Download Shoulder, Elbow, Wrist, and Hand

JOINT MOBILITY –
Joint Mobility of Upper Extremity
Huei-Ming Chai, Ph.D., PT
School of Physical Therapy
National Taiwan University
教學目標
• 修習本單元後, 學生應可
– 描繪上肢關節的基本構造, 包括所屬關節、關節形
狀、相關的肌群與韌帶等
– 了解上肢關節產生的動作，如關節動作與關節面動
作，以及牽制動作產生的因子
– 分辨不同自由度關節的異同
1
The Elbow Complex
Functions of Elbow
• to add mobility of hand in space by
shortening and/or lengthening the arm,
rotating the forearm, or combination of the
above both
• to provide control and stability for skilled hand
motions and forceful upper extremity motions
2
The Elbow Complex
 Joint structure of the elbow
–
–
–
–
humeroulnar joint
humeroradial joint
proximal radioulnar joint
carrying angle
• Kinematics of the elbow
• Muscle function at the elbow
• Elbow joint stability
Components of Elbow Complex
• 3 joint enclosed in ONLY one joint capsule
humeroradial
joint
L
proximal
radioulnar
joint
radius
humerus
M
humeroulnar
joint
ulna
3
Joint Motions at Elbow
• Humeroulnar joint
– primary joint for elbow flexion/ extension
• Humeroradial joint
– moves with flexion/extension but promarily affect
pronation/supination
• Proximal radioulnar joint
– primary for forearm pronation/supination
Anterior View of Distal Humerus
coronoid fossa
(coronoid = like crown)
lateral
epicondyle
capitellum
(small head)
medial
epicondyle
trochlea
(= pulley)
4
Posterior View of Distal Humerus
olecranon
fossa
medial
epicondyle
lateral
epicondyle
capitellum
trochlea
Lateral View of Humeroulnar Joint
coronoid fossa
olecranon
fossa
humerus
coronoid process
ulna
olecranon process
(funny bone)
trochlear notch
5
Humeroulnar Joint
• Proximal component: humerus
– hourglass-shaped trochlea (trochlea=pulley)
– olecranon fossa
– coronoid fossa (coronoid= like crown)
• Distal component: ulna
– saddle-shaped trochlear notch
– olecranon process
– coronoid process
hourglass
anterior view
posterior view
Bony Prominence of Elbow
• Bony prominence gives attachment to the
muscle
–
–
–
–
medial epicondyle: for wrist and hand flexors
lateral epicondyle: for wrist and hand extensors
olecranon process: for triceps brachii
radial tuberosity: for biceps brachii
6
Characteristics of Humeroulnar Joint
• joint type: hinged (ginglymus)
– elbow complex = HU + HR = trochleoginglymoid joint
(Jazrawi LM et al., 2001)
• motions: concave on convex
– elbow flexion/extension with
anterior/ posterior glide of
trochlea notch of ulna on
trochlea of humerus
• degree of freedom: 1
– elbow complex DOF = 2
• closed-packed position: full elbow extension
• resting position:70° of elbow flexion and 10° of
forearm supination
Humeroradial Joint
• Proximal component :humerus
– spherical (ball-shaped) capitulum
– radial fossa
• Distal component: radius
– cup-shaped radial head
radial
head
radial
neck
anterior view
posterior view
7
Characteristics of Humeroradial Joint
• joint type: ball-and-socket
• motions: concave on convex joint
– elbow flexion/extension with anterior/posterior glide
of radial head on capitulum
– forearm pronation and supination with radial head
spinning on capitulum
• degree of freedom: 2? 3?
• rest position： full elbow extension with
forearm supination
Proximal Radioulnar Joint
• Proximal component: ulna
– concave radial notch
• Distal component: radius
– convex rim of radial head
• Distal radioulnar joint
– structurally separate from elbow complex but moves
with proximal radioulnar joint as a functional unit
8
Characteristics of
Proximal Radioulnar Joint
• joint type: pivot
• motions: convex on concave
– forearm pronation with posterior glide of radial head
– forearm supination with anterior glide of radial head
• degree of freedom: 1
• rest position: 70º of elbow flexion and 35º of
forearm supination
• Will be discussed in details on the session of
"wrist complex".
