Acknowledgements. Methods of Learning. The Dorsal Interossei 11/2/17. Special thanks to:

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1 The Dorsal Interossei Mike Cricchio, MBA, OT/L, CHT Site Manager UFHealth Hand and Upper Extremity Acknowledgements Special thanks to: Michelle Darnell, DPT, PT Kimberly Hellriegel, OTR/L Jill Bitz, OTS Justine Chan, OTS Sarah Hansen, Bsc UFHealth Hand and Upper Extremity Center Methods of Learning Anatomical Study within Clinical Case Context Clinical Questions 1

2 Knowledge of Anatomy Examples: Discussion Recognizing and responding appropriately to an incomplete and/or incorrect referral. Minimizes Error Advances patient experience Advances physician/therapist relations Improves quality of care Recognizing and responding appropriately to an descriptive, detailed, correct referral Educating the patient to their diagnosis, outline P.O.C. simply and convincingly Discussing the diagnosis and P.O.C with student and/or colleague Global Objectives Detailed study of intrinsic anatomy Utilize case-study analysis Review intrinsic literature Suggest treatment rationale based on case-study analysis Fabrication custom digital orthoses; review soft tissue & special test of the hand Suggest a clinical/anatomical rationale for the treatment of intrinsic pathologies Case Study Rationale: descriptive method of delivering a unique story with ubiquitous meaning. Principles Pathology with immobilization Lose ground substance: lose ground Effects of effusion & edema Efficient Posture Window of time We tend to teach patients/students about areas in which we feel most competent. 2

3 Evening Schedule Hand Intrinsics Part 1 The Dorsal Interossei (Didactic Presentation) The Dorsal Interossei (Anatomical Drawing Lab: 1 st and 3 rd Dorsal Interossei) Case Study: Pathology of the Dorsal Interossei Literature Review over Dinner (Richard Smith, MD Article) Mallet Finger Orthotic Lab Soft Tissue Mobilzation of the Hand BOTH BONE FOREARM FRACTURE: Low Ulnar Nerve Palsy CASE # 1 Case # 1 Patient is an 18 year old female, MVA, sustained both bone forearm fracture Pokehole laceration on volar aspect of forearm; open fracture Numbness of 4 th & 5 th digits Open Reduction and Internal Fixation (ORIF) of radius and ulna; no surgical intervention to ulnar nerve 3

4 Case Study # 1 Forecasted Complications (Dorsal Interossei) Sensory loss (cuts, burns etc. ) Mal-union/non-union 7/21 7/22 8/6 8/14 Synonstosis (radius and ulna) Car accident Surgery and cast Cast removed, evaluation meunster orthotic fabricated Cont d assessment: Froment s, intrinsic tightness, Wartenberg s sign, Elson s test, intrinsic examination Intrinsic wasting RF & SF claw deformity; 1 st web space contracture Adductor pollicis wasting Loss AROM & functional strength (Hand/wrist) RF & SF volar plate contracture Intrinsic tightness, long extensor and flexor tightness Clinical Presentation Clinical Presentation: ulnar claw Light gauze over suture sites Ace wrap and compression glove to assist with edema control 4

5 Clinical Presentation (Froment s sign) Clinical Presentation Semmes Weinstein: RF: 6.65 SF: 6.65 Clinical Presentation Intrinsic Tightness Testing Intrinsic Tightness Test Described by Finochietto in 1920 Less passive PIP flexion when MCP extended than when MCP is flexed Joint stiffness characterized by limited PIP flexion with MCP flexed Clinical Presentation Clinical Presentation Low ulnar nerve entrapment Ulnar clawing Inability to extend the PIP and DIP of digits 4 and 5 Inability to abduct or adduct the fingers Inability to oppose all the fingers Positive Froment s Sign Low ulnar nerve entrapment: Atrophy of the interossei (especially the first) and of the hypothenar eminence Loss of sensation over ulnar nerve distribution 5

6 Ulnar Nerve Orthosis Lumbrical plus position Right hand affected Clinical Presentation Ulnar nerve innervation: Dorsal interossei Palmar interossei Lumbricals 3 and 4 FDP to digits 4 and 5 Median nerve innervation: Lumbrical plus position Right hand affected Lumbricals 1 and 2 FDS FDP to digits 2 and 3 Clinical Presentation Flattening of hypothenar eminence and arches of hand Clinical Presentation Lumbrical action: Primary IP extensors Weak MCP flexors When interossei are paralyzed, the lumbricals can assist with MCP flexion Unopposed long finger flexor leads to IP joint flexion 6

