Biomechanics of the hand

Gwenda Sharp OTR and Dave Thompson PT

Some biologists believe that the development of the human hand accorded an
advantage to the development of a large and complex brain.

The hand's very existence potentiated brain development by allowing humans to

manipulate, interact with, explore, and gain information from their environment.

Development of a more complex brain permitted us in turn to make and use tools
and to develop language, which in turn led to the growth of an elaborate system of
shared meanings, what we know as culture.

Outline

 Types of grasp
 Arches of the hand
 Functional position of the hand
 Joints of the hand
 Mechanism for finger flexion
 Mechanism for finger extension; the extensor mechanism
 Muscles that transmit force to the extensor mechanism
 How does the extensor mechanism work?
 Clinical appearance of peripheral nerve injuries in the hand
 Internet links related to the hand

Types of grasp

Two types of grasp are differentiated (Smith, Weiss, & Lehmkuhl, 1995, pp. 216-219;
Hertling & Kessler, 1996, pp.259-260) according to the position and mobility of
the thumb's CMC and MP joints.

1. POWER grasp (The terms grasp, grip, and prehension are interchangeable.)

(The adductor pollicis stabilizes an object against the palm; the hand's position is
static.)

 cylindrical grip (fist grasp is a small diameter cylindrical grasp)

 spherical grip
 hook grip (MP extended with flattening of transverse arch; the person may
or may include the thumb in this grasp)
 lateral prehension (this can be a power grip if the thumb is adducted, a
precision grip if the thumb is abducted).
2. PRECISION

(Muscles are active that abduct or oppose the thumb; the hand's position is
dynamic.)

 palmar prehension (pulp to pulp), includes 'chuck' or tripod grips

 tip-to-tip (with FDP active to maintain DIP flex)
 lateral prehension (pad-to-side; key grip)

Three arches balance

stability and mobility in the
hand.

The proximal transverse arch is

rigid, but the other two arches
are flexible, and are maintained
by activity in the hand's
intrinsic muscles.

1. PROXIMAL TRANSVERSE ARCH

Hertling and Kessler (p. 257) describe this arch as a composite of two arches, the
proximal and distal carpal arches.)

a stable bony arch that forms the posterior border of the carpal tunnel.
The arch's integrity is maintained by a soft tissue "strut" formed by the
flexor retinaculum or transverse carpal ligament (also called the volar carpal
ligament). This ligamentous strut connects the scaphoid and trapezium on
the arch's radial side with the hamate on its ulnar side, and forms the
anterior border of the carpal tunnel.
2. DISTAL TRANSVERSE ARCH

Hertling and Kessler (p. 257) call this the metacarpal arch, because it is formed by
the metacarpal heads; metacarpals 2 and 3 are stable while 4 and 5 are relatively
mobile. You can observe the arch's combination of "radial" stability and "ulnar"
mobility by loosely closing your fist, then squeezing more tightly, when you will
observe movement in the more mobile fourth and fifth metacarpals.
 3. LONGITUDINAL ARCH

Observe this arch's behavior as you loosely close your fist. Tighten the fist and
watch the fourth and fifth metacarpals.

The arches provide a balance between stability and mobility for grasping. For instance, we
produce the so-called "chuck grasp" by using the more stable second and third
metacarpals, instead of the more mobile fourth and fifth metacarpals.

Therapeutic splints must support these three arches.

Functional position of the hand

(Norkin & Levangie, 1992, p. 296; Hertling & Kessler, 1996, p. 260)

 Wrist
 extended 20 degrees
 ulnarly deviated 10 degrees
 Digits 2 through 5
 MP joints flexed 45degrees
 PIP joints flexed 30-45 degrees
 DIP joints flexed 10-20 degrees
 Thumb
 first CMC joint partially
abducted and opposed
 MP joint flexed 10 degrees
 IP joint flexed 5 degrees Compare this figure with the one
in Hertling and Kessler (1996, Fig.11-25).

When therapists immobilize a patient's hand, they often position it this way. During a
period of immobilization, the resting lengths of the hand's ligaments and muscles change.
This hand position provides the best balance of resting length and force production so the
hand can function when the patient mobilizes it again.

