UPPER LIMBS - WRIST AND HAND MAY 2022.pdf
- 2. ARACELI G. DIZON, MD, DPPS Department of Human Anatomy: Gross Anatomy
- 3. OBJECTIVES Identify the wrist & the hands. Identify the bones, muscles of the wrist & hands. Identify the joints & ligaments of the wrist & hands. Identify the blood supply, innervation & actions of the wrist & hands. Discuss conditions associated with the wrist & hands.
- 4. WRIST Wrist is a joint complex consisting of radio- carpal joint & many relationships between the carpal bones. A. k. a. the CARPAL BONES 2 ROWS OF WRIST/CARPAL BONES 1. Proximal row – (PTLS) Pisiform, Triquetrum, Lunate & Scaphoid 2. Distal row - (CHT2) Hamate, Capitate, Trapezoid & Trapezium Scaphoid has a notoriously poor blood supply & recovers poorly following injury.
- 7. WRIST & HAND BONES ON X-RAY
- 9. Mnemonic for Learning Carpals She Likes To Play Lunate In the moonlight Triquetrum The third T Bone Pisiform Pea-shaped Try To Catch Her Trapezium: “It’s by the thumb” Trapezoid “Is by its side” Capitate Hamate A hambone With a hook Scaphoid A boat Click R Button for Slideshow WRIST BONES
- 10. Bones of the Wrist (Which hand? what view?)
- 11. WRIST & HAND HAND – DORSAL VIEW
- 12. BONES OF WRIST & HAND
- 14. CROSS SECTION OF THE WRIST
- 15. All carpal bones articulate via GLIDING or PLANE JOINTS. A more or less joint exists between proximal row & distal row of bones called mid-carpal – a series of gliding joints. BONES INVOLVED: Scaphoid, Lunate and Triquetrum with Trapezium, Trapezoid, Capitate & Hamate Pisiform is not involved. WRIST
- 16. CARPAL BONES & ARTICULATIONS PROXIMAL ROW Scaphoid Lunate Triquetrum Pisiform Radiocarpal joint Ulnocarpal joint Intercarpal joints DISTAL ROW Trapezium Trapezoid Capitate Hamate Intercarpal joints Carpometacarpal joints (related to hand)
- 17. RADIOCARPAL JOINT Also referred as the WRIST JOINT. It is a condyloid synovial joint of the distal upper limb. Connects & serves as a transition point between the forearm & the hand. A condyloid joint is a modified ball & socket joint that allows for flexion, extension, abduction, & adduction movements.
- 18. ULNAR-CARPAL/CARPOULNAR JOINT It serves as part of forearm rotation as well as part of the carpal movements. The joint is comprised of the distal radio-ulnar articulation, triangular fibrocartilage complex, Lunate, Triquetrum, Hamate, & Pisiform, & the intra & extracapsular ligamentous & soft tissue constraints.
- 19. INTERCARPAL JOINTS Intercarpal joints are all classified as synovial plane joints. The articular surfaces are functionally considered as nearly flat & lined with fibrocartilage. The joints are enclosed by the thin fibrous capsules whose internal surfaces are lined by the synovial membranes.
- 20. ARTICULATIONS & RANGE OF MOTION (ROM) Distal Radioulnar joint Supination & Pronation – 80-90o Ulna moves posteriorly & laterally with pronation.
- 21. ARTICULATIONS & RANGE OF MOTION (ROM) Radiocarpal joint & Ulnocarpal joint Flexion (80-90o) & Extension (75-85o) Radial (20o) & Ulnar (35o) Deviation
- 22. ARTICULATIONS & RANGE OF MOTION (ROM) Intercarpal joint - Gliding movements Proximal intercarpal joints allow noticeable flexion & extension. Distal intercarpal joints move significantly less.
- 23. SOFT TISSUE OF THE WRIST LIGAMENTS - Covered by a fibrous capsule Radial & Ulnar Collateral ligaments - Limit the ulnar & radial deviation - Collectively limits flexion & extension - Intercarpal & Carpometacarpal
- 24. ULNAR COLLATERAL LIGAMENT Is a rounded cord. Attached above to the end of the STYLOID PROCESS of the Ulna, & dividing below into two. One of which is attached to the medial side of the Triquetrum & Pisiform.
