Download 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, 5th digit and ulnar
side of the 4th 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 2nd,
3th, the half of the 4th 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 4th
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