dupuytren’s Contracture Problems of the Hand

37. MCP joint held in slight extension while examiner moves the PIP joint into flexion – if can’t be flexed, intrinsic or joint capsule tightness • Place MCP joint in a few degrees of flexion to relax intrinsics – if joint can now flex, then it was intrinsic tightness • If when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture. Bunnell-Lister Test for Intrinsic Tightness

38. Bunnell-Lister Test for Intrinsic Tightness: Step 1 • MCP joint held in slight extension will therapist moves the PIP joint into flexion – if can’t be flexed, intrinsic or joint capsule tightness

39. Bunnell-Lister Test for Intrinsic Tightness: Step 2 • Place MCP joint in a few degrees of flexion to relax intrinsics – if joint can now flex, then it was intrinsic tightness

40. Bunnell-Lister Test for Intrinsic Tightness: Step 3 • If when MCP joint placed in flexion still can’t flex PIP – then it is a joint capsule tightness or contracture

41. 1.) Coracoid process (may be injured during surgery) • 2.) Coracobrachialis muscle • 3.) Distal lateral arm as it goes through investing fascia • 4.) Lateral Forearm – Vulnerable to blunt trauma Musculotaneous nerve (C5, C6 – Continuation of the lateral cord)Points of entrapment

42. http://video.google.com/videosearch?sourceid=navclient&rlz=1T4ADBF_enUS296US296&q=tenodesis&um=1&ie=UTF-8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0http://video.google.com/videosearch?sourceid=navclient&rlz=1T4ADBF_enUS296US296&q=tenodesis&um=1&ie=UTF-8&sa=N&hl=en&tab=wv#q=quadriplegia+c6&hl=en&emb=0 Tenodesis- C6

43. Unable to oppose thumb • Unable to make a complete fist • Atrophy of thenar eminence • Weak wrist flexion • Weak pronation of the forearm Median Nerve Injury

44. 1.) Ligament of struthers/supracondylar process (medial ridge) 2.) Bicipital aponeurosis 3.) Between 2 heads of pronator teres (Pronator syndrome) 4.) Sublimis Bridge (FDS borders) 5.) AIN (Anterior interosseous nerve branch)- may also be entrapped by pronator 6.) Carpal Tunnel- between flexor tendons and transverse carpal ligament 7.) Metacarpal tunnel – between metacarpal ligaments and MCP’s Median Nerve = C5-C6, Medial and Lateral cords

45. Flexor Carpi Radialis • Palmaris Longus • Flexor Digitorum Superficialis • Radial Half of Flexor Digitorum Profundus • Two Radial Lumbricals • Flexor Pollicus Longus • Superficial portion of Flexor Pollicus Brevis • Opponens Pollicus • Abductor Pollicus Brevis (may have ulnar innervation) Muscles Innervated by the Median Nerve

46. Carpal Tunnel Syndrome

47. Carpal Tunnel Syndrome – Tinel’s Sign • Tinel’s Sign – When therapist taps over the carpal tunnel, the client will feel parasthesias or tingling distally

48. Phalen’s Test • Therapist flexes client’s wrists manually and holds together for one minute. Positive test elicits tingling in thumb, index finger, and middle and lateral half of the ring finger and is indicative of Carpal Tunnel Syndrome.

49. Ape Hand Deformity

50. Low injury = Thumb, index, middle. Loss of 2 lateral lumbricals • Index and middle have noticeable claw, • Thumb is rotated and flexed and in same plane as fingers, looses opposition (ape) High injury = Only FCU and ulnar half of FDP are spared. Similar claw but not as pronounced because don’t have the force of the long flexors. (pope) Hand is virtually useless Median Nerve Injury (ape or pope)