chapter 16 forearm, wrist and hand. overview the carpus, or wrist, represents a highly complex...

Chapter 16Chapter 16

Forearm, Wrist and HandForearm, Wrist and Hand

OverviewOverview

The carpus, or wrist, represents a The carpus, or wrist, represents a highly complex anatomic structure, highly complex anatomic structure, comprising:comprising:– A core structure of eight bonesA core structure of eight bones– More than twenty radiocarpal, More than twenty radiocarpal,

intercarpal, and carpometacarpal jointsintercarpal, and carpometacarpal joints– Twenty-six named intercarpal ligamentsTwenty-six named intercarpal ligaments– The six or more parts of the triangular The six or more parts of the triangular

fibrocartilage complex (TFCC) fibrocartilage complex (TFCC)

OverviewOverview

The hand accounts for about 90% of The hand accounts for about 90% of upper limb functionupper limb function– The thumb is involved in 40-50% of hand The thumb is involved in 40-50% of hand

functionfunction– The index finger is involved in about 20% The index finger is involved in about 20%

of hand functionof hand function– The middle finger, which accounts for The middle finger, which accounts for

about 20% of all hand function, is the about 20% of all hand function, is the strongest finger, and is important for both strongest finger, and is important for both precision and power functionsprecision and power functions

AnatomyAnatomy

Distal radio-ulnar jointDistal radio-ulnar joint – A double pivot joint that unites the distal A double pivot joint that unites the distal

radius and ulna and an articular disc (TFCC)radius and ulna and an articular disc (TFCC)– The rounded head of the ulnar head The rounded head of the ulnar head

contacts both the ulnar notch of the radius contacts both the ulnar notch of the radius laterally, and the TFCC distallylaterally, and the TFCC distally

– The ulnar styloid process is approximately The ulnar styloid process is approximately one-half inch shorter than the radial styloid one-half inch shorter than the radial styloid process, resulting in more ulnar deviation process, resulting in more ulnar deviation than radial deviation than radial deviation

AnatomyAnatomy

Triangular fibrocartilage complex Triangular fibrocartilage complex (TFCC)(TFCC)– The TFCC is essentially comprised of the The TFCC is essentially comprised of the

fibrocartilage disc interposed between the fibrocartilage disc interposed between the medial proximal row and the distal ulna medial proximal row and the distal ulna within the medial aspect of the wristwithin the medial aspect of the wrist

– The primary function of the TFCC is to The primary function of the TFCC is to improve joint congruency and to cushion improve joint congruency and to cushion against compressive forcesagainst compressive forces

The TFCC transmits about 20% of the axial load The TFCC transmits about 20% of the axial load from the hand to the forearmfrom the hand to the forearm

AnatomyAnatomy

The WristThe Wrist– Comprised of the distal radius and ulna, Comprised of the distal radius and ulna,

eight carpal bones, and the bases of five eight carpal bones, and the bases of five metacarpalsmetacarpals

– The carpal bones lie in two transverse The carpal bones lie in two transverse rowsrows

The proximal row contains (lateral to medial) The proximal row contains (lateral to medial) the scaphoid (navicular), lunate, triquetrum, the scaphoid (navicular), lunate, triquetrum, and pisiformand pisiform

The distal row holds the trapezium, trapezoid, The distal row holds the trapezium, trapezoid, capitate, and hamatecapitate, and hamate

AnatomyAnatomy

Mid Carpal JointsMid Carpal Joints– The midcarpal joint lies between the two The midcarpal joint lies between the two

rows of carpalsrows of carpals– A ‘compound’ articulation because each row A ‘compound’ articulation because each row

has both a concave and convex segmenthas both a concave and convex segment The proximal row of the carpals is convex The proximal row of the carpals is convex

laterally and concave medially. laterally and concave medially. The scaphoid, lunate, trapezium trapezoid, and The scaphoid, lunate, trapezium trapezoid, and

triquetrum present with a concave surface to the triquetrum present with a concave surface to the distal row of carpalsdistal row of carpals

The scaphoid, capitate and hamate present a The scaphoid, capitate and hamate present a convex surface to a reciprocally arranged distal convex surface to a reciprocally arranged distal rowrow