Carrying Angle
• synonym: cubitus angle
• 10-15º valgus angle when elbow extended and
forearm supinated
• decreased when elbow flexed
• female > male
• trochlea more distally than capitellum
• inner lip of trochlea more distally
than outer lip
• anomaly
– cubitus valgus: cubitus angle >15º
– cubitus varus
10-15º
valgus
9
Biomechanics of the Elbow
• Joint structure of the elbow
 Kinematics of the elbow
• Elbow flexion/ extension
• Forearm pronation/ supination
• Muscle function at the elbow
• Elbow joint stability
Description of Joint Motions
• joint(s) involved
• plane of motion
• axis of rotation
• degree of freedom
• range of motion
• functional range
• open vs. closed kinematic chain
• arthrokinematic movements
• factors limited motion
10
Elbow Flexion/ Extension
• joint involved
– humeroulnar joint
– humeroradial joint
• plane of motion
– sagittal plane
• axis of rotation
–
–
–
–
not a fixed point
a line through centers of trochlea and capitullum
palpation: both epicondyles
not perpendicular to the longitudinal axis of the
humerus (4-8º of valgus)
Osteokinematic Movements
• DOF = 1? or 2? (saddle joint)
• range of motion (ROM)
– 0-145º of elbow flexion
– some hyperextension
• functional range: 30-130º
• closed kinematic chain motion
– pull-up
– press-up (伏地挺身)
– push a heavy object
11
Elbow Adduction
• 6° adduction from full extension to full flexion
(Morrey & Chao, 1976)
• < 1° from full extension to full flexion (London
et al., 1981)
• no clinical significance (An et al., 1984)
Arthrokinematic Movements
• concave on convex joint
• anterior glide of ulna on humerus with elbow flexion
• posterior glide of ulna on humerus with elbow extension
• distraction/ compression of ulna on humerus
12
Factors Limiting Elbow Flexion
• soft tissue approximation at anterior humerus
• coronoid process into coronoid fossa
• radial head into radial fossa
• passive tension of triceps and posterior capsule
13
Factors Limiting Elbow Extension
• Olecranon process into olecranon fossa (most
important)
• passive tension of elbow flexors, collateral
ligaments, and anterior capsule
Forearm Pronation/ Supination
• joint involved
– proximal radioulnar joint
– distal radioulnar joint
– humeroradial joint
• 1 degree of freedom
• transverse plane motion
• axis of rotation: a line through radial and ulnar
heads
14
Osteokinematic Movements
• range of motion
– pronation: 0-70º
– supination: 0-85º
• functional range
– 50º of pronation and 50º of supination
Arthrokinematic Movements
• anteromedial glide with forearm supination
• posterolateral glide with forearm pronation
15
Factors Limiting Forearm Pronation
• radius hitting on ulna
• quadrate ligament
• posterior radioulnar ligament
• oblique cord
16
Factors Limiting Forearm Supination
• anterior radioulnar ligament
• quadrate ligament
• oblique cord
• interosseous membrane
The Wrist Complex
17
Functions of Wrist
• To argument fine hand and finger function
• To control length/ tension of finger long flexors
and extensors
• To provide stability for skilled or forceful hand
movements
The Wrist Complex
 Joint structure of the wrist
–
–
–
–
radiocarpal joint
midcarpal joint
intercarpal joints
distal radioulnar joint
• Kinematics of the wrist
• Muscle function at the wrist
• Wrist joint stability
18
Components of Wrist Complex
• No muscle attaches onto proximal row.