7 Clinical Presentation Ulnar nerve innervation: Dorsal interossei Palmar interossei Lumbricals 3 and 4 FDP to digits 4 and 5 Median nerve innervation: Lumbricals 1 and 2 FDS FDP to digits 2 and 3 Dorsal Interossei Osseous Base Extensor tendons Trifurcation: central slip and lateral slips Lateral band Conjoined lateral band Terminal tendon Sagittal bands, transverse fibers, and oblique fibers Static stabilizers Oblique retinacular ligament Transverse retinacular ligament Triangular ligament 7

8 11/2/17 Dorsal Interossei Dorsal Interossei (Dorsal Interossei) Bipennate 1, 2 and 4 have superficial + deep muscle bellies 3 only has deep muscle belly DAB: Dorsal interossei Abduction Orientation based on 3rd digit 8

9 11/2/17 (1st Dorsal Interossei: Superficial belly) Origin: Adj. sides of all metacarpals Insertion: continues as medial tendon to insert on lateral tubercle at base of proximal phalanx Action: Abduction Weak flexor of MCP joint Innervation: deep branch of ulnar nerve 1st Dorsal Interossei: Superficial Belly (Dorsal Interossei: Superficial Belly) (Dorsal Interossei: Superficial Belly) (Dorsal Interossei: Superficial Belly) 9

10 11/2/17 (1st Dorsal Interossei: Deep belly) Origin: Same as superficial belly Insertion: Continues distally as lateral tendon to: Contribute fibers to lateral band Contribute fibers to transverse fibers Action: MCP joint flexion Innervation: deep branch of ulnar nerve (1st Dorsal Interossei: Deep Belly) Intrinsic Anatomy Lateral band from intrinsics is joined by lateral slips of long extensors to form the conjoined lateral band Lateral band Conjoined lateral band At distal 1/3 of proximal phalanx Dorsal Interossei: Deep Belly Insertion Continues as lateral tendon to: Contributes fibers to lateral band Contributes fibers to transverse fibers 10

11 Intrinsic/Extrinsic Anatomy (Terminal Tendon) Conjoined lateral bands merge to form terminal tendon Central slip Lateral slip Terminal tendon Conjoined lateral band Lateral band Terminal tendon Inserts: base of distal phalanx Action: extends DIP EDC tendon Intrinsic Anatomy (Dorsal Interossei: Deep Belly) Action: Strong flexor and weak abductor of the proximal phalanges (Dorsal Interossei: Deep Belly) 11

12 (1 st Dorsal Interossei: Deep belly) Dorsal Interossei (Digits 2-4) IF MF MF RF Radial Side Radial Side Ulnar side Ulnar side Super belly Deep belly Super belly Deep belly Deep belly Only Superficial belly Deep belly Dorsal Interossei (Points to Consider) 3 rd Dorsal Interossei 1 st (DI) largest and strongest; often only has a superficial belly (strong abductor) 3 rd (DI) only deep belly merges with lateral SLIP to form conjoined lateral band Abduction of MF in ULNAR direction significantly weaker than MF abduction in the RADIAL direction 1 st (DI) and 2 nd (DI) very similar (radial sided & two muscle bellies) 4 th (DI) ulnar sided & two muscle bellies 3 rd Dorsal Interossei 12

13 1-4 days Acute Inflammatory Response Case Study # days Fibroplasia/Collagen deposition/scar formation Tissue Healing days Maturation/Remolding Strength/Conditioning Pain I d e a Ideally: stress applied during alignment & stiffening phase ROM Edema/Effusion Light gauze over suture sites Ace wrap and compression glove to assist with edema control Effluerage, petrisage techniques to move effusion & edema 13

14 Without strap over RF and SF With strap over RF and SF 7/22/2014: Cast fabricated to prevent AROM of wrist, forearm, and elbow 8/6/2014: Progressed to Meunster orthotic (9/3/2014) (10/15/2014) Progressed to a handbased orthotic during 11 th week post-op Instructed to wear wrist control orthosis if doing any heavy-lifting activities 14

15 Drawing Lab The Dorsal Interossei 15

16 Lab: Principles Swarm Intelligence (20 min) Learn it Draw it Extensor mechanism & dorsal interossei Teach it Lab: Outline EDC: central slip Sagittal bands Lab: EDC & Sagittal bands Step #1: draw EDC Step #2: draw sagittal bands Transverse fibers Oblique fibers EDC: lateral slips Dorsal Interossei 1,2,4 Dorsal Interossei 3 Lab: Transverse fibers & Oblique fibers Step #3: draw transverse fibers Step #4: draw oblique fibers Lab: Lateral slips & D1, D2, D4 Step #5: draw lateral slips Step #6: draw D1, D2, D4 (superficial belly & medial tendon) 16