AnatomyAnatomy

Carpal LigamentsCarpal Ligaments– The major ligaments of the wrist The major ligaments of the wrist

include the palmar intrinsic ligaments, include the palmar intrinsic ligaments, the volar extrinsic and the dorsal the volar extrinsic and the dorsal extrinsic and intrinsic ligamentsextrinsic and intrinsic ligaments

The extrinsic palmar ligaments provide the The extrinsic palmar ligaments provide the majority of the wrist stabilitymajority of the wrist stability

The intrinsic ligaments serve as rotational The intrinsic ligaments serve as rotational restraints, binding the proximal row into a restraints, binding the proximal row into a unit of rotational stability unit of rotational stability

AnatomyAnatomy

Radiocarpal JointRadiocarpal Joint– Formed by the large articular Formed by the large articular

concave surface of the distal end of concave surface of the distal end of the radius, the scaphoid and lunate the radius, the scaphoid and lunate of the proximal carpal row, and the of the proximal carpal row, and the TFCCTFCC

AnatomyAnatomy

Antebrachial FasciaAntebrachial Fascia– A dense connective tissue ‘bracelet’ A dense connective tissue ‘bracelet’

that encases the forearm and that encases the forearm and maintains the relationships of the maintains the relationships of the tendons that cross the wrist tendons that cross the wrist

AnatomyAnatomy

The Extensor RetinaculumThe Extensor Retinaculum– This retinaculum serves to prevent This retinaculum serves to prevent

the tendons from ‘bow-stringing’ the tendons from ‘bow-stringing’ when the tendons turn a corner at when the tendons turn a corner at the wristthe wrist

– The tunnel-like structures formed by The tunnel-like structures formed by the retinaculum and the underlying the retinaculum and the underlying bones are called fibro-osseous bones are called fibro-osseous compartmentscompartments

AnatomyAnatomy

The extensor retinaculum compartments, The extensor retinaculum compartments, from lateral to medial, contain the from lateral to medial, contain the tendons of:tendons of:– Abductor pollicis longus and extensor pollicis Abductor pollicis longus and extensor pollicis

brevisbrevis– Extensor carpi radialis longus and brevisExtensor carpi radialis longus and brevis– Extensor pollicis longusExtensor pollicis longus– Extensor digitorum and indicisExtensor digitorum and indicis– Extensor digiti minimiExtensor digiti minimi– Extensor carpi ulnarisExtensor carpi ulnaris

AnatomyAnatomy

The Flexor RetinaculumThe Flexor Retinaculum– Transforms the carpal arch into a tunnel, Transforms the carpal arch into a tunnel,

through which pass the median nerve and through which pass the median nerve and some of the tendons of the handsome of the tendons of the hand

Proximally, the retinaculum attaches to the Proximally, the retinaculum attaches to the tubercle of the scaphoid and the pisiformtubercle of the scaphoid and the pisiform

Distally it attaches to the hook of the hamate, Distally it attaches to the hook of the hamate, and the tubercle of the trapeziumand the tubercle of the trapezium

– In the condition known as ‘carpal tunnel In the condition known as ‘carpal tunnel syndrome’ the median nerve is syndrome’ the median nerve is compressed in this relatively unyielding compressed in this relatively unyielding space space

AnatomyAnatomy

Carpal TunnelCarpal Tunnel– Serves as a conduit for the median nerve Serves as a conduit for the median nerve

and nine flexor tendonsand nine flexor tendons The palmar radiocarpal ligament and the palmar The palmar radiocarpal ligament and the palmar

ligament complex form the floor of the canalligament complex form the floor of the canal The roof of the tunnel is formed by the flexor The roof of the tunnel is formed by the flexor

retinaculum (transverse carpal ligament)retinaculum (transverse carpal ligament) The ulnar and radial borders are formed by carpal The ulnar and radial borders are formed by carpal

bones (trapezium and hook of hamate bones (trapezium and hook of hamate respectively)respectively)

Within the tunnel, the median nerve divides into Within the tunnel, the median nerve divides into a motor branch and distal sensory branchesa motor branch and distal sensory branches

AnatomyAnatomy

Tunnel of GuyonTunnel of Guyon– A depression superficial to the flexor A depression superficial to the flexor

retinaculum, located between the hook of retinaculum, located between the hook of the hamate and the pisiform bonesthe hamate and the pisiform bones