distal row
proximal row
capitate
hamate
trapezoid
midcarpal joint
trapezium
pisiform
scaphoid
triquetrum
radiocarpal joint
lunate
distal radioulnar joint
radius
ulna
Joints at Wrist
• Radiocarpal joint
– primary joint for wrist extension
• Midcarpal joint
– primary joint for wrist flexion
• Intercarpal joint
• Distal radioulnar joint
– primary for forearm pronation/supination
19
Radiocarpal Joint
• Proximal component -- radius
– biconcave distal radius
– triangular fibrocartilage complex (TFCC)
– Note: only articulate with radius
• Distal component -- proximal row
– biconvex scaphoid,
lunate, and triquetrum
S
L
R
T
articular
disc (TFCC)
U
Characteristics of RC Joint
• joint type: biconvex
• degree of freedom: 2
• motions
– wrist flexion/ extension
– wrist radial/ ulnar deviation
• closed-packed position
– full wrist extension
20
Midcarpal Joint
• trapezii on scaphoid
• capitate on lunate
• capitate on triquetrum
• hemate on triquetrum
Intercarpal Joints
• trapezoid on capitate
• hamate on capitate
• pisiform on triquetrum
21
Distal Radioulnar Joint
• Proximal component -- ulna
– convex ulna head
• Distal component -- radius
– concave ulnar notch of radius
• moves with proximal radioulnar joint as a
functional unit
Characteristics of
Distal Radioulnar Joint
• joint type: pivot
• degree of freedom: 1
• concave on convex joint
– forearm pronation with anterior glide of radius
– forearm supination with posterior glide of radius
22
Functional Position
• 15°of extension
• 10°of ulnar deviation
ulnar deviation 15
functional range for daily activities
flexion
10
extension
35
radial deviation 10
Carpal Tunnel
• proximal transverse arch covered with flexor
retinaculum
• All extrinsic finger long flexors and median
nerve passes through carpal tunnel except
flexor carpi ulnaris
• carpal tunnel syndrome
median
nerve
– increase intratunnel pressure
– compression of median nerve
23
Anatomic Snuff Box
• fovea radialis
• area bounded by tendons of
– extensor pollicis longus
– extensor pollicis brevis
The Wrist Complex
• Joint structure of the wrist
 Kinematics of wrist
• Wrist flexion/ extension
• Wrist radial/ ulnar deviation
• Forearm pronation/ supination
• Muscle function at the wrist
• Wrist joint stability
24
Osteokinematic Movements
• biconvex joint
• 2 degrees of freedom
– flexion/ extension
– radial/ ulnar deviation
R L
C
sagittal view
• circumduction
– cone-like motion
– F-RD-E-UD
– F-UD-E-RD
anterior view
Wrist Flexion/ Extension
• joint involved
dorsal side
40%
– radiocarpal joint
– midcarpal joint
60%
• sagittal plane motion
• normal range
flexion
– 85-90º of flexion
– 75-80º of extension
34%
67%
extension
palmar side
25
Axis of Wrist Flexion/ Extension
• a frontal axis through capitate
• palpation
– both styloid processes
capitate
axis
styloid process
styloid process
radius
ulna
Osteokinematic Movements
-- closed chain motions
• press-up (伏地挺身)
• push and pull a heavy object
26
Functional Range of Motion
• 10º of wrist flexion
• 35º of wrist extension
• Loss of wrist function does not seriously
impede performance of daily activities
Arthrokinematic Movements
-- Wrist Flexion/ Extension
• convex on concave joint
– articular surface moves in the opposite direction as
the moving bone
• volar glide (anterior glide)
– with wrist extension
• dorsal glide (posterior glide)
– with wrist flexion
• distraction
27
Volar/ Dorsal Glide of Wrist
dorsal side
dorsal side
palmar side
palmar side
wrist flexion with
dorsal glide
wrist extension with
volar glide
Factors Checking Motions
• limiting wrist flexion
– dorsal radiocarpal lig
• radiolunate
• radiotriquetral
• radioscaphoid
• limiting wrist extension
dorsal
palmar
– dorsal surface of the radius
– palmar ligaments：
stronger than the dorsal
ligaments
28
Wrist Radial/ Ulnar Deviation
• joint involved
– radiocarpal joint
– midcarpal joint
• frontal plane motion
• normal range
– 15-25º of radial deviation
– 30-45º of ulnar deviation
Axis of Radial/ Ulnar Deviation
• a line between capitate and lunate perpendicular to
the palm
capitate
• palpation
axis
lunate
radius
ulna
29
Arthrokinematic Movements
-- Wrist Radial/ Ulnar Deviation
• convex on concave joint
– articular surface moves in the opposite direction as
the moving bone
• radial glide (lateral glide)
– with wrist ulnar deviation
• ulnar glide (medial glide)
– with wrist radial deviation
Radial vs. Ulnar Glides
• double V system of ligament
– med. and lat. palmar intercarpal lig
– palmar ulnocarpal lig
– palmar radiocarpal lig
radial deviation
radial
glide
ulnar deviation
compression
stress for stability
ulnar
glide
30
Forearm Pronation/ Supination
• joint involved
– proximal radioulnar joint
– distal radioulnar joint
– humeroradial joint
