Physical therapy of the wrist and hand

Physical therapy of the wrist and hand

Functional anatomy wrist and hand The wrist includes distal radius, scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate. The hand includes five metacarpals and 14 phalanges make up the hand and five digits The wrist is allowed for FL, EXT, radial deviation and ulnar deviation

Functional anatomy: the radiocarpal joint The radiocarpal joint: The concave distal end of the radius and radioulnar disc connects the convex proximal row of the scaphoid, lunate, and triquetrum. The triquetrum is mainly articulated with the disc

Functional anatomy: the radiocarpal joint Physiological motion of wrist Flexion Extension Radial deviation Ulnar deviation Carpal glide of the proximal row Dorsal Volar Ulnar Radial

Functional anatomy: the midcarpal joint The proximal row of the scaphoid, lunate, and triquetrum articulates with the distal row the trapezium, trapezoid, capitate, and hamate. The capitate and hamate are convex and glide on the concave surface of the scaphoid, lunate, and triquetrum The concave trapezium and trapezoid glide on the convex distal surface of the scaphoid

Functional anatomy: the carpometacarpal (CMC) joint of digit 2 through 5 Between each metacarpal and the distal row of carpals and the articulations between the base of each metacarpal The flexion of the metacarpals and additional adduction of the fifth contribute to the cupping of the hand, improving prehension.

Functional anatomy: the carpometacarpal (CMC) joint of the thumb Saddle-shaped joint between the trapezium and base of the first metacarpal. For flexion-extension of the thumb occurring in the frontal plane, the trapezium is convex and the base of the metacarpal is concave. For abduction-adduction occurring in the sagittal plane, the trapezium is concave and the metacarpal is convex

Functional anatomy: the carpometacarpal (CMC) joint of the thumb The first metacarpal of the thumb Flexion Extension Abduction Adduction Direction of glide of base of metacarpal Ulnar Radial Dorsal Volar

Functional anatomy: the metacarpophalangeal (MCP) joint of the thumb Convex distal end of each metacarpal and concave proximal phalanx Supported by a volar and two collateral ligaments

Functional anatomy: the interphalangeal (IP) joint PIP and DIP for digit 2 to 5; the thumb has only one IP The articulating surface at the distal end of each phalanx is convex, the articulating surface at the proximal end of each phalanx is concave

Hand function: length-tension relationships As the fingers or thumb flex, the wrist must be stabilized by the wrist extensors from simultaneously flexing the wrist. For strong fingers or thumb extension, the wrist flexors stabilize or flex the wrist so the extensors can function more efficiently.

Hand function: cupping and flattening Cupping of the hand occurs with finger flexion, and flattening of the hand occurs with extension.

Hand function: extensor mechanism Isolated contraction of the extensor digitorum produces clawing of he fingers (MCP hyperextension with IP flexion from passive pull of the extrinsic flexor tendons) PIP and DIP extensions occur concurrently and can be caused by the interossei or lumbrical muscles There must be tension in the extensor digitorum communis tendon for there to the interphalangeal extension

Hand function: grips and prehension patterns Grips invlove clamping an object with partially flexed fingers against the palm of the hand, with counterpressure from the adducted thumb. Varieties include cylindrical grip, spherical grip, hook grip, and lateral prehension. Precisions involve manipulating an object that is not in contact with the palm of the hand between the opposing abducted thumb and fingers varieties include pad-to-pad, tip-to-tip, and pad-to-side prehensions

Hand function: grips and prehension patterns Combined grips involve digit 1 and 2 performing precision activities, whereas digit 3-5 supplement with power

Median nerve subject to pressure and trauma around the wrist and hand Median nerve passes through the carpal tunnel at the wrist with the flexor tendons. Nerve entrapment in the tunnel may occur. Sensory changes: over the radial 2/3 of the palm, the aplmar surfaces of the first three and ½ digits, and the dorsum of the distal phalanges. Weakness distal to the wrist: opponens pollicis, abductor pollicis brevis, superficial head of the flexor pollicis brevis, and lumbricals I and II Ape-hand deformity

Ulnar nerve subject to pressure and trauma around the wrist and hand Ulnar nerve enters the hand through a tunnel formed by the pisiform and hook of hamate and is covered by the volar carpal ligament and palmaris brevis muscle Sensroy chnge: ulnar 1/3 of the hand, 5 th digit and ulnar side of the 4 th digit Weakness to muscle distal to the site: palmaris brevis, muscles of the hypothenar eminence, lumbricals III and IV, interossei, adductor pollicis, and deep head of the flexor pollicis brevis Claw-hand deformity

Radial nerve subject to pressure and trauma around the wrist and hand Radial nerve enters the hand on the dorsal surface as the superficial radial nerve, only sensory. Sensory change: over the radial 2/3 of the dorsum of the hand and thumb and the proximal phalanx of the 2 nd, 3th, the half of the 4 th digit Muscles innervated by radial nerve are proximal to the wrist