- 25. RADIAL COLLATERAL CARPAL LIGAMENT Attaches to the Styloid process of the Radius & the radial side of the Scaphoid bone.
- 26. RADIAL & ULNAR COLLATERAL LIGAMENTS
- 27. TRANSVERSE CARPAL LIGAMENT A. k. a. the Flexor Retinaculum. A strong, fibrous band, converting the deep groove on the front of the carpal bones into a tunnel, the Carpal tunnel, through which the Flexor tendons of the digits & the Median nerve pass.
- 28. COLLATERAL LIGAMENTS Found on either side of each finger & thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.
- 29. VOLAR PLATE This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened & keeps the PIP joint from bending back too far (hyperextending).
- 30. PALMAR RADIOCARPAL LIGAMENT Broad membranous band, attached above to the anterior margin of the lower end of the Radius, to its Styloid process, & to the front of the lower end of the Ulna. Its fibers pass downward to be inserted into the volar surfaces of the Scaphoid, Lunate, & some being continued to the Capitate.
- 31. DORSAL RADIOCARPAL LIGAMENT Less thick & strong than the Palmar ligament. The ligament begins on the Radius. Its fibers are directed downward & medially, & are fixed, below, to the dorsal surfaces of the Scaphoid & Lunate.
- 32. SOFT TISSUE OF WRIST LIGAMENTS 1. Dorsal – Limits flexion - Dorsal Radiocarpal ligament (red arrow) 2. Palmar - Limits extension - Transverse carpal ligament (blue arrow) Palmar radiocarpal Multiple divisions Palmar ulnocarpal ligament Multiple divisions
- 35. TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) It is a cartilage structure located on the small finger side of the wrist that, cushions & supports the small carpal bones in the wrist. The TFCC keeps the forearm bones (Radius & Ulna) stable when the hand grasps or the forearm rotates. An injury or tear to the TFCC can cause chronic wrist pain.
- 36. MUSCLE OF THE WRIST EXTENSOR MUSCLES Extensor Retinaculum 8 Extensor muscles Muscles innervated by Radial nerve. FLEXOR MUSCLES Flexor retinaculum (a.k.a. Transverse Carpal Ligament) Two compartments Superficial – 4 Deep – 3 Innervated by Median & Ulnar nerve.
- 38. FLEXOR TENDONS The muscles that flex the wrist are on the palmar side. A group of muscles that begins at the Medial epicondyle of the Humerus at the elbow.
- 39. FLEXOR DIGITI MINIMI BREVIS Origin: Hook of Hamate & Flexor Retinaculum Insertion: Medial side of base of proximal phalanx of Little Finger Action: Flexes proximal phalanx of the Little (5th) finger Innervation: Ulnar nerve
- 40. FLEXOR POLLICIS BREVIS Origin: Flexor retinaculum & tubercles of Scaphoid & Trapezium Insertion: Lateral side of base of proximal phalanx of thumb Action: Flexes thumb
- 41. FLEXOR POLLICIS BREVIS Innervation: Superficial head – lateral terminal branch of the Median nerve. 1. Deep part - deep branch of the Ulnar nerve (C8 &T1). 2. Recurrent branch of Median nerve (C8 & T1) .
- 46. FLEXOR POLLICIS LONGUS Origin: Anterior surface of Radius & adjacent Interosseous membrane Insertion: Base of distal phalanx of thumb Action: Flexes phalanges of 1st digit (thumb) Innervation: Anterior Interosseous nerve from Median nerve (C8 & T1)
- 47. THE 2 MUSCLES OF PRONATION Two muscles work together to turn the Radius over the Ulna & put the hand in a prone position. 1. Pronator teres 2. Pronator quadratus
- 48. ABDUCTOR DIGITI MINIMI Origin: Pisiform Insertion: Medial side of base of proximal phalanx of Little finger. Action: Abducts Little finger . Innervation: Ulnar nerve (C8 & T1)
- 49. ABDUCTOR POLLICIS BREVIS Origin: Scaphoid & Trapezium Insertion: Lateral side of base of proximal phalanx of thumb Action: Abducts thumb Innervation: Median nerve (C8 & T1)
- 50. ABDUCTOR POLLICIS LONGUS Origin: Posterior surfaces of the Ulna Insertion: Base of 1st Metacarpal Action: Abducts thumb Innervation: Radial nerve
- 51. ADDUCTION & ABDUCTION ADDUCTION Movement towards the midline of the body. ABDUCTION Movement away from the midline of the body.