• 1 degree of freedom
• transverse plane motion
• axis of rotation: a line through radial and ulnar
heads
Physiological Movements
-- Forearm Motions
• range of motion
– pronation: 0-70º
– supination: 0-85º
• functional range
– 50º of pronation and 50º of supination
31
Arthrokinematic Movements
proximal radioulnar joint
• anteromedial glide with forearm supination
• posterolateral glide with forearm pronation
Arthrokinematic Movements
Distal Radioulnar Joint
• posterior glide with forearm supination
• anterior glide with forearm pronation
32
Factors Limiting Forearm Supination
• posterior radioulnar ligament
• quadrate ligament
• oblique cord
• interosseous membrane
33
The Shoulder Complex
Functions of Shoulder Complex
• To link the upper extremity to the trunk
– dependent arm position: the arm is hanging down by
the side of the trunk
– control of rotator cuff muscles
• To provide extensive mobility of the arm in
space
• To provide stability for elbow and hand skillful
or forceful movements
34
The Shoulder Complex
 Structures of the shoulder
–
–
–
–
–
–
–
glenohumeral joint
sternoclavicular joint
acromioclavicular joint
scapulothoracic articulation
suprahumeral articulation
bicipital groove
plane of scapula
• Kinematics of the shoulder
• Shoulder joint stability
• Muscle actions at the shoulder
Components of Shoulder Complex
• ST: muscle-bone articulation
acromioclavicular
(AC) joint
sternoclavicular
(SC) joint
glenohumeral
(GH) joint
scapulthoracic
(ST) articulation
35
Joints in Shoulder Complex
-- Smith, Weiss, and Don Lehmkuhl, 1996
• bony articulations
– gelnohumeral joint
– sternoclavicular joint
– acromioclavicular joint
• functional joints
– scapulothoracic articulation
– suprahumeral articulation (subacromial)
– bicipital groove
Glenohumeral Joint (GH Joint)
• proximal component -- scapula
– concave glenoid cavity covered with glenoid labrum
• distal component -- humerus
– convex humeral head
• glenoid labrum
– fibrocartilage
– deepens glenoid cavity
scapula
anterior
view
gelnoid
labrum
humerus
lateral view
36
Characteristics of GH Joint
• joint type: ball and socket (not a real socket)
• DOF = 3
• convex on concave joint
– shoulder flexion/extension with post./ ant. glide
– shoulder abduction/ adduction with inf./ sup. glide
– shoulder external/ internal rotation with ant./ post. glide
• close-packed position
– 90º of shoulder abduction and full external rotation
• resting position
– 70º of shoulder abduction and 30º of flexion (horizontal
adduction)
Retroversion of Humeral Head
• humeral head rotated ~ 30º posterior to the
frontal axis of the elbow joint
humeral head
sternum
acromion
A
P
20º
30º
30-35º
superior view
37
Plane of Scapula
• the plane at the angle of 30º anterior to the
frontal plane
– Not parallel to the frontal plane
• capsules in rest position
• no impingement in suprahumeral joint
plane of scapula
H
frontal plane
S
Sternoclavicular (SC) Joint
• proximal component -- sternum
– saddle-shaped sternal manubrium
• distal component -- clavicle
– saddle-shaped medial end of clavicle
interclavicular
ligament
C
costoclavicular ligament
Rib1
S
anterior and
posterior SC ligament
articular disc
38
Clavicle
• convex forward medially and concave forward
laterally
• quadripedal animals do not have clavicles
• isokinetic strength of shoulder flexor and
abductor decreases 50% if the clavicle is
removed
A
C
S
superior view
Characteristics of SC Joint
• joint type: saddle joint
elevation
• degree of freedom = 3
• motions
– clavicle elevation/ depression
– clavicle protraction/ retraction
– clavicle posterior rotation
P
A
depression
retraction
protraction
posterior
rotation
39
Acromioclavicular (AC) Joint
• proximal component -- clavicle
– convex lateral end of the clavicle
• distal component -- scapula
– concave acromion process of the scapula
coracoacromial
ligament
superior view
A
C
acromioclavicular
ligament
Characteristics of AC Joint
• motion: convex on concave
– scapular winging: medial border moves backwards
– scapular tipping: inferior angle moves backwards
– scapular upward/downward rotation: inferior angle
rotates upwards/downwards
• DOF = 3
superior border
superior angle
medial border
(vertebral border)
inferior angle
spine of scapula
acromion process
glenoid cavity
lateral border
(axillary border)
40
Scapulothoracic (ST) Articulation
• proximal component -- rib cage
– convex posterior aspect of rib cage
• distal component -- scapula
– concave anterior surface of scapula
• an articulation between bone and muscle;
not a synovial joint
Motions at ST Articulation
• degree of freedom: 3
• concave on convex articulation
abduction
(protraction)
upward
rotation
elevation
adduction
(retraction)
depression
downward
rotation
41