The palmar (volar) carpal ligament, palmaris The palmar (volar) carpal ligament, palmaris brevis muscle, and the palmar aponeurosis form brevis muscle, and the palmar aponeurosis form its roofits roof

Its floor is formed by the flexor retinaculum Its floor is formed by the flexor retinaculum (transverse carpal ligament), pisohamate (transverse carpal ligament), pisohamate ligament, and pisometacarpal ligamentligament, and pisometacarpal ligament

– The tunnel serves as a passage way for The tunnel serves as a passage way for the ulnar nerve and artery into the handthe ulnar nerve and artery into the hand

AnatomyAnatomy

PhalangesPhalanges– Fourteen in numberFourteen in number– Each consist of a base, shaft, and headEach consist of a base, shaft, and head

Two shallow depressions, which Two shallow depressions, which correspond to the pulley-shaped heads of correspond to the pulley-shaped heads of the adjacent phalanges, mark the concave the adjacent phalanges, mark the concave proximal basesproximal bases

Two distinct convex condyles produce the Two distinct convex condyles produce the pulley-shaped configuration of the pulley-shaped configuration of the phalangeal headsphalangeal heads

AnatomyAnatomy

Metacarpophalangeal (MCP) Joints Metacarpophalangeal (MCP) Joints of the 2nd-5th Fingersof the 2nd-5th Fingers– The 2nd-5th metacarpals articulate The 2nd-5th metacarpals articulate

with the respective proximal with the respective proximal phalanges in biaxial jointsphalanges in biaxial joints

– The MCP joints allow flexion-The MCP joints allow flexion-extension and medial-lateral extension and medial-lateral deviation associated with a slight deviation associated with a slight degree of axial rotation degree of axial rotation

AnatomyAnatomy

Carpometacarpal JointsCarpometacarpal Joints– Articulation between Articulation between the distal the distal

borders of the distal carpal row borders of the distal carpal row bones and the bases of the bones and the bases of the metacarpalsmetacarpals

– Stability of the CMC joints is Stability of the CMC joints is provided by the palmar and dorsal provided by the palmar and dorsal carpometacarpal and carpometacarpal and intermetacarpal ligamentsintermetacarpal ligaments

AnatomyAnatomy

First Carpometacarpal JointFirst Carpometacarpal Joint– Functionally the sellar (saddle-Functionally the sellar (saddle-

shaped) carpometacarpal (CMC) shaped) carpometacarpal (CMC) joint is the most important joint of joint is the most important joint of the thumbthe thumb

– Consists of the articulation between Consists of the articulation between the base of the first metacarpal and the base of the first metacarpal and the distal aspect of the trapeziumthe distal aspect of the trapezium

AnatomyAnatomy

First Carpometacarpal Joint First Carpometacarpal Joint – Motions that can occur at this joint Motions that can occur at this joint

include flexion/extension, include flexion/extension, adduction/abduction and opposition adduction/abduction and opposition (which includes varying amounts of (which includes varying amounts of flexion, internal rotation, and palmar flexion, internal rotation, and palmar adduction)adduction)

AnatomyAnatomy

Metacarpophalangeal Joint of the Metacarpophalangeal Joint of the ThumbThumb– A hinge jointA hinge joint– Consists of a convex surface on the Consists of a convex surface on the

head of the metacarpal, and a head of the metacarpal, and a concave surface on the base of the concave surface on the base of the phalanxphalanx

AnatomyAnatomy

Interphalangeal (IP) JointsInterphalangeal (IP) Joints– Adjacent phalanges articulate in hinge Adjacent phalanges articulate in hinge

joints that allow motion in only one planejoints that allow motion in only one plane– The congruency of the IP joint surfaces The congruency of the IP joint surfaces

contributes greatly to finger joint stabilitycontributes greatly to finger joint stability The proximal IP joint is a hinged joint capable The proximal IP joint is a hinged joint capable

of flexion and extensionof flexion and extension The distal IP joint has similar structures but The distal IP joint has similar structures but

less stability and allows some hyperextension. less stability and allows some hyperextension.