- 52. ADDUCTOR POLLICIS Origin: 2nd & 3rd Metacarpals & Capitate Insertion: Medial side of base of proximal phalanx of thumb Action: Adducts thumb Innervation: Ulnar nerve
- 53. WRIST EXTENSORS & FLEXORS The Extensors of the wrist are on the dorsal side of the forearm. A majority of the wrist extensors begin at the Lateral epicondyle Majority of the wrist Flexors are on the anterior side of the forearm begin at the Medial epicondyle.
- 54. OPPOSITION The ability to touch the thumb & the Little finger (pinky)
- 55. OPPONENS DIGITI MINIMI Origin: Hook of Hamate & Flexor retinaculum Insertion: Medial border of 5th metacarpal Action: Brings little finger (5th digit) into opposition with thumb. Innervation: Deep branch of Ulnar nerve (C8 and T1)
- 56. OPPONENS POLLICIS Origin: Flexor retinaculum & tubercles of Scaphoid & Trapezium Insertion: Lateral side of 1st Metacarpal Action: Draws 1st Metacarpal laterally to oppose thumb toward center of palm. Innervation: Recurrent branch of Median nerve (C8 & T1)
- 57. THENAR EMINENCE Body of muscle on the palm of the human hand just beneath the thumb. Abductor pollicis brevis, Flexor pollicis brevis & Opponens pollicis
- 58. HYPOTHENAR EMINENCE Body of muscle on the palm of the human hand just beneath the 5th phalange. Abductor digiti minimi, Flexor digiti minimi & Opponens digiti minimi
- 59. DEEP MUSCLES OF THENAR & HYPOTHENAR GROUP
- 60. LUMBRICALS Origin: Radial side of the 2nd most radial tendon of the Flexor digitorum profundus. Insertion: Extensor expansion near the metacarpophalangeal joint.
- 61. LUMBRICALS Action: Flex the metacarpophalangeal joints, & extend the interphalangeal joints. Innervation: Lumbricals 1-2: Median nerve (C8-T1) Lumbricals 3-4: Ulnar nerve (C8-T1)
- 62. INTEROSSEI MUSCLES They are intrinsic muscles of the hand located between the metacarpals. They consist of the following: 1. Palmar/Volar interossei (four or three) 2. Dorsal interossei(four) Action: Finger adduction & abduction. Innervation: Deep ulnar branch of the ulnar nerve.
- 65. WRIST & HAND ANATOMY Nerves/Vessels Radial & Ulnar artery & veins Radial, Ulnar, & Median nerves CARPAL TUNNEL Flexor Tendons - 9 Median Nerve
- 67. NERVE SUPPLY OF THE WRIST & HANDS MEDIAN NERVE RADIAL NERVE ULNAR NERVE
- 68. MEDIAN NERVE Supplies sensory to the palmar side of the 1st, 2nd,3rd, & medial 4th fingers. Involved with Carpal tunnel syndrome.
- 69. MEDIAN NERVE
- 70. ULNAR NERVE Supplies sensory & motor function to the lateral 4th & 5th fingers.
- 71. RADIAL NERVE Innervates most of the Extensors & supplies the sensation on the dorsal side of the 1st three (3) digits
- 72. RADIAL NERVE
- 73. MOVEMENTS OF THE WRIST Flexion/Extension – about 70 °- 80° of ROM Radiocarpal vs. Mid Carpal Flexion is initiated in mid carpal joint & 60% occurs in this location. Extension is also initiated at mid carpal but most occurs in radio-carpal. Need 35° for good function – at least 10 for any significant function. Abduction/Adduction – about 15° - 20° Intercarpal – proximal row slides over distal row
- 75. MOVEMENTS OF THE WRIST
- 76. CARPO-METACARPAL JOINTS 2 - 5 Hamate with 4 and 5 Capitate with 3 Trapezoid with 2 Gliding joints with limited range – mostly passive Palmar & Dorsal carpometacarpal ligaments
- 78. CARPO-METACARPAL THUMB Trapezium with 1st metacarpal Saddle Adds rotary component – very mobile Capsule support
- 79. METACARPOPHALANGEAL JOINTS ELLIPSOID PASSIVE ROTATION COLLATERAL LIGAMENTS DEEP TRANSVERSE METACARPAL LIGAMENTS PALMAR LIGAMENTS (PLATES)
- 80. INTERPHALANGEAL JOINTS HINGE COLLATERAL LIGAMENTS PALMAR LIGAMENTS (PLATES)
- 82. RADIAL ARTERY Gives off Radial Recurrent to Radial collateral artery from Deep Brachial artery. Enters wrist & hand to form Deep Palmar Arch.
