Examination of the Hand & Wrist

By

Dr.Abdullah H.A. Juma

Medical Institutes

• The role of medical Institutes is to provide medical education tools in a multimedia form to upgrade the art of education & learning with the era of advanced technology.

The objectives

• To improve the learning scale of basic study linked with observatory media.

• To apply the basic textbook knowledge in a clinically applied sense.

Hand & Wrist

• The anatomy of the hand & wrist is important to understand the multi-functions of both when considering the normal and abnormal pathological conditions affecting both.The delicate structures entails the precision of work needed to carry out different modalities of activities in life.Hands & wrists are the path to every thing in life.

The arches of the hand• The arches of the hand is a

vital component for the proper functions carried out by the anatomically related structures of bones,joints,capsules and tendons.

• If the hand is flat then it will be typically malfunctioning as stated in the Holy Koran :“ كباسط

وما فاه ليبلغ الماء الى كفيهببالغه ” هو

The mobile & rigid segments

• The rigid segments are the middle ones and they are the 2nd & 3d metacarpal bones which provide stability for the efficiency of power grip.

• The mobile columns are the peripheral ones to accommodate different shapes and sizes of objects.

The hand & wrist skeleton

• Formed of carpal bones in 2 rows proximally : scaphoid,lunate,pisiform& triquetrum.

distally : capitate,hamate,trapezium

& trapezoid. 5 metacarpal bones

articulate proximally to form part of the wrist joint and distally to form the hand .

The dorsum of the hand

• The direction of the skin creases and elastic tissues are illustrated .

• The importance when a surgical incision is planned for to give a good looking scar.

The anatomy of a finger

• The lateral structures of the index finger are illustrated.

• The vascular bundles , the nerves and the lymphatics run on the radial & ulnar compartments of each finger.

The anatomy of a finger

• The side view of the anatomical structures are illustrated.

• The relation of the vascular branches & it’s distal network in the pulp space indicates it’s role in the blood supply.

Fingers & hand proportions in the brain

• Fingers & hands are predominantly represented in comparison to the other parts of the body.

• A thumb has more topographical sites of pesentation.

Wrist dissection

• Surgical dissection of the wrist reveals the superficial structures.

• Deeper structures are illustrated by retracting the overlying tendons.

Sensory tools

• 2 points of sensory discrimination, pin prick and light touch sensations are the examination tools to assess the sensory changes affecting the dorsal & palmar surfaces of the hand and the wrist.

The power of grip

• Gross grip is the action manifested when holding large objects in the palm of the hand and certain power is required to do the action.

• Delicate,fine grip requires little power but more precision.

Test for ulnar nerve function

• Interosseous muscle is supplied by the ulnar nerve and is attached to the base of the proximal phalanx to move the finger side way.

• Affection of the ulnar nerve causes paralysis of those intrinsic small muscles of the hand.

The dorsum of the hand

• The extensors of the fingers & wrist are illustrated as they pass behind the extensor retinuculum within their tendon sheaths.

• They form distally the extensor expansion.

The collateral ligaments

• The lateral ligaments are shown.

• They stabilize the joints and allow safe flexion & extension and side way movements.

The ligaments in relation to the tendon

• The tendon sheath & it’s related tendon are closely applied to the collateral ligaments.

• The flexor tendon gives a secure excursion enabled by the efficiency of those ligaments.

Instability of the MC/P

• Rupture of the lateral ligaments & the volar plate cause marrked instability of the joint especially in the sagittal plane.

• This is seen more obviously when flexing the finger aided by the pull of the tendon.

Metacarpal Head

• The CAM-like action of the MC head is seen clearly in flexion & extension.

• Those are different from the PIP & DIP joints.

Testing the flexor tendons

• The flexor digitorum profundus runs distally.

• It is tested by stabilizing the proximal joints and allowing flexion of the DIP joint.

The ROM of the thumb

• The C / MC joint of the thumb has more ROM in all directions.

• This is vitally important for it to perform the multi functional activities.

Opposition movements

• Fingers are brought in apposition to the thumb to perform delicate functions of a fine grip.

• Hence thumb’s actions are considered >50% of the other fingers.

The types of grip

• Delicate & fine grip requires the thumb , fingers and intrinsic small muscles of the hand to be in an optimal normal functions.

• Gross grip requires normal functioning of previous factors plus tendons.

The inferior radio-ulnar joint

• The inferior R/U joint forms with the proximal row of the carpal bones the WRIST joint.

• The triangular cartilage is illustrated and is vulnerable to injury.

Tendons of the wrist joint

• The attachment of extensor & flexor tendons of the wrist distally to the MC bones.

• They pass over the radius & carpal bones and their main functions are to move the wrist joint.

The ROM at the wrist joint

• Dorsiflexion is compared with the other side in an indian style of prayer.

• The ROM is recorded in a measurable angle.

ROM of the wrist together with the fingers movement

• Dorsiflexion og the wrist joint while flexing & extending the fingers.

• The power & excursion of the grip are both reduced in this position and increased in neutral position.

ROM of the wrist in relation to the functions of the fingers

• The power of the grip is reduced in palmar-flexion.

• The best grip to get is when the wrist joint in a neutral position.

ROM of the DIP joint

• Flexion of the distal interphalangeal joint is taking place by the flexor digitorum profundus.

• This is illustrated by stabilizing the proximal joints.

ROM of the PIP joint

• Flexion of the proximal interphalangeal joint is taking place by the flexor digitorum sublimis( superficilis).

• Other fingers are held in extension to allow the pip joint to flex.

Injury to the wrist area

• Injury to this area can cause a lot of damage especially the tendons and the neurovascular bundle.

• Careful examination is essential prior to take any action.

Deep structures

• Deep structures are seen distally in the fingers such as : pulleys,volar plates,zones of the tendon sheaths.

• Proximally, the lumbrical muscles are seen with the carpal tunnel.

The hand as a flag in a Titanic ship

• The hand leads the body ( the Ship ) in the ocean ( Life ).

• The strings to the body direct the ship to sail in the ocean. If any thing goes wrong then the hand is the cause to sink.

Tendons around the finger

• The delicate arrangement of the tendons around the finger allow them to perform their sophisticated functions.

Dissection of the dorsum of the finger

Lateral dissection of the finger

The action of flexors & extensors

Clawing of the fingers

Clawing of fingers & wasting of the 1st dorsal interosseous muscle

Extension of the thumb

1st dorsal interosseous muscle in action

Swan neck deformity

Testing DIP joint

Finger flexion & extension

Segments of the hand during action

Different postures at function

Grip ( prehension )

Difference in the grip facility

Demo of the 2 grips

Delicate & fine & precise

Factors precipitating in action

A test

Tests for Median nerve

Pointing index finger test

Flex. Dig. Profundus

Wasting of the thenar eminence

Detailed anatomy

Deformity

Sublaxation & instability

Grip

Topographic presentation

Wasting dorsally

Ulnar nerve testing

Dorsum of the hand

Deep structures

Radiological involvement of deep layers

MC heads & MC/P joints

Volar & dorsal movements

Combined actions

The arches of the hand

Anatomy of the finger

Review of median nerve testing

Different forces applied

A hand in a Titanic ship

Tendons required

Review of further deep structures