AnatomyAnatomy

Palmar AponeurosisPalmar Aponeurosis– A dense fibrous structure continuous with A dense fibrous structure continuous with

the palmaris longus tendon and fascia the palmaris longus tendon and fascia covering the thenar and hypothenar covering the thenar and hypothenar musclesmuscles

– Dupuytren’s contractureDupuytren’s contracture is a fibrotic is a fibrotic condition of the palmar aponeurosis that condition of the palmar aponeurosis that results in nodule formation or scarring of results in nodule formation or scarring of the aponeurosis, and which may ultimately the aponeurosis, and which may ultimately cause finger flexion contractures cause finger flexion contractures

AnatomyAnatomy

Extensor HoodExtensor Hood– A complex tendon, which covers the dorsal A complex tendon, which covers the dorsal

aspect of the digits is formed from a aspect of the digits is formed from a combination of the tendons of insertion combination of the tendons of insertion from extensor digitorum, extensor indicis, from extensor digitorum, extensor indicis, and extensor digiti minimiand extensor digiti minimi

– Creates a ‘cable’ system that provides a Creates a ‘cable’ system that provides a mechanism for mechanism for extendingextending the MCP and IP the MCP and IP joints, and allows the lumbrical, and joints, and allows the lumbrical, and possibly interosseous muscles, to assist in possibly interosseous muscles, to assist in the the flexionflexion of the MCP joints of the MCP joints

AnatomyAnatomy

Synovial SheathsSynovial Sheaths– Long narrow balloons filled with Long narrow balloons filled with

synovial fluid, which wrap around a synovial fluid, which wrap around a tendon so that one part of the tendon so that one part of the balloon wall (visceral layer) is balloon wall (visceral layer) is directly on the tendon, while the directly on the tendon, while the other part of the balloon wall other part of the balloon wall (parietal layer) is separate(parietal layer) is separate

AnatomyAnatomy

Flexor PulleysFlexor Pulleys– Annular (A) and cruciate (C) pulleys Annular (A) and cruciate (C) pulleys

restrain the flexor tendons to the restrain the flexor tendons to the metacarpals and phalanges and contribute metacarpals and phalanges and contribute to fibro-osseous tunnels through which the to fibro-osseous tunnels through which the tendons traveltendons travel

A1 from the MP joint and volar plateA1 from the MP joint and volar plate A2 from the proximal phalanxA2 from the proximal phalanx A3 from the PIP joint volar plateA3 from the PIP joint volar plate A4 from the middle phalanxA4 from the middle phalanx A5 from the DIP joint volar plateA5 from the DIP joint volar plate

AnatomyAnatomy

Muscles of the Wrist and ForearmMuscles of the Wrist and Forearm– Can be subdivided into the 19 intrinsic Can be subdivided into the 19 intrinsic

muscles that arise and insert within the muscles that arise and insert within the hand, and the 24 extrinsic muscles that hand, and the 24 extrinsic muscles that originate in the forearm and insert within originate in the forearm and insert within the handthe hand

– The flexors, located in the anterior The flexors, located in the anterior compartment flex the wrist and digitscompartment flex the wrist and digits

– The extensors, located in the posterior The extensors, located in the posterior compartment, extend the wrist and the compartment, extend the wrist and the digitsdigits

AnatomyAnatomy

Anterior CompartmentAnterior Compartment– Superficial muscles Superficial muscles

Pronator teresPronator teres Flexor carpi radialis (FCR)Flexor carpi radialis (FCR) Palmaris longusPalmaris longus Flexor carpi ulnaris (FCU)Flexor carpi ulnaris (FCU)

AnatomyAnatomy

Anterior CompartmentAnterior Compartment– Intermediate MuscleIntermediate Muscle

Flexor Digitorum superficialis (FDS)Flexor Digitorum superficialis (FDS)

– Deep MusclesDeep Muscles Flexor pollicis longus (FPL)Flexor pollicis longus (FPL) Flexor digitorum profundus (FDP) Flexor digitorum profundus (FDP) Pronator quadratus Pronator quadratus

AnatomyAnatomy

Posterior CompartmentPosterior Compartment– Superficial muscles Superficial muscles

Extensor carpi radialis longus (ECRL) Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) Extensor carpi radialis brevis (ECRB) Extensor digitorum and Extensor digiti Extensor digitorum and Extensor digiti

minimi minimi Extensor carpi ulnaris (ECU) Extensor carpi ulnaris (ECU)