Common wrist and hand deformities: Colles fracture Disturbance of the inferior radio-ulnar joint Residual deformities: radial deviation of the hand and prominence of the ulna Loss of movement of supination and wrist extension Two complications after Colles fracture: Delayed rupture of extensor pollicis longus may occur some months after injury and is due to ischaemia or attrition of the tendon

Common wrist and hand deformities: Colles fracture Sudeck s atrophy: marked swelling of the wrist, hand and fingers, gross stiffness of the fingers, and carpal decalcification

Common wrist and hand deformities: ganglions In the carpal joint or tendon sheath or in the fingers Size fluctuated local swelling and tenderness may only obvious when the wrist is flexed.

Common wrist and hand deformities: De Quervain s disease Tenosynovitis involving abductor pollicis longus and extensor pollicis brevis P t may complain of pain on certain movement of the wrist, and weakness of grip Splitting the lateral wall of the sheath is the choice of treatment

Common wrist and hand deformities: carpal tunnel syndrome Compression of the median nerve leads to symptoms related to its distribution Premenstrual fluid retention, early RA with synovial tendon sheath thickening, and old colles or carpal fractures may be responsible by restricting the space P t complains paresthesia in the hand except little finger; symptoms may become obvious in midnight; shaking the hand to release the symptoms is usually needed P t may have both signs of the cervical spondylosis and carpal tunnel syndrome

Common wrist and hand deformities: ulnar tunnel syndrome Ulnar nerve is compressed as passing through the ulnar canal between the pisiform and the hook of the hamate Symptoms include small muscle wasting and weakness in the hand with sensory disturbance on the volar aspect of the little finger Causes of nerve involvement are ganglion, occupational trauma, old carpal or metacarpal fractures

Common wrist and hand deformities: Dupuytren s contracture Nodular thickening and contracture of the palmar fascia The palm of the hand is affected first, and later the 4 th finger, followed by the little and middle fingers The progressive flexion of the affected fingers interferes with the function of the hand affect men more than women over 40 May be hereditary tendency, or associated with epilepsy, diabetes or alcoholic cirrhosis

Common wrist and hand deformities: tendon and tendon sheath lesions Mallet finger: DIP is held in a permanent position of flexion; unable to extend the distal joint The extensor tendon either ruptures close to insertion in the distal phalanx, or it avulses its bony attachment Healing may occur over 6 to 12 month period Use of light splint holding the DIP in hyperextension for 6 weeks is practical

Common wrist and hand deformities: tendon and tendon sheath lesions Mallet thumb: Delayed rupture of the extensor pollicis longus tendon may follow Colles fracture or rheumatic arthritis, and repair by tendon transfer is advised

Common wrist and hand deformities: tendon and tendon sheath lesions Swan-neck deformity: Flexion of the metacarpophalangeal and distal interphalangeal joints in addition to extension of the proximal interphalangel joint A result of contracture of the intrinsic muscles and often seen in rheumatoid arthritis

Common wrist and hand deformities: tendon and tendon sheath lesions Boutonniere deformity: Flexion of the interphalangeal joint of a finger with extension of the distal interphalangeal joint Due to rupture of the central slip of the extensor tendon attached to the base of the middle phalanx Due to incised wounds on the dorsum of the finger and avulsion injuries; Commonly seen in rheumatoid arthritis Surgical repair of the extensor band is often undertaken

Common wrist and hand deformities: trigger finger and thumb Thickening of a fibrous tendon sheath or nodular thickening in a flexor tendon When the fingers are extended, the affected finger lag behind and then quite suddenly straightens. The middle, ring finger or thumb are most frequently involved. Nodular thickening at the level of the MP joint may also be palpable.

Common wrist and hand deformities: Z deformity of the thumb The thumb is flexed at the metacarpophalangeal joint and hyperextended at the interphalangeal joint May related to heredity, or rheumatic arthritis.

Common wrist and hand deformities: rheumatic arthritis In the early stage the hands are warm and moist Later the joints become obviously swollen and tender. Synovial tendon sheath and joint thickening with effusion, muscle wasting, and deformity then become apparent Tendon rupture and joint subluxation are the main factors leading to the more severe deformities

Common wrist and hand deformities: osteoarthritis of the interphalangeal joint Heberden s nodes: nodular swellings situated dorsally over the bases of the distal phalanges Bouchard s nodes: nodular over the bases of the middle phalanges; less common Occur most in women after the menopause; not related to osteoarthritis elsewhere Most are symptom-free, may be related to joint damage and consequent pain

Common wrist and hand deformities: osteoarthritis of the carpo-metacarpal joint of the thumb common between the thumb metacarpal and trapezium and may give rise to disabling pain and dysfunction May related to Bennett s fracture or occupational overuse