Joints of the hand

CLOSE-PACKED
JOINT STRUCTURE AXIS MOTION
POSITION
Metacarpo-phalangeal biaxial lateral flexion/extension first: extension
(MP) (condylar) A-P abduction/adduction 2nd-5th: flexion
Proximal uniaxial lateral flexion/extension extension
Interphalangeal (PIP)
Distal Interphalangeal
uniaxial lateral flexion/extension extension
(DIP)

 Metacarpophalangeal (MP)
 condyloid, biaxial joints
 joint's palmar aspect is palpable at level of distal palmar crease
 proximal joint surface is convex and distal surface is concave

roll and glide occur in same direction

 anterior with flexion

 posterior with extension.
 large metacarpal joint surface
 a fibrocartilaginous volar plate is lined with hyaline cartilage so that it
augments or enlarges the proximal phalanx' relatively small articular
surface.
 superficial to volar plate is the transverse metacarpal ligament
 joint capsule supported by two collateral ligaments
 close-packed position:
 MP joints of digits 2 through 5: close-packed in flexion; you cannot
abduct or adduct these joints when they are flexed.
 MP joint of thumb: close-packed in extension
 Interphalangeal (IP)
 uniaxial hinge joints
 supported by two collateral ligaments, and by smaller versions of a volar
plate.
 Like MP joint, proximal joint surface is convex and distal surface is concave

roll and glide occur in same direction

 anterior with flexion

 posterior with extension
 close-packed in extension

Mechanism for finger flexion

 FDP: flexor digitorum profundus (the deeper of the two)

 FDS: flexor digitorum superficialis (the more superficial muscle)

Although the FDP is deep to the FDS over most of its course, it attaches to the skeleton
more distally, because it passes through a 'split' in the FDS tendon.
Mechanism for finger extension

We can extend the PIP and DIP joints without also extending the MP joints.

But we can't extend the PIP joint without extending the DIP joint at the same time.

Flexing only the DIP joint without also flexing the PIP joint is difficult.

Full (active or passive) flexion of the PIP joint prevents active extension of the DIP
joint.

We can understand these finding by learning the structure of the EXTENSOR

MECHANISM, also known as the:

 extensor expansion  dorsal aponeurosis

 extensor assembly  aponeurotic sleeve
 extensor apparatus

The extensor mechanism is an elaboration of the extensor digitorum comunis (EDC)

tendon on the dorsum of each phalanx. The extensor indicis (EI) and the extensor digiti
minimi (EDM) insert into the extensor mechanisms of the second and fifth digits,
respectively.

Several tendinous structures comprise the extensor mechanism:

1. The EDC tendon attaches by a

tendinous slip to the proximal
phalanx, through which it extends
the MP joint.
2. The central tendon (or "slip")
proceeds dorsally to attach to base
of middle phalanx, where tension
can extend the PIP joint.

3. the lateral bands proceed on either side of 4. the extensor hood surrounds the MP
dorsal midline and rejoin before attaching to the joint laterally, medially, and dorsally,
distal phalanx. Tension in the lateral bands and receives tendinous fibers from the
extends the DIP joint. lumbricales and interossei.

5. Fibers of the oblique retinacular ligament (ORL) attach at the sides of the proximal
phalanx and digital tendon sheaths, and proceed to distal portion of lateral bands. Thus, the
ORL's line of application is volar to the PIP joint's lateral axis and dorsal to the DIP joint's
lateral axis.
PIP extension (produced by other tissues in the DIP flexion (produced by the FDP)
extensor mechanism) elongates the ORL, elongates the ORL, creating passive
creating passive tension that extends the DIP. tension that flexes the PIP. The PIP
The DIP extension helps open the hand. flexion assists in finger closure.

More views of the extensor mechanism, adapted from Smith, Weiss, & Lehmkuhl (1996,
Fig. 6-12):

 lateral view with MP joint flexed

 lateral view with MP joint extended
 dorsal view

Muscles that transmit force to the otherwise non-contractile extensor

mechanism:

1. Dorsal interossei (DI)

 The dorsal interossei attach proximally between adjacent metacarpals.

 They attach distally either to bone (proximal phalanx) or to soft tissue
(extensor mechanism).

Apply resistance as you attempt to abduct the second and fourth MP joints.
Abduction is stronger at the second MP joint because the most of the first DI's
muscle fibers attach directly to the second proximal phalanx. Abduction of the
fourth MP joint is relatively weak because the fourth DI attaches largely to the
extensor mechanism itself.

