FOREARM, WRIST AND HAND

Prepared by: Floriza P. de Leon, PTRP

Distal Radioulnar Joint

Uniaxial pivot joint that has one degree of freedom

Resting position: 10 supination

Close packed position: 5 supination Capsular pattern: full ROM with pain at extreme of

rotation

Radiocarpal (Wrist) Joint

Biaxial ellipsoid joint

Radius articulates with scaphoid and lunate

Distal radius is not straight but is angled toward the ulna

(15-20), and its posterior margin projects more distally to provide a buttress effect Lunate and triquetrium also articulate with the triangular cartilaginous disc and not the ulna. (the disc extends from the ulnar side of the distal radius and attaches to the ulna at the base of the ulnar styloid process) The disc adds stability to the wrist; creates a close relation between the ulna and carpal bones and binds together the distal ends of the radius and ulna.

Radiocarpal (Wrist) Joint

With the disc in place, the radius bears 60% of the load and the

ulna bears 40%. If the disc is removed, the radius transmits 95% of the axial load and the ulna transmits 5% Therefore, the cartilaginous disc acts as a cushion for the wrist joint and as a major stabilizer of the distal radioulnar joint; the disc can be damage by forced extension and pronation Distal end of radius is concave and the proximal row of carpals is convex Has two degrees of freedom Resting position: neutral with slight ulnar deviation Close packed position: extension Capsular pattern: flexion and extension equally limited

Intercarpal Joints
Include the joints between the individual bones of the proximal

row of carpal bones (scaphoid, lunate, and triquetrium) and the joints between the individual bones of the distal row of carpal bones (trapezium, trapezoid, capitate and hamate). Bound together by small intercarpal ligaments (dorsal, palmar and interosseus), which allow only a slight amount of gliding movement between the bones. Close packed position: extension Resting position: neutral or slight flexion Capsular pattern is none Pisotriquetral joint is considered separately because the pisiform sits on the triquetrium and does not take a direct part in the other intercarpal movements

Midcarpal Joints
Form a compound articulation between the proximal and distal

rows of carpal bones with the exception of pisiform On the medial side, the scaphoid, lunate, and triquetrium articulate with capitate and hamate, forming a compound sellar (saddle-shaped joint). On the lateral aspect, the scaphoid articulates with the trapezoid and trapezium, forming another compound sellar joint These articulations are bound together by dorsal and palmar ligaments; however, there are no interosseus ligaments between the proximal and distal rows Therefore, greater movement exists at the midcarpal joints than at the intercarpal joints Close packed position: extension with ulnar deviation Resting position: neutral or slight flexion with ulnar deviation Capsular pattern: equal limitation of flexion and extension

Carpometacarpal Joint
Sellar joint that has 3 degrees of freedom (thumb) Plane joint for 2nd to 5th CMC joints Capsular pattern of CMC jt (thumb): abduction is most limited,

followed by extension Resting position (thumb): midway between the abduction and adduction and midway between flexion and extension Close packed position (thumb): full opposition Capsular pattern (2-5): equal limitation in all directions Bones of are held together by dorsal and palmar ligaments Thumb articulation has a strong lateral ligament extending from the lateral side of the trapezium to the radial side of the base of the 1st metacarpal, and the medial four articulations have an interosseus ligament similar to that found in the carpal articulation CMC articulations of fingers allow only gliding movements CMC articulations of thumb is unique that it allows flexion, extension, abduction, adduction, rotation, and circumduction

Intermetacarpal Joints
Have only a small amount of gliding movements between

them and do not include the thumb articulation They are bound together by palmar, dorsal and interosseus ligaments

Metacarpophalangeal Joints
Condyloid joints 2nd and 3rd MCP joints tend to be immobile and are the primary

stabilizing factor of the hand, whereas the 4th and 5th joints are more mobile. Collateral ligaments of these joints are tight on flexion and relaxed on extension These articulations are also bound by palmar ligaments and deep transverse metacarpal ligaments Has two degrees of freedom 1st CMC has 3 degrees of freedom Close packed position: maximum opposition (thumb); maximum flexion (fingers) Resting position: slight flexion Capsular pattern: more limitation of flexion than extension

Interphalangeal Joints
Uniaxial hinge joints with one degree of freedom

Close packed position: full extension

Resting position: slight flexion Capsular pattern: flexion more limited than extension During flexion, there is some rotation in these joints so

that the pulp of the fingers face more fully the pulp of the thumb Cascade sign if the MCP jts and PIP jts of the fingers are flexed, they converge toward the scaphoid tubercle If one or more fingers do not converge, it usually indicates trauma to the digits that has altered their normal alignment

Patient History
Lunate dislocation fall on the outstretched hand Dislocation of fingers extension of fingers Galleazzi fx fracture of the radius and dislocation of the distal end of

the ulna Wrist is commonly injured by weight bearing, by rotation stress combined with ulnar deviation, by twisting, and by impact loading If flexor tendons (which are round, have synovial sheaths, and have a longer excursion that the extensor tendons) are injured, they respond much more slowly to treatment than do extensor tendons (which are flat or ovoid) Surgical no mans land region between the distal palmar crease and the midportion of the middle phalanx of the fingers; damage to the flexor tendons in this area that requires surgical repair usually leads to the formation of the adhesive bands that restrict gliding. In addition, the tendons may become ischemic, being replaced by scar tissue. Because of this, the prognosis after surgery in this area is poor

Observation
Skin creases occur because of movement at the various joints Note of any muscle wasting on the thenar eminence (median nerve),

