Download chapter 21 Wrist and Hand Importance of the Hand

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21
Wrist and Hand
Importance of the Hand
• The hand is extremely complex and requires
fine balance of all structures to function
properly.
• Finger and hand injuries can be among the
most devastating if not well cared for because
we use our hands daily for hundreds of
activities.
Complexity of the Hand
•
•
•
•
29 bones
30+ tendinous insertions
Complex neurological system
25% of the body’s pacinian corpuscles’ sensory
endings are in the hands
• 9 muscles in thumb; 7 in index finger
• #1 and #2: dexterity activities
• #3, #4, and #5: grasping activities
Figure 21.1
Skeletal Structure
• Structures must maintain flexibility and strength
to maintain adaptability.
• Wrist joint: Concave radius joins with convex
proximal carpal row.
Wrist Motions
•
•
•
•
•
Flexion
Extension
Abduction: radial deviation or radial flexion
Adduction: ulnar deviation or ulnar flexion
Combined motions: circumduction
Joints
• Intercarpal joints: held in place by ligaments
• Carpometacarpal joints: permit flexion,
extension, abduction, adduction of metacarpals
(MC)
• Thumb, 4th, 5th MC: rotate to provide
opposition
• Metacarpophalangeal (MCP), interphalangeal
(IP; proximal, distal [PIP, DIP]) joints: convex
proximal segment, concave distal segment of
each joint
Fascia of the Hand
• Palmar fascia
– Superficial = extension of transverse carpal ligament
and palmaris longus tendon; goes to fingers
– Deep = floor from thenar to hypothenar; serves to
cushion and protect hand and maintain hand’s
concavity
• Dorsal fascia: in two layers but less dense
Figure 21.2a
Figure 21.2b
Tendon Sheaths and Pulleys
• Extensor tendon sheaths are limited to the wrist
area (extensor retinaculum at wrist).
• An elaborate pulley system holds finger flexor
tendons in place.
Tendons and Muscles
• 20 extrinsic.
• 19 intrinsic (#4 to #1, #3 to #5).
• Extensor tendons are attached to proximal
phalanx by sagittal bands on volar plate.
• Beyond MCP joints, extensor tendons split into
three segments: one attaches at middle
phalanx and two converge and attach at distal
phalanx.
(continued)
Figure 21.3a
Dorsal Soft-Tissue Zones
• I and II: mallet or swan neck deformities
• III and IV: boutonniere deformity
• V and VI: adhesions of tendons and extensor
hood
• VII: adhesions of synovial sheaths, retinaculum
• See figure 21.3b.
Figure 21.3b
Tendons and Muscles
• Flexor digitorum sublimis (FDS) splits and
attaches at middle phalanx to flex PIP joint.
• Flexor digitorum profundus (FDP) attaches to
distal phalanx and flexes DIP joint.
• FDS tendons have separate muscle bellies;
FDP does not, so distal finger movement
cannot be isolated.
Figure 21.4a
Palmar Surface of the Hand Zones
• I: Ruptures; poor tendon gliding, contracture,
repair failures
• II: Adhesions of tendons and sheaths
• III: Intrinsic muscle adhesions
• IV: Tendon adhesions
• V: Tendon sheath adhesions
• See figure 21.4b
Figure 21.4b
Tendons and Muscles
• Extrinsic muscles: gross motor activity
• Intrinsic muscles: fine motor activity
• Lumbricals originate on flexor tendons in palm
and insert on extensor tendons to flex MCPs
and extend IPs.
• Dorsal and palmar interossei muscles are
responsible for finger abduction and adduction.
Skin of Hand
• Volar surface
– Thick
– Underlying fascial
attachments
– Inelastic
– Hairless
– Ridges for grasping
• Dorsal surface
–
–
–
–
–
–
Elastic
Mobile
Thinner
Loose
Pliable
Must stretch 1 in. for
fingers to close
Edema in Hand
• Frequently accumulates in dorsum.
• Can lead to contractures.
• Excessive swelling on dorsum can cause hand
arches to collapse anteriorly and adduct the
thumb.
• Finger range of motion (ROM) can be impaired.
• Edema causes reduced mobility and function of
the hand in short term and in long term if
fibrous formations occur.
Treating Hand Edema
• Must reduce early edema
• Measured by circumferential gauge or string
wrapped around finger
• Use of elevation, ice, compression, other
modalities
• See figure 21.5
Figure 21.5
Tendon Excursion
• Inhibition of normal tendon gliding can inhibit
normal hand function.
• Repaired extensor tendon excursion should be
limited to 5 mm during healing; exact degrees
of motion vary from finger to finger.
• There are implications for splinting and motion
limitations.
Power Grips
• Power grips = 20% 9 (see figure 21.55)
–
–
–
–
Fist
Hook
Cylinder
Spherical
• Ulnar hand is used. Thumb opposes other
fingers.
• Fingers flex and rotate and move into ulnar
deviation. Fingers point toward thenar
eminence.
Figure 21.6a
Figure 21.6b
Figure 21.6c
Figure 21.6d
Prehensile Grips
• Intricate tasks = 80% of time
– Digital prehension pinch
– Lateral prehension pinch
– Tip-to-tip pinch
• Fingers: flexed and abducted at MCP
• Radial digits used
Figure 21.7a
Figure 21.7b
Figure 21.7c
Splinting
• Purposes: prevent damage or maintain or
improve balance; based on three-point
pressure system
• Static splints: no moving parts; used to prevent
movement, support and protect hand, maintain
motion
• Dynamic splints: used to gain motion or guide
or assist movement
Figure 21.8
Splint Precautions
• Avoid friction and pressure: Fit should be firm
yet comfortable.
• Check periodically for skin breakdown or
redness; pad as needed.
• Additional padding may change force of splint.
• Adjust as needed as patient’s condition
changes.
• Take care over bony prominences.
Figure 21.10
Soft-Tissue Mobilization
• Trigger points:
– Extensor carpi radialis longus (ECRL), extensor
carpi radialis brevis (ECRB), ECR (rarely has active
trigger points)
– Flexor carpi radialis (FCR), flexor carpi ulnaris (FCU)
– Adductor pollicis
• Palmar fascia release
Figure 21.12a1
Figure 21.12a2
Figure 21.12a3
Figure 21.12b
Figure 21.12c
Figure 21.13a
Figure 21.13b
Figure 21.13c
Figure 21.13d
Figure 21.13e
Figure 21.13f
Figure 21.14a
Figure 21.14b
Figure 21.14c
Figure 21.14d
Figure 21.14e
Figure 21.16
Capsular Patterns
• Wrist:
– Flexion = extension.
– Pronation = supination.
• Fingers: Flexion limits > extension limits.
• Thumb: Abduction limits > adduction limits.
Joint Mobilization
• Distal radioulnar joint • Carpometacarpal joints
– Anteroposterior (AP)
– Posteroanterior (AP)
glides
• Wrist joint
–
–
–
–
–
Traction
Dorsal glide
Volar glide
Radial glide
Ulnar glide
– Traction
– Glides
• MCP and IP joints
–
–
–
–
–
Traction
Rotations
PA glides
AP glides
Lateral glides
Figure 21.17
Figure 21.18
Figure 21.19
Figure 21.20
Figure 21.21
Figure 21.22
Figure 21.23
Figure 21.24
Figure 21.25
Figure 21.26
Figure 21.27
Figure 21.28
Figure 21.29
Figure 21.30
Figure 21.31
Figure 21.32