 The dorsal interossei produce MP abduction and, in certain instances, MP

flexion. Because they attach to the extensor mechanism, they also produce
PIP and DIP extension.
 2. Palmar interossei (PI):

Four palmar interossei (anatomists often include the ulnar head of flexor
pollicis brevis in this group) attach proximally to a metacarpal, and distally
to the same digit's proximal phalanx and/or its extensor mechanism.
 They produce MP adduction and, in certain instances, MP flexion. They also
produce PIP and DIP extension when they introduce tension into the
extensor mechanism.
3. Lumbricales:
 The four lumbricales attach proximally to the tendons of the flexor
digitorum profundus, and distally to the extensor mechanism on its radial
side at the level of the lateral bands. The muscles pass on the volar side of the
transverse metacarpal ligament.
 If they act alone, they produce MP flexion. They also produce PIP and DIP
extension when they introduce tension into the extensor mechanism.
 The lumbricales permit a dynamic interaction between flexors and extensors.
Their attachments transmit their force to both the FDP tendon and the
extensor mechanism. Specifically, lumbrical activity:
1. increases passive tension in the extensor mechanism.
2. decreases passive tension in FDP tendon's distal portion.
 Palpate the lumbricals on yourself

How does the extensor mechanism work?

Although the extensor mechanism's fibers are tendinous, and therefore incapable of
producing active force, they still transmit force to their attachments.

Force develops in the extensor mechanism in two ways:

1. Many of the hand's intrinsic muscles attach to the extensor mechanism. Activity in
any of these muscles produces force that the extensor mechanism communicates to
its distal attachments.
2. The extensor mechanism develops passive tension whenever it is elongated. Hand
movements that passively elongate either the extensor mechanism or a structure
that attaches to the extensor mechanism produce force in the extensor mechanism
itself.

The extensor mechanism's fibers have lines of application that are always dorsal to the
lateral axes of the PIP and DIP joints. Therefore,
 1. activity in the intrinsic muscles that attach to the extensor mechanism always
produces DIP and PIP extension.
2. Passive flexion of the MP joint (try it yourself!) elongates the extensor mechanism
and extends the PIP and DIP joints.

The fibrous lines of application in the hood and lateral bands pass very near the MP joint's
lateral axis. Whether these structures move the MP joint in the sagittal plane depends on
whether the MP joint is already flexed or extended.

1. in MP flexion:
 MP flexion occurs when activity in the FDS or FDP flexes the MP joint.
 The extensor mechanism is not 'stretchy.' When the digits flex (at the MP,
PIP, or DIP joints), passive tension in the lateral bands and central slip pull
the hood distally.
 When the MP joint is already flexed, the lines of application of the interossei
fall on volar side of the MP joint, and so produce MP flexion.
 The distal shift in the extensor hood also increases the lumbricales' moment
arm so they can produce a greater flexor moment at the MP joint. However,
your text describes EMG studies which show quite consistently that the
lumbricales do not act at the same time as the FDP! The lumbricales'
function evidently does not include closure of the hand.
2. in MP extension:
 Action in the extensor digitorum extends the MP joint, and also pulls the
extensor mechanism (including the hood) proximally.
 In this position, the interosseous muscles' lines of application are very close
to the MP joint's lateral axis.
 With such small moment arms, these muscles have little effect on MP joint
movement in the sagittal plane. However, they still produce MP
abduction/adduction when the MP joint is extended.

CLINICAL APPEARANCE OF PERIPHERAL NERVE INJURIES IN THE

HAND

1. Median:
 Often due to carpal tunnel sd.
 Wasting of thenar eminence
 Decreased thumb function, especially opposition.
 Thumb moves into plane of palm.
2. Ulnar:
 Damage to ulnar nerve can occur with trauma to elbow region. Ulnar
neuropathy is a frequent complication of diabetes mellitus
 Wasting of web space and interosseous spaces.
 Affects strength of intrinsic muscles of hand, so person can't hold a piece of
paper between extended but adducted fingers
  Affects adductor pollicis and ulnar head of FPB. A person who lacks strength
in these muscles cannot grasp with the thumb unless he or she flexes the IP
joint by substituting with the flexor pollicis longus.
3. Radial:
 Associated with gunshot or stab wounds, fracture of humerus, "Saturday
night palsy."
 person demonstrates a "dropped wrist," and cannot reposition thumb.
 lack of wrist extension may cause hand grip to be weak.

References:

Hertling, D., & Kessler, R. M. (1996). Management of common musculoskeletal

disorders: Physical therapy principles and methods. (3rd ed.).Philadelphia: J.B.
Lippincott.

Norkin, C.C., & Levangie, P.K. (1992). Joint structure and function. (2nd ed.).
Philadelphia: F.A. Davis.

Smith, L.K., Weiss, E.L. & Lehmkuhl, L.D. (1996). Brunnstrom's clinical
kinesiology. (5th ed.). Philadelphia: F.A. Davis.

Last updated 11-27-01 ©Dave Thompson PT

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