1st dorsal interosseus mm (C7 nerve root), or hypothenar eminence (ulnar nerve) that may be indicative of nerve or nerve root injury Note of any localized swelling In the wrist and hand, effusion and synovial thickening are most evident on the dorsal and radial aspects Swelling of MCP and IP jts are most obvious on the dorsal aspects Dominant hand tends to be larger than the non dominant Any vasomotor, sudomotor, pilomotor, and trophic changes should be recorded; indicative of PNI, PVD, DM, reynauds dse, or reflex neurovascular syndromes such as shoulder-hand syndrome or sudecks atrophy Note any hypertrophy; may be indicative of pagets dse, neurofibromatosis, AV fistula

Observation
Presence of heberdens or bouchards nodes Heberdens nodes appear on the dorsal surface of the DIP jts

and are associated with OA Bouchards nodes are on the dorsal surface of the PIP joints; associated with gastrectasis and rheumatoid arthritis Any ulcerations may indicate neurological or circulatory problems Any alteration in the color of the limb with changes in position may indicate a circulatory problem Ulnar drift may be seen in RA Spoon-shaped nails are often result of fungal infection, anemia, iron deficiency, long term DM, local injury, developmental abnormality, chemical irritants or psoriasis. Clubbed nails associated with COPD, congenital heart defects, or cor pulmonale

Common Hand Deformities

Swan-neck deformity Involves only the fingers. There is flexion of the MCP and DIP. There is hyperextension of the PIP jt. Result of contracture of intrinsic mm and is often seen in RA Boutonniere deformity Extension of the MCP and DIP and flexion of PIP jt Result of the rupture of the central tendinous slip of the extensor hood Most common after trauma or in RA Ulnar drift Commonly seen in patients with RA but can occur with other conditions Results in ulnar deviation of the digits due to weakening of the capsuloligamentous structures of the MCP jts and the accompanying bowstring effect of the extensor communis tendons Extensor plus deformity Caused by adhesions or shortening of the extensor communis tendon proximal to the MCP jt Results in inability to simultaneously flex the MCP and PIP jts, although they may be flexed individually

Common Hand Deformities

Claw fingers Results from loss of intrinsic mm action and the overaction of the extrinsic (long) extensor mm on the proximal phalanx of the fingers. MCP jts are hyperextended, and the proximal and distal IP jts are flexed. If intrinsic function is lost, the hand is called intrinsic minus hand Normal cupping of the hand is lost, both the longitudinal and transverse arches of the hand disappear. There is intrinsic mm wasting Often caused by a combined median and ulnar nerve palsy Trigger finger Aka digital tenovaginitis stenosans Result of a thickening of the flexor tendon sheath which causes sticking of the tendon when the patient attempts to flex the finger A low grade inflammation of the proximal fold of the flexor tendon leads to swelling and constriction (stenosis) in the digital flexor tendon. When px attempts to flex the finger, the tendon sticks, and the finger lets go, often with a snap Usually occurs in middle aged women Trigger thumb usually occurs in young children; condition usually occurs in the third or fourth finger. Often associated with RA and tends to be worse in the morning

Common Hand Deformities

Ape hand deformity
Wasting of the thenar eminence of the hand occurs as a result of the

median nerve palsy Thumb falls back in line with the fingers as a result of the pull of the extensor mm Px is unable to oppose or flex the thumb
Bishops hand or Benediction hand deformity
Wasting of the hypothenar mm of the hand, the interossei mm, and the

2 medial lumbrical mm Occurs because of the ulnar nerve palsy Flexion of the 4th and 5th fingers is the most obvious resulting change
Drop-wrist deformity Extensor mm of the wrist are paralyzed as a result of the radial nerve palsy, and the wrist and fingers cannot be extended

Common Hand Deformities

Z deformity of the thumb Thumb is flexed at the MCP jt and hyperextended at the IP jt. Caused by heredity, or it may be associated with RA Dupuytrens deformity Result of contracture of the palmar fascia There is a fixed flexion of deformity of MCP and PIP jts. Usually seen in ring or little finger. Skin is often adherent to the fascia Affects men more than women and seen in 50-70 year age group Mallet finger Result of the rupture or avulsion of the extensor tendon where it inserts into the distal phalanx of the finger. Distal phalanx rests in a flexed position

Types of Grip
Power Grip Requires fine control and gives greater flexor asymmetry to the hand Used whenever strength or force is the primary consideration Digits maintain the object against the palm Thumb may or may not be involved, and the extrinsic mm are more important For a power grip to be formed, fingers are flexed and the wrist in ulnar deviation and slightly extended
Hook grasp in which all or the second and third fingers are used as a hook

controlled by the FA flexors and extensors; involve the IP and MCP jts (thumb not involved) Cylinder grasp type of palmar prehension, thumb is used, and the entire hand wraps around an object Fist grasp/digital palmar prehension - hand moves around a narrow object Spherical grasp type of palmar prehension, in which there is more opposition and the hand moves around the sphere

 Precision or prehension grip An activity limited mainly to the MCP joints and involves primarily the radial side of the hand Used whenever accuracy and precision are required Radial digits (index and long fingers) provide control by working in concert with the thumb to form a dynamic tripod for precision handling There is pulp to pulp contact between the thumb and fingers, and the thumb opposes the fingers. Intrinsic mm are more important Types of pinch grip
Three point chuck, three fingered, or digital prehension, in which palmar

pinch, or subterminal opposition, is achieved; precision grip with power