AnatomyAnatomy

Posterior CompartmentPosterior Compartment– Deep musclesDeep muscles

Abductor pollicis longus (APL) Abductor pollicis longus (APL) Extensor pollicis brevis (EPB) Extensor pollicis brevis (EPB) Extensor pollicis longus (EPL) Extensor pollicis longus (EPL) Extensor indicis (EI) Extensor indicis (EI)

AnatomyAnatomy

Muscles of the HandMuscles of the Hand– Short muscles of the thumbShort muscles of the thumb

Abductor pollicis brevis (APB)Abductor pollicis brevis (APB) Flexor pollicis brevis (FPB)Flexor pollicis brevis (FPB) Opponens pollicis (OP)Opponens pollicis (OP) Adductor pollicis (AP)Adductor pollicis (AP)

AnatomyAnatomy

Muscles of the HandMuscles of the Hand– Short muscles of the 5Short muscles of the 5thth digit digit

Abductor digiti minimi (ADM)Abductor digiti minimi (ADM) Flexor digiti minimi (FDM)Flexor digiti minimi (FDM) Opponens digit minimi (ODM)Opponens digit minimi (ODM)

AnatomyAnatomy

Muscles of the handMuscles of the hand– Interosseous muscles of the handInterosseous muscles of the hand

Three palmar interossei. Each functions Three palmar interossei. Each functions to adduct the digit, to which it is to adduct the digit, to which it is attached, toward the middle digitattached, toward the middle digit

Four dorsal interossei. Each functions to Four dorsal interossei. Each functions to abduct the index, middle and ring abduct the index, middle and ring fingers from the mid-line of the hand fingers from the mid-line of the hand

AnatomyAnatomy

Muscles of the handMuscles of the hand– LumbricalesLumbricales

Function to perform the motion of IP Function to perform the motion of IP joint extension with the MCP joint held joint extension with the MCP joint held in extensionin extension

Can assist in MCP flexionCan assist in MCP flexion

AnatomyAnatomy

Anatomic Snuff BoxAnatomic Snuff Box– A depression on the dorsal surface of the A depression on the dorsal surface of the

hand at the base of the thumb, just distal to hand at the base of the thumb, just distal to the radiusthe radius

– Formed by the tendons of the APL and EPB, Formed by the tendons of the APL and EPB, while the ulnar border is formed by the while the ulnar border is formed by the tendon of the EPLtendon of the EPL

– Along the floor of the snuffbox is the deep Along the floor of the snuffbox is the deep branch of the radial artery and the branch of the radial artery and the tendinous insertion of the ECRL. tendinous insertion of the ECRL. Underneath these structures, the scaphoid Underneath these structures, the scaphoid and trapezium bones are found and trapezium bones are found

AnatomyAnatomy

Functional arches of the handFunctional arches of the hand– The transverse arch The transverse arch – The metacarpal arch The metacarpal arch – The longitudinal archThe longitudinal arch– The oblique arches The oblique arches

AnatomyAnatomy

NeurologyNeurology– The three peripheral nerves that The three peripheral nerves that

supply the skin and muscles of the supply the skin and muscles of the wrist and hand include the median, wrist and hand include the median, ulnar, and radial nerveulnar, and radial nerve

AnatomyAnatomy

Vasculature of the wrist and handVasculature of the wrist and hand – The brachial artery bifurcates at the The brachial artery bifurcates at the

elbow into radial and ulnar elbow into radial and ulnar branches, which are the main branches, which are the main arterial branches to the handarterial branches to the hand

Vascular arches of the handVascular arches of the hand – Dorsal archesDorsal arches– Palmar archesPalmar arches

BiomechanicsBiomechanics

The wrist contains several The wrist contains several segments whose combined segments whose combined movements create a total range movements create a total range of motion that is greater than the of motion that is greater than the sum of its individual partssum of its individual parts


PronationPronation Approximately 90° of forearm pronation Approximately 90° of forearm pronation

is availableis available During pronation, the concave ulnar During pronation, the concave ulnar

notch of the radius glides around the notch of the radius glides around the peripheral surface of the relatively fixed peripheral surface of the relatively fixed convex ulnar headconvex ulnar head

Pronation is limited by the bony Pronation is limited by the bony impaction between the radius and the impaction between the radius and the ulnaulna


