Wrist and Hand Anterior Structures PDF

WRIST AND HAND: ANTERIOR STRUCTURES Wrist Flexor Tendons Flexor pollicis longus Flexor carpi radialis (cut) Palmaris longus (cut) Flexor carpi ulnaris The wrist flexor tendons (flexor carpi radialis, ulnaris, palmaris longus, flexor digitorum superficialis, and flexor digitorum profundus) crossi...

WRIST AND HAND: ANTERIOR STRUCTURES Wrist Flexor Tendons Flexor pollicis longus Flexor carpi radialis (cut) Palmaris longus (cut) Flexor carpi ulnaris The wrist flexor tendons (flexor carpi radialis, ulnaris, palmaris longus, flexor digitorum superficialis, and flexor digitorum profundus) crossing at the wrist may exhibit osteopathic lesions. They may also become entrapped within the carpal tunnel causing pain and numbness in the hand. Flexor digitorum superficialis Flexor digitorum profundus Palpation Procedure E6296/Speicher/Fig. 11.01/532340/JG/R1 • Position the patient supine with the wrist in a relaxed flexed position. • Start palpation at either the medial or lateral wrist. • Strum across the wrist flexor tendons with one or two fingers, moving to the next tendon. • Note the location of any tender points or fasciculatory response at the tendons and their attachments. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Wrist flexor tendons palpation procedure. PRT Clinician Procedure • Place the patient supine with the elbow flexed to approximately 70°. • With your far hand, apply marked wrist flexion. • Apply wrist deviation and rotation with your far hand to target specific wrist tendons (e.g., radial deviation for the flexor carpi radialis tendon). • With your far hand, apply light compression at the wrist toward the elbow. • Corollary tissues treated: Flexor group, common flexor tendon Wrist flexor tendons PRT clinician procedure. 266 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. WRIST AND HAND: ANTERIOR STRUCTURES Metacarpophalangeal Joint Interphalangeal joints Metacarpophalangeal joint Phalanges Distal Middle Proximal Metacarpals (5) The metacarpophalangeal (MCP) joints are formed by the articulation of each metacarpal and the proximal end of the associated proximal phalange. The joint is a synovial ellipsoid joint enclosed in a fibrous capsule further supported by ligaments and tendons. When the MCP joints are stabilized, their respective proximal phalanges can be translated forward, backward, and side to side and rotated about the long axis. Carpometacarpal joint Palpation Procedure E6296/Speicher/Fig. 11.02/532343/JG/R1 • Place the patient supine with the wrist and hand in a relaxed position. • Visually locate the MCPs, or knuckles. • Grasp the MCP between the thumb and forefinger. • While applying light pressure, roll over the dorsal and palmar aspects of the joint. • Flex and extend the proximal phalange to discern the joint’s articulation between the metacarpal and proximal phalange. • Note the location of any tender points or fasciculatory response at the joint and its overlying tissues. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient supine. • With your near hand and fingers, stabilize the MCP joint and its immediate neighbors. The hand can be placed either on the table or with the elbow at 90°. • With your far hand and fingers, apply long axis compression of the phalange toward the wrist. • Apply phalange flexion with your far hand and fingers for palmar MCP points and extension for dorsal points. MCP joint palpation procedure. MCP joint PRT clinician procedure. • Rotate the proximal phalange with your far hand and fingers. • Apply extension and flexion of the metacarpal with the stabilizing fingers of your near hand. • Corollary tissues treated: Extensor digitorum tendon, carpometacarpals T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 267 WRIST AND HAND: ANTERIOR STRUCTURES Proximal and Distal Interphalangeal Joints Interphalangeal joints Metacarpophalangeal joint Phalanges Distal Middle Proximal Lesions at the proximal and distal interphalangeal joints of the fingers often present with both acute and chronic injury or conditions such as a jammed finger, pulley rupture, and osteoarthritis. Each finger has two synovial hinge interphalangeal joints, proximal and distal, and the thumb has only a distal interphalangeal joint. Each joint is stabilized with collateral and palmar ligaments. Metacarpals (5) Carpometacarpal joint Palpation Procedure • Place the patient’s hand and wrist in a relaxed E6296/Speicher/Fig. 11.02/532343/JG/R1 position. • Flex the proximal joint to 90° of flexion. • Start the palpation of the joint in its flexed position at the dorsal aspect. • The joint line can be explored even though it is covered centrally by the extensor digitorum dorsal expansion. • Move to the collateral ligaments and strum across them; then strum across the ventral aspect of the joint. • To palpate the distal joint, repeat the procedure performed on the proximal joint. • Note the location of any tender points or fasciculatory response at the joint and its overlying tissues. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient’s hand in a relaxed and supported position on the table or your thigh. • Grasp both sides of the joint with the forefingers and thumbs of both hands. • Palpate the lesion with one of your near forefingers. • Using the fingers of both hands, apply compression to the joint. • Extend the joint for dorsal lesions, and apply flexion for palmar lesions. 268 Proximal and distal interphalangeal joints palpation procedure. Proximal and distal interphalangeal joints PRT clinician procedure. • Apply a valgus force for medial lesions and a varus force for lateral lesions. • Apply rotation with either hand. • Corollary tissues treated: MCP joints, extensor and flexor tendons or slips, digital collateral ligaments T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. WRIST AND HAND: ANTERIOR STRUCTURES Lumbricals of the Hand Opponens pollicis Flexor pollicis brevis The lumbricals of the hand join both the flexor and extensor tendon systems of the hand and fingers. The lumbricals arise from the flexor digitorum profundus tendon to join the extensor hood of the radial side of each middle phalange (2 through 5). Because they have a relationship with both the flexors and extensors of the fingers, the lumbricals assist with both actions at the fingers. However, they are covered by the palmar aponeurosis, occluding direct palpation of these tissues as well as the palmar interossei. Opponens digiti minimi Origin: Flexor digitorum profundus tendon (second through fifth digits) Insertion: Extensor digitorum expansion, radial side of the corresponding digit Adductor pollicis Lumbricals Flexor digitorum profundus tendons Action: Metatarsophalangeal joint flexion (second through fifth), proximal interphalangeal (PIP) and distal interphalangeal (DIP) extension, fifth digit opposition Innervation: First and second lumbricals: C8-T1 (median nerve) Third and fourth lumbricals: C8-T1 (ulnar nerve) Palpation Procedure • Place the wrist and hand in a relaxed flexed position on the treatment table or your thigh. E6296/Speicher/Fig. 11.04/532349/JG/R1 • Grasp each metacarpal with your thumb and forefinger, with your thumb over the palmar side. • Roll your thumb off the metacarpal and into the space between it and the adjacent metacarpal. • While stabilizing the metacarpal(s) on the dorsal side with your forefinger, strum deeply between them and along their shafts. • Note: Use indirect pressure to assess lesions at this location. • Note the location of any tender points or fasciculatory response between the metacarpals and in their overlying tissues. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. Lumbricals of the hand PRT clinician procedure. PRT Clinician Procedure • Place the patient’s hand and wrist in a supported and flexed position on your thigh or the treatment table and cup the dorsum of the hand and fingers in your far hand. • Apply flexion as well as adduction to the metacarpals and fingers with your far hand. • Adduct the metacarpals by squeezing the patient’s hand together with your far hand. • Rotate the metacarpals with your far hand for fine-tuning. • Corollary tissues treated: Palmar interossei, palmar aponeurosis, metacarpophalangeal joints Lumbricals of the hand palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 269 WRIST AND HAND: ANTERIOR STRUCTURES Opponens Pollicis and Adductor Pollicis The opponens and adductor pollicis share a common deep location within the thenar eminence of the thumb and also a similar function, which is why they are grouped for palpation and treatment. As their names indicate, these short muscles of the thumb bring it across the palm— the opponens pollicis to the fifth ray and the adductor pollicis to the second and third fingers. Origin: Opponens pollicis: Trapezium, flexor retinaculum Adductor pollicis: Capitate, bases of the second and third metacarpals, flexor retinaculum Opponens pollicis Flexor pollicis brevis Insertion: Opponens pollicis: Entire radial side of the first metacarpal Opponens digiti minimi Action: Opponens pollicis: Opposition (flexion, abduction, and medial rotation of the CMC joint) Adductor pollicis Lumbricals Flexor digitorum profundus tendons Palpation Procedure • Place the patient’s wrist and hand in a relaxed position. E6296/Speicher/Fig. • Locate the base of 11.04/532349/JG/R1 the first metacarpal and place your thumb over this location with your fingers on the dorsal wrist for stabilization. • Strum firmly over the base of the first metacarpal and through the superficial and intermediate thenar muscles to apply indirect palpatory pressure to the opponens pollicis. • The inferior fibers of the adductor pollicis can be felt at the web space between the thumb and forefinger. To identify these fingers, have the patient oppose the thumb and forefinger and then apply firm strumming to the adductor pollicis. • Note the location of any tender points or fasciculatory response at the muscles and their attachments. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. 270 Adductor pollicis: Thumb (proximal phalange base, ulnar side), extensor retinaculum (medial aspect of the thumb) Adductor pollicis: CMC joint adduction; assists with MCP adduction and flexion Innervation: C8-T1 (ulnar nerve, and also median nerve for opponens pollicis) Opponens pollicis and adductor pollicis palpation procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. WRIST AND HAND: ANTERIOR STRUCTURES PRT Clinician Procedure • Place the patient’s wrist and hand in a supported position on your chest, thigh, or the table. • With your far hand, apply marked first metacarpal adduction toward the medial wrist for the opponens and toward the third ray for the adductor pollicis. • With the far hand, apply flexion and rotation to the first metacarpal for the opponens and adductor. Also apply third finger and metacarpal flexion toward the thumb for the adductor pollicis with either hand. • Corollary tissues treated: Palmar interossei, lumbricals, abductor pollicis brevis, flexor pollicis brevis Opponens pollicis and adductor pollicis PRT clinician procedure. See video 11.1 for the opponens pollicis and adductor pollicis PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 271 WRIST AND HAND: ANTERIOR STRUCTURES Abductor Pollicis Brevis and Flexor Pollicis Brevis The abductor and flexor pollicis brevis are the superficial and intermediate muscles that form the thenar eminence of the thumb along with their deeper neighbors, the opponens pollicis and adductor pollicis. As their names denote, they abduct and flex the thumb. The individual bellies of these muscles are difficult to differentiate from one another; therefore, they are palpated and treated as a group. Origin: Abductor pollicis brevis: Flexor retinaculum, scaphoid, trapezium, abductor pollicis longus tendon Abductor pollicis brevis Flexor pollicis brevis: Flexor retinaculum and trapezium (superficial head) and trapezoid; capitate and palmar ligaments (deep head) Adductor pollicis Flexor pollicis brevis Palmar interosseous Flexor digiti minimi brevis Abductor digiti minimi Flexor digitorum superficialis tendons 11.05/532352/JG/R1 PalpationE6296/Speicher/Fig. Procedure • Place the patient’s hand in a relaxed position. • Grasp the thenar eminence with your thumb and forefinger, and place the thumb on the dorsal metacarpal for stabilization. • Start at the MCP joint of the thumb and strum toward it, capturing both the abductor and flexor pollicis brevis; use the metacarpal as a base against which to apply palpatory pressure. • Continue the palpation down the thumb toward the wrist. • Note the location of any tender points or fasciculatory response at the muscles and their attachments. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. PRT Clinician Procedure • Place the patient’s hand and wrist on your chest, thigh, or the treatment table. • With your far hand, apply marked thumb flexion. • Apply adduction to the first metacarpal with your far hand. • Apply long axis compression to the first metacarpal with the thumb of your far hand. • Rotate the thumb with your far hand to fine-tune. 272 Insertion: Abductor pollicis brevis: Proximal radial base of the first phalange Flexor pollicis brevis: Proximal ulnar base of the first phalange Action: Carpometacarpal (CMC) and MCP joint abduction, thumb opposition Innervation: Abductor pollicis brevis: C8-T1 (median nerve) Flexor pollicis brevis: C8-T1 (superficial head: median nerve; deep head: ulnar nerve) Abductor pollicis brevis and flexor pollicis brevis palpation procedure. Abductor pollicis brevis and flexor pollicis brevis PRT clinician procedure. • Corollary tissues treated: Opponens pollicis, adductor pollicis See video 11.2 for the abductor pollicis brevis and flexor pollicis brevis PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. WRIST AND HAND: POSTERIOR STRUCTURES Dorsal Interossei of the Hand The dorsal interossei of the hand are accessible to palpation between the metacarpals. The four bipennate dorsal interossei muscles arise from the sides of each of the metacarpals. Their primary function is finger abduction. Origin: Sides of the first through fourth metacarpals Abductor digiti minimi Insertion: Dorsal extensor expansion, base of the associated proximal phalanges Action: Finger abduction; assist with flexion of the MCP joints and extension of the interphalangeal (IP) joints, as well as thumb abduction Dorsal interosseous Palpation Procedure • Place the patient’s wrist 11.07/532358/JG/R1 and hand in a relaxed E6296/Speicher/Fig. position. • Grasp the patient’s hand with your thumb on the palmar hand for stabilization and your forefinger between the metacarpals. • Stroke up and down each side of the metacarpals and the overlying interossei. • Note the location