Wrist and Hand Anatomy/Biomechanics Kristin Kelley, DPT, OCS, - - PDF document

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Property of VOMPTI, LLC www.vompti.com Wrist and Hand Anatomy/Biomechanics Kristin Kelley, DPT, OCS, FAAOMPT Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018 Orthopaedic Manual Physical Therapy Series 2017-2018 Anatomy -

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Orthopaedic Manual Physical Therapy Series 2017-2018

Orthopaedic Manual Physical Therapy Series Charlottesville 2017-2018

Wrist and Hand Anatomy/Biomechanics

Kristin Kelley, DPT, OCS, FAAOMPT

Orthopaedic Manual Physical Therapy Series 2016-2017 www.vompti.com

Anatomy - Hand

  • The wrist
  • The metacarpals
  • The Phalanges

– Digit 1 – thumb – Digit 5 – digiti minimi

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Osteology

  • Proximal Row

– Scaphoid

  • Tubercle – palpated on palmar

surface

– Lunate – Triquetrum (triangular bone) – *Pisiform

  • Distal Row

– Trapezium – Articulates w/ 1st MC – Trapezoid –Articulates w/ 2nd MC – Capitate – Articulates w/ 3rd MC – Hamate – Articulates w/4th & 5th MC

  • *Hook of Hamate

*Space between hook of Hamate and Pisiform = Guyon’s Canal

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Carpal Arch

  • The carpal bones form

an arch, concave anteriorly

  • The flexor retinaculum

forms the roof of the carpal tunnel

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Metacarpals

  • Base

– Articulate with carpals – Bases of MC bones of digits articulate with one another

  • Body
  • Head

– Articulate with the proximal phalanges of the digits

  • MC 1 - Thumb
  • MC 2-5 – Associated with

digits 2-5

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Phalanges

  • Each Phalange

– Base – Body – Head

  • Proximal
  • Middle

– Thumb lacks a middle phalange

  • Distal
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Joints of Wrist

  • Radio-carpal

– Proximal: distal surface of radius, radioulnar disc – Distal: scaphoid, lunate, triquetrum

  • Mid-carpal

– Proximal: 1st row of carpals - scaphoid, lunate, triquetrum – Distal: 2nd row of carpals – trapezium, trapezoid, capitate, hamate – Pisiform does not participate

  • Inter-carpal

– The synovial joints between the carpals

  • The movements at these joints

contribute to hand position

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Radiocarpal Joint

  • Classification

– Synovial – Ellipsoidal/Modified Ovoid

  • Two degrees of movement

– Flexion/Extension – Radial and ulnar deviation

– Compound – more than one articular surface – Complex – due to presence

  • f TFCC
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TFCC

  • Triangular Fibrocartilage

Complex (TFCC)

– Radioulnar disc – Connective Tissue Wedge – Attachments

  • Apex – On ulna, between

styloid process and articular surface of the head

  • Base – Fans out, on radius,

between ulnar notch and articular surface of the carpal bones

  • It expands the articular

surface of the RC joint

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Midcarpal Joint

  • Classification

– Synovial – Modified ovoid – as a whole, convex on concave – Compound

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Intercarpal Joints

  • Classification

– Synovial – Modified ovoid – Planar – A lot of ligamentous support – not much movement – Assess/treat in volar/dorsal glide

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Wrist Motions

  • Frontal plane

– Radial deviation/abduction – Ulnar deviation/adduction

  • Sagittal plane

– Flexion – Extension

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Finger Abduction/adducton

  • Abduction and

Adduction are defined using the long axis of the middle finger as a reference

  • The 3rd digit only

abducts (radial or ulnar)

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Thumb Movements

Movements of the thumb are at right angles to the movements of the other digits

Abduction-Adduction Extension-Flexion Opposition

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Wrist Ligaments

(highlights)

  • Palmar radiocarpal

ligaments

– Resist extension/palmar glide

  • f carpals

– To scaphoid, capitate, triquetral, lunate

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Wrist Ligaments

  • Palmar Ulnocarpal

ligaments

– To lunate, triquetrum, and capitate

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Wrist Ligaments

  • Dorsal radiocarpal

ligament

  • Resists flexion/dorsal

glide of carpals on the radius

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Wrist Ligaments

  • Dorsal Intercarpal

ligaments

  • Palmar Intercarpal

Ligaments

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Wrist Ligaments

  • Radial (lateral)

collateral ligament

– Resists varus stress to the wrist

  • Ulnar

(medial)collateral ligament

– Resists valgus stress to the wrist

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Carpometacarpal Joints (CMC)

  • 5 CMC joints between the

base of each MC and the distal carpal bones

  • 1st CMC – 1st

MC/Trapezium

  • 2nd CMC – 2nd

MC/Trapezoid

  • 3rd CMC – 3rd MC/Capitate
  • 4th CMC – 4th MC/Hamate
  • 5th CMC – 5th MC/Hamate
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1st CMC Joint

  • Unique
  • Synovial
  • Saddle shape
  • Unmodified sellar joint –

allows 2 degrees of freedom

– Sagittal plane – Abd/add. Convex MC on concave trapezium – Coronal plane – Flexion/extension. Concave 1st MC on convex trapezium – Combined Motion –

  • pposition (circumduction)

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1st Metacarpophalangeal Joint

  • Synovial
  • Modified ovoid
  • Condyloid
  • Compound
  • 1 degree of freedom

– Frontal plane: Flexion/Extension

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2nd-5th CMP Joints

  • Synovial
  • Ellipsoidal
  • Modified ovoid
  • Compound
  • 2 Degrees of Freedom