- 83. DEEP PALMAR ARCH
- 84. ULNAR ARTERY Gives off Common Interosseous artery (trunk) near its origin. Runs through antebrachium with Ulnar nerve. Enters wrist & hand to form Superficial Palmar arch.
- 86. ULNAR ARTERY Common Interosseous artery gives off Anterior & Posterior Interosseous arteries: Run on either side of the Interosseous membrane in the Antebrachium.
- 88. CLINICAL APPLICATIONS DEFORMITIES INFECTIONS NERVE COMPRESSIONS
- 89. WRIST & HAND DEFORMITIES Wrist, hand & finger deformities include: SWAN-NECK DEFORMITY BOUTONNIERE DEFORMITY DUPUYTREN’S CONTRACTURE These deformities may be caused by an injury or may result from another disorder (Rheumatoid arthritis Gouty arthritis). Doctors base the diagnosis of hand & finger deformities on an examination.
- 90. SWAN-NECK DEFORMITY Hyperextension of the proximal interphalangeal (PIP) joint. Flexion of the distal interphalangeal (DIP) joint. Flexion of the metacarpophalangeal (MCP) joint. The usual cause of the deformity is weakness or tearing of a ligament on the palm side of the middle joint of the finger.
- 91. SWAN-NECK DEFORMITY It can also be due to it is tearing of the tendon that flexes the middle joint. In other cases, injury of the tendon that straightens the end joint is the cause. Can be seen in patients with Rheumatoid arthritis (RA). RA is an autoimmune disorder, where joints become inflamed, leading to pain & deformity of the joints. Ruptured finger tendon can also a cause of this deformity.
- 92. BOUTONNIERE DEFORMITY It may develop either in the acute setting (secondary to trauma) or progressively (secondary to arthritis). It is generally caused by a forceful blow to the top (dorsal) side of a bent (flexed) middle joint of a finger.
- 93. BOUTONNIERE DEFORMITY The patient’s finger exhibits the following: - Pathologic flexion at the proximal interphalangeal (PIP) joint. - Hyperextension at the distal interphalangeal (DIP) joint. Extremely rare in pediatric age group.
- 94. BOUTONNIERE DEFORMITY A severe cut to the top of the finger can cause the tendon to be severed from the bone. In some severe cases, the bone may come out through the cut. In rare cases it may be Congenital. Genetic conditions such as Ehlers-Danlos syndrome can cause a Boutonniere deformity.
- 95. SWAN NECK DEFORMITY VS BOUTONNEIRE DEFORMITY
- 96. DUPUYTREN’S CONTRACTURE A condition that causes nodules, or knots, to build up underneath the skin of the fingers & palms. It can cause the fingers to become stuck in place (Contracture). It is also said to be familial. cause: Unknown It may be linked to Cigarette smoking, Alcoholism, DM, Nutritional deficiencies, or Anticonvulsant drugs.
- 97. DUPUYTREN’S CONTRACTURE Most commonly affects the ring & little fingers. It causes the proximal & middle joints, which are those closest to the palm, to become bent & difficult to straighten. Treatment varies depending on the severity of the nodules
- 98. WRIST & HAND DEFORMITIES Deformities can sometimes be treated by splinting or exercises, but if the deformity has lasted for weeks or months, these treatments may be ineffective because scarring has developed. When splinting or exercises are not helpful, surgery may be needed.
- 99. WRIST & HAND INFECTIONS Human & animal bites can cause an infection of the hands. Some other infections are: FELON & PARONYCHIA HERPETIC WHITLOW HAND ABSCESS INFECTION OF THE TENDON SHEATH Hand & finger infections can cause constant, intense, throbbing pain.
- 100. WRIST & HAND INFECTIONS Doctors base the diagnosis of hand & finger infections on the history, an examination & sometimes x-rays. These infections are treated with antibiotics taken by mouth or by vein & sometimes surgery.
- 101. FELON FINGER A bacterial infection in the pad of the fingertip. It causes pain, swelling & erythema. If not treated immediately, a pus- filled sac (ABSCESS) can form. Early-stage infections can usually be treated with antibiotics. Once an abscess forms, the felon usually needs surgically drained.
- 102. PARONYCHIA Inflammation of the skin around the fingernail. It when the skin around the nail gets irritated or injured. Microorganisms get into the skin & cause an infection. It can be bacteria or a fungus. Often, the skin is injured because of biting, chewing, or picking at the nails.
- 103. NERVE COMPRESSION SYNDROMES OF THE WRIST & HAND Carpal tunnel syndrome Cubital tunnel syndrome Radial tunnel syndrome
- 104. CARPAL TUNNEL SYNDROME (CTS) A common symptom is numbness or tingling in the thumb & first three fingers. The compression of the Median nerve, the nerve that passes through your wrist. Treatments for CTS are generally successful, but early diagnosis is important.
- 105. CONTENTS OF THE CARPAL TUNNEL
- 107. THENAR MUSCLE WASTING DUE TO CARPAL TUNNEL SYNDROME
- 108. TREATMENT OF CARPAL TUNNEL SYNDROME NONSURGICAL TREATMENTS 1. Wrist splinting. A splint that holds the wrist still while sleeping can help relieve nighttime symptoms of tingling & numbness. 2. Nonsteroidal anti-inflammatory drugs (NSAIDs). 3. Corticosteroids
- 109. PREVENTION OF CARPAL TUNNEL SYNDROME Adjusting the daily routine to reduce stress on your hands & wrists in the following ways: 1. Minimize repetitive hand movements. 2. Alternate between activities or tasks to reduce the strain on your hands & wrists. 3. Keep wrists straight or in a neutral position.
- 110. POSITION OF THE WRIST & HANDS
- 111. CUBITAL TUNNEL SYNDROME It is a condition that involves pressure or stretching of the ULNAR NERVE (a. k. a. the “funny bone” nerve) ULNAR NEUROPATHY. It can cause numbness or tingling in the ring & small fingers, pain in the forearm, &/or weakness in the hand. The Ulnar nerve runs in a groove on the inner side of the elbow.
- 112. RADIAL TUNNEL SYNDROME It is caused by increased pressure on the Radial nerve as it travels from the upper arm (the brachial plexus) to the hand & wrist. The Radial nerve becomes irritated &/or inflamed from friction caused by compression by muscles of the Forearm.
- 113. RADIAL TUNNEL SYNDROME Signs & symptoms - Pain that worsens when rotating the wrist. - Outer elbow tenderness. - Decreased ability to grip. - Loss of strength in the forearm, wrist, & hand. - Difficulty extending wrist. - Tingling & numbness may be present, but pain will be the most noticeable of the symptoms.
- 114. RADIAL TUNNEL SYNDROME The pain, numbness, and/or paresthesia, especially in the middle finger, index finger, thumb, back of the hand, &/or arm. Wrist drop & finger drop may also be present.
- 115. TREATMENT OF RADIAL TUNNEL SYNDROME Anti-inflammatory medications, IBUPROFEN (NSAIDs) Steroid injections to relieve inflammation & pressure on the radial nerve, if necessary. Wearing a wrist &/or elbow splint to reduce movement & irritation on the Radial nerve (this is particularly common at night, while you're sleeping).
- 116. NERVE INJURIES/COMPRESSIONS MANIFESTED IN THE WRIST & HANDS
- 117. NERVE COMPRESSION SYNDROMES OF WRIST & HAND In these disorders, something, usually bone or CT, presses on a nerve, causing abnormalities of sensation, movement, or both. Symptoms of nerve compression syndromes include tingling sensation, pain, loss of sensation, weakness, or a combination.
- 118. NERVE COMPRESSION SYNDROMES OF THE HAND & WRIST The diagnosis of nerve compression syndromes is suggested by the examination & can be confirmed by Electromyography & Nerve conduction studies. In these syndromes, surgery may be necessary to relieve pressure on the nerve if symptoms are severe despite noninvasive treatments or if there is persistent loss of sensation or weakness.
- 119. REFERENCES Gray, H. (2020). Gray’s Anatomy. Medina University Press International. Snell, R. S. (2012). Clinical Anatomy By Regions. Lippincott Williams & Wilkins.