SupinationSupination Approximately 85-90° of forearm Approximately 85-90° of forearm

supination is availablesupination is available Supination is limited by the Supination is limited by the

interosseous membrane, and the bony interosseous membrane, and the bony impaction between the ulnar notch of impaction between the ulnar notch of the radius, and the ulnar styloid processthe radius, and the ulnar styloid process


Wrist flexion and extensionWrist flexion and extension– The movements of flexion and The movements of flexion and

extension of the wrist are shared extension of the wrist are shared among the radiocarpal articulation, among the radiocarpal articulation, and the intercarpal articulation, in and the intercarpal articulation, in varying proportionsvarying proportions


Wrist flexion and extensionWrist flexion and extension– During wrist flexion, most of the motion During wrist flexion, most of the motion

occurs in the midcarpal joint (60% or 40° occurs in the midcarpal joint (60% or 40° versus 40% or 30° at the radiocarpal versus 40% or 30° at the radiocarpal joint), and is associated with slight ulnar joint), and is associated with slight ulnar deviation and supination of the forearmdeviation and supination of the forearm

– During wrist extension, most of the motion During wrist extension, most of the motion occurs at the radiocarpal joint (66.5% or occurs at the radiocarpal joint (66.5% or 40° versus 33.5% or 20° at the midcarpal 40° versus 33.5% or 20° at the midcarpal joint), and is associated with slight radial joint), and is associated with slight radial deviation and pronation of the forearmdeviation and pronation of the forearm


Radial DeviationRadial Deviation– Radial deviation occurs primarily Radial deviation occurs primarily

between the proximal and distal between the proximal and distal rows of the carpal bonesrows of the carpal bones

– The motion of radial deviation is The motion of radial deviation is limited by impact of the scaphoid limited by impact of the scaphoid onto the radial styloid, and ulnar onto the radial styloid, and ulnar collateral ligamentcollateral ligament


Ulnar deviationUlnar deviation– Ulnar deviation occurs primarily at Ulnar deviation occurs primarily at

the radiocarpal jointthe radiocarpal joint– Ulnar deviation is limited by the Ulnar deviation is limited by the

radial collateral ligamentradial collateral ligament


Thumb motionsThumb motions– Within the first CMC joint, the longitudinal Within the first CMC joint, the longitudinal

diameter of the articular surface of the diameter of the articular surface of the trapezium is generally concave from a trapezium is generally concave from a palmar to dorsal directionpalmar to dorsal direction

– The transverse diameter is generally The transverse diameter is generally convex along a medial to lateral directionconvex along a medial to lateral direction

– The proximal articular surface of the first The proximal articular surface of the first metacarpal is reciprocally shaped to that metacarpal is reciprocally shaped to that of the trapeziumof the trapezium


Thumb flexion and extensionThumb flexion and extension– Thumb flexion and extension occur Thumb flexion and extension occur

around an anterior-posterior axis in around an anterior-posterior axis in the frontal plane that is the frontal plane that is perpendicular to the sagittal plane of perpendicular to the sagittal plane of finger flexion and extensionfinger flexion and extension

– In this plane, the metacarpal surface In this plane, the metacarpal surface is concave, and the trapezium is concave, and the trapezium surface is convexsurface is convex


Thumb Thumb abduction and adductionabduction and adduction– Thumb abduction and adduction occur Thumb abduction and adduction occur

around a medial-lateral axis in the around a medial-lateral axis in the sagittal plane, that is perpendicular to sagittal plane, that is perpendicular to the frontal plane of finger abduction and the frontal plane of finger abduction and adductionadduction

– During thumb abduction and adduction, During thumb abduction and adduction, the convex metacarpal surface moves the convex metacarpal surface moves on the concave trapeziumon the concave trapezium


A number of grips have been A number of grips have been recognized:recognized:– Fist gripFist grip– Cylindrical gripCylindrical grip– Ball gripBall grip– Hook gripHook grip– Ring gripRing grip– Pincer gripPincer grip– Pliers gripPliers grip

ExaminationExamination

The examination of the forearm, The examination of the forearm, wrist and hand requires a sound wrist and hand requires a sound knowledge of differential knowledge of differential diagnosis, and must include an diagnosis, and must include an examination of the entire upper examination of the entire upper kinetic chain, and the cervical and kinetic chain, and the cervical and thoracic spinethoracic spine