– Flexion/Ext – Abduction/Adduction

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MCP Joints

  • Palmar Ligament
  • Medial Collateral

Ligament

– Resists valgus stress

  • Lateral Collateral

ligament

– Resists varus stress

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Interphalangeal (IP) Joints

  • Synovial
  • Modified ovoid
  • Hinge joints
  • 1 degree of freedom –

Flex/ext

  • 2nd degree – a little

rotation in transverse plane in full fist

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Palmar Fascia

  • Deep fascia that covers the
  • palm. Anchored to skin

distally

  • Apex is continuous w/

Palmaris longus tendon/flexor retinaculum

  • Distal fibers to base of

each digit

  • Function: Protection of

vessels, nerves, and tendons of the palm

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Extensor Hood

  • Extensor digitorum extends and

attaches to middle phalanx of each digit 2-5 by central tendon

  • slip. If ruptured, lack of

extension of proximal IP joint

  • Medial and lateral wing tendons

from intrinsics (lumbricals, interrosei) of the hand extend dorsally to terminal tendon at distal phalanx. Rupture causes lack of ability to extend the DIP

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Extensor Hood

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Carpal Tunnel

  • Formed by the arch of the

carpal bones and the flexor retinaculum

(transverse carpal ligament)

  • 4 tendons of the flexor

digitorum profundus

  • 4 tendons of the flexor

digitorum superficialis

  • Tendon of the flexor

pollicis longus

  • Median nerve

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Carpal Tunnel

  • Over the top of the tunnel

– Ulnar artery – Ulnar nerve – Palmaris Longus tendon – Palmar cutaneous branch of median nerve

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Anatomical Snuff Box

  • Base of triangle at the

wrist and the apex in the thumb

  • Lateral border – tendons
  • f the abductor Pollicis

Longus and the Extensor Pollicis Brevis

  • Medial Border – tendons
  • f the Extensor Pollicis

Longus

  • Floor Scaphoid and

Trapezium – A great place to palpate these

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Muscles of the Hand Thenar Muscles

  • Flexor pollicis brevis
  • Abductor pollicis

brevis

  • Opponens pollicis
  • Innervated by median

n.

  • Deep head of FPB also

innervated by ulnar n.

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Hypothenar Muscles

  • Palmaris brevis
  • Flexor digiti minimi

brevis

  • Abductor digiti minimi
  • Opponens digiti

minimi

  • Innervated by ulnar n.

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Intermediate Muscles

  • Lumbricals

– Dual innervation – 1,2: median n – 3,4: ulnar n

  • Adductor pollicis

– Ulnar n.

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Deep Muscles

  • Dorsal Interossei

– 4 total – 3rd digit abducts medially and laterally – Thumb and 5th finger have separate abductors

  • Palmar Interossei

– 3 total – 3rd digit doesn’t adductor – Thumb has it’s own adductor

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Flexor Tendon Pulleys

  • A2 and A4 most

important for finger function and prevent bowstringing

  • A1 – Trigger Finger
  • 9cm of flexor tendon

excursion for wrist/finger flexion

  • 2.5cm required for full

finger flexion

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Dorsal Compartments of Wrist/Hand

  • I – APL/EPB
  • II – ECRL/ECRB
  • III – EPL
  • IV – EI/EDC
  • V – EDM
  • VI – ECU

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Biomechanics/Kinematics

  • Flexion – 60% midcarpal, 40% radiocarpal
  • Extension – 66% radiocarpal, 33% midcarpal
  • Radial Deviation – Scaphoid/Lunate Volar Flexion
  • Ulnar Deviation – Scapoid/Lunate Palmer Flexion
  • Distal row moves first, Proximal row follows
  • Flexion – Distal row flexes and UD
  • Extension – Distal row extends and RD
  • RD – Distal row RD and extends, Proximal row UD and

flexes

  • UD – Distal row UD and flexes, Proximal row RD and

extends

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Vasculature – Ulnar Artery

  • Ulnar a/n enter the

hand on the medial side of the wrist superficial to the flexor retinaculum

  • Branches in the hand

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Radial Artery

  • Curves around the lateral

side of the wrist

  • Over the floor of the

anatomical snuff box

  • Between 2 heads of the 1sr

dorsal interrosei

  • Between the 2 heads of the

adductor pollicis

  • To the palm to form the

deep palmar arch

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Veins

  • Dorsal venous

network drains the back of the hand

  • Cephalic Vein – Radial
  • Basilic Vein – Medial

side

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Innervation of the Hand – Ulnar Nerve

  • Enters hand lateral to the

pisiform with the ulnar a. in the Guyon’s canal

  • 2 branches

– Superficial branch

  • Palmaris brevis
  • Cutaneous to palmar

surface of the medial 1 ½ digits

– Deep branch

  • Hypothenar muscles
  • DL, PL, AP and medial 2

lumbricals

– Articular branches to the wrist

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Cutaneous Distribution of Ulnar Nerve

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Cutaneous Distribution of Ulnar Nerve

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Median Nerve

  • Enters hand through

carpal tunnel

  • 2 branches

– Recurrent branch

  • Thenar musles

– Palmar digital branches

  • Skin on lateral 3 ½ digits
  • n palmar surface and

dorsal aspects of these digits distal to the DIP joints

  • Innervates lateral 2

lumbricals

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Radial Nerve – Superficial Branch

  • Through anatomical snuffbox
  • Innervates skin dorsal lateral 3 ½ digits distal to the DIP jts.