17 Lab: D3 & deep belly & lateral tendon Literature Review The Intrinsics Step #7: draw D1, D2, D3, D4 (deep belly & lateral tendon) Richard Smith, MD May 29 th every year (Cambridge, Mass) is Smith Day in honor of Dr. Richard J. Smith, MD, who served as the Chief of the Hand and Upper Extremity Service from 1972 until Smith Day is a time for hand surgeons to present their original research and discuss this research with their peers. Dr. Smith was devoted to education, the pursuit of excellence and the advancement of the specialty of hand surgery, and Smith Day commemorates his legacy. Richard Smith, MD Henry Mankin, MD, in writing Richard Smith s obituary in the Journal of Bone and Joint Surgery in 1987, stated so eloquently, his capacities, talents, and commitment made him, in the eyes of man, our finest flower and the thirty years he gave to hand surgery, one of its finest periods. 17

18 Richard Smith, MD (Intrinsic Article) Message to the Reader: Versatility and power of human hand dependent of the BALANCE of the intrinsics; anatomical axis of the hand coincides with the third metacarpal Level of Evidence: Level 5 (expert opinion/anatomy) Purpose: to provide the reader with detailed, descriptive understanding of the intrinsics in an effort to problem solve and treat PATHOLOGIES of the hand How will change clinical practice:??????????? Central slip Lateral slip Terminal tendon Conjoined lateral band Lateral band EDC tendon Intrinsic Anatomy Dorsal Interossei: Deep Belly Insertion Continues as lateral tendon to: Contributes fibers to lateral band Contributes fibers to transverse fibers Lateral band from intrinsics is joined by lateral slips of long extensors to form the conjoined lateral band At distal 1/3 of proximal phalanx Lateral band Conjoined lateral band (9/3/2014) The Mallet Orthotic Lab 18

19 Mallet Orthosis Lab Step # 1 Step # 2 Step # 3 Step #4 Step # 5 19

20 Step # 6 Step # 7 References Thank you Boyer, M. I. & Gelberman, R. H. (1999). Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand. Journal of the American Academy of Orthopaedic Surgeons, 7 (2), Brand, Paul W. Biomechanics of Balance in the Hand. J Hand Therapy , Brand, Paul W. Lessons from Hot Feet: A Note on Tissue Remodeling. J Hand Therapy , Brand, Paul W. Mechanical Factors in Joint Stiffness and Tissue Growth. J Hand Therapy , Brand, Paul W. Pain-It s All in Your Head: A Philosophical Essay. J Hand Therapy. 10:59-63, Brand, Paul W. The Mind and Spirit in Hand Therapy. J Hand Therapy , Dell, P. C. & Sforzo, C. R. (2005). Ulnar intrinsic anatomy and dysfunction. Journal of Hand Therapy, 18, Elson, R. A. (1986). Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. Journal of Bone & Joint Surgery, British Volume, 68(2), References Glasgow C, Tooth LR, Fleming J. Mobilizing the Stiff Hand: Combining Theory and Evidence to Improve Clinical Outcomes. J Hand Therapy. 23: , Gruber, J. S., Bot, A. G. J., & Ring, D. (2014). A prospective randomized controlled trial comparing night splinting with no splinting after treatment of mallet finger. Hand, 9, Hollister A, Giurintano DJ. Thumb Movements, Motions, and Moments. J Hand Therapy. 8: , References Smith, Richard J. Balance and Kinetics of the Fingers Under Normal and Pathological Conditions. Clinical Orthopaedics and Related Research. 104:92-111, Smith, Richard J. Intrinsic Muscles of the Fingers: Function, Dysfunction, and Surgical Reconstruction. A.A.O.S: Instructional Course Lectures. 12: Leversedge, F. J., Goldfarb, C. A., Boyer, M. I. ( 2010). A pocketbook manual of hand and upper extremity anatomy. Philidephia, PN: Williams & Wilkins. Leversedge, Fraser J. Anatomy and Pathomechanics of the Thumb. Hand Clinics. 24: , Mackin, Callahand, Skerven, Schneider, Osterman (2002). Rehabilitation of the hand and upper extremity. Saint Louis, Missouri: Mosby. Moore, K. L. (1992). Clinically oriented anatomy. Baltimore, Maryland: Williams & Wilkins. Smith, R. J. (1975). Intrinsic muscles of the fingers: Function, dysfunction, and surgical reconstruction. AAOS: Instructional Course Lecture, 24,

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