HistoryHistory– The assessment of the forearm, wrist, and The assessment of the forearm, wrist, and

hand begins by recording a detailed historyhand begins by recording a detailed history– The history helps focus the examinationThe history helps focus the examination– All relevant information must be gathered All relevant information must be gathered

about the site, nature, behavior and onset about the site, nature, behavior and onset of the current symptomsof the current symptoms

– This should include information about the This should include information about the patient’s age, hand dominance, patient’s age, hand dominance, avocational activities, and occupationavocational activities, and occupation


Systems reviewSystems review– The clinician should be able to determine The clinician should be able to determine

the suitability of the patient for physical the suitability of the patient for physical therapytherapy

– If the clinician is concerned with any signs If the clinician is concerned with any signs or symptoms of a visceral, vascular, or symptoms of a visceral, vascular, neurogenic, psychogenic, spondylogenic neurogenic, psychogenic, spondylogenic or systemic disorder that is out of the or systemic disorder that is out of the scope of physical therapy, the patient scope of physical therapy, the patient should be referred back to their physicianshould be referred back to their physician


ObservationObservation– The physical examination should begin The physical examination should begin

with a general observation of the patient’s with a general observation of the patient’s posture-especially the cervical spine, and posture-especially the cervical spine, and the thoracic spine, and the position of the thoracic spine, and the position of hand in relation to the bodyhand in relation to the body

– The contour of the palmar surface, The contour of the palmar surface, including the arches, should be examinedincluding the arches, should be examined

– If a finger is involved, its attitude should If a finger is involved, its attitude should be observed be observed


ObservationObservation– The clinician inspects for lacerations, surgical The clinician inspects for lacerations, surgical

scars, masses, localized swelling, or erythemascars, masses, localized swelling, or erythema– Scars should be examined for degree of Scars should be examined for degree of

adherence, degree of maturation, hypertrophy adherence, degree of maturation, hypertrophy (excess collagen within boundary of wound), (excess collagen within boundary of wound), and keloid (excess collagen that no longer and keloid (excess collagen that no longer conforms to wound boundaries)conforms to wound boundaries)

– The location and type of edema should be The location and type of edema should be notednoted


AROM, then PROM with over AROM, then PROM with over pressurepressure – The gross motions of wrist, hand, The gross motions of wrist, hand,

finger and thumb flexion, extension, finger and thumb flexion, extension, and radial and ulnar deviation are and radial and ulnar deviation are tested, first actively and then passivelytested, first actively and then passively

– Any loss of motion compared with the Any loss of motion compared with the contralateral, asymptomatic wrist and contralateral, asymptomatic wrist and hand should be notedhand should be noted


PalpationPalpation– Palpation of the muscles, tendon, Palpation of the muscles, tendon,

insertions, ligaments, capsules, insertions, ligaments, capsules, bones of the wrist and hand should bones of the wrist and hand should occur occur as indicatedas indicated, and be compared , and be compared with the uninvolved sidewith the uninvolved side


Pain provocation testsPain provocation tests– These tests are used to These tests are used to determine determine

the cause of a painful or the cause of a painful or dysfunctional motion by dysfunctional motion by systematically testing each of the systematically testing each of the articulations to see whether the articulations to see whether the maneuvers reproduce the patient’s maneuvers reproduce the patient’s symptoms symptoms


Strength testingStrength testing– Isometric tests are carried out in the extreme Isometric tests are carried out in the extreme

range, and if positive, in the neutral rangerange, and if positive, in the neutral range– These isometric tests must include the These isometric tests must include the

interossei and lumbricalesinterossei and lumbricales– The straight plane motions of wrist flexion, The straight plane motions of wrist flexion,

extension, ulnar and radial deviation are extension, ulnar and radial deviation are tested initiallytested initially

– Pain with any of these tests requires a more Pain with any of these tests requires a more thorough examination of the individual thorough examination of the individual muscles muscles


Functional AssessmentFunctional Assessment– The The functional range of motionfunctional range of motion for for

the hand is the range in which the the hand is the range in which the hand can perform most of its grip hand can perform most of its grip and other functional activitiesand other functional activities

– A number of assessment tools are A number of assessment tools are availableavailable


Passive Physiological Mobility TestingPassive Physiological Mobility Testing– In each of the tests, the clinician In each of the tests, the clinician

notes the quantity of motion as well notes the quantity of motion as well as the joint reaction (end feel). as the joint reaction (end feel).

– The tests are always repeated on, The tests are always repeated on, and compared to, the same joint in and compared to, the same joint in the opposite extremitythe opposite extremity


Passive Accessory Mobility TestsPassive Accessory Mobility Tests – In each of the tests, the clinician In each of the tests, the clinician

notes the quantity of accessory joint notes the quantity of accessory joint motion as well as the joint reactionmotion as well as the joint reaction

– The tests are always repeated on, The tests are always repeated on, and compared to, the same joint in and compared to, the same joint in the opposite extremitythe opposite extremity


Ligament StabilityLigament Stability– A number of tests are available to A number of tests are available to

evaluate the ligamentous stability of evaluate the ligamentous stability of the forearm, wrist, hand and finger the forearm, wrist, hand and finger jointsjoints


Neurovascular StatusNeurovascular Status– Allen TestAllen Test – Tinel’s test for Carpal Tunnel Tinel’s test for Carpal Tunnel

SyndromeSyndrome


Sensibility TestingSensibility Testing – The assessment of sensibility of the The assessment of sensibility of the

hand is an important component of hand is an important component of every hand examination because every hand examination because sensation is essential for precision sensation is essential for precision movements and object manipulationmovements and object manipulation

– Two types of sensibility are assessedTwo types of sensibility are assessed ProtectiveProtective Functional Functional


Special testsSpecial tests– Carpal Shake testCarpal Shake test– Sit to Stand testSit to Stand test– Ulnar Impaction testUlnar Impaction test– Finkelstein’s testFinkelstein’s test– Flexor digitorum superficialis (FDS) testFlexor digitorum superficialis (FDS) test– Flexor digitorum profundus testFlexor digitorum profundus test– Extensor Hood rupture testExtensor Hood rupture test– Froment’s signFroment’s sign– Murphy’s signMurphy’s sign


Diagnostic testingDiagnostic testing– Diagnostic testing of the forearm, wrist and Diagnostic testing of the forearm, wrist and

hand is limited to plain radiographs for most hand is limited to plain radiographs for most patientspatients

– Bony tenderness with a history of trauma or Bony tenderness with a history of trauma or a suspicion of bone or joint disruption a suspicion of bone or joint disruption indicates a need for radiographsindicates a need for radiographs

– Standard projections for the wrist are the Standard projections for the wrist are the posteroanterior, lateral, and obliqueposteroanterior, lateral, and oblique

– For the patient with a suspicion of a For the patient with a suspicion of a scaphoid injury, a scaphoid view should be scaphoid injury, a scaphoid view should be added added

Intervention Intervention StrategiesStrategies Acute phase goals:Acute phase goals:

– Protection of the injury site to allow healingProtection of the injury site to allow healing– Control pain and inflammationControl pain and inflammation– Control and then eliminate edemaControl and then eliminate edema– Restoration of pain-free range of motion in the entire Restoration of pain-free range of motion in the entire

kinetic chainkinetic chain– Improve patient comfort by decreasing pain and Improve patient comfort by decreasing pain and

inflammationinflammation– Retard muscle atrophyRetard muscle atrophy– Minimize detrimental effects of immobilization and Minimize detrimental effects of immobilization and

activity restrictionactivity restriction– Scar management if appropriateScar management if appropriate– Maintain general fitnessMaintain general fitness

– Patient to be independent with home exercise programPatient to be independent with home exercise program

Intervention Intervention StrategiesStrategies Functional phase goalsFunctional phase goals

– Attain full range of pain free motionAttain full range of pain free motion– Restore normal joint kinematicsRestore normal joint kinematics– Improve muscle strength to within Improve muscle strength to within

normal limitsnormal limits– Improve neuromuscular controlImprove neuromuscular control– Restore normal muscle force couple Restore normal muscle force couple

relationshipsrelationships

ConditionsConditions

chapter 16 forearm, wrist and hand. overview the carpus, or wrist, represents a highly complex...

Documents

distal row slide

distal row of carpals

hand slide

distal ulna

distal radius

medial proximal row

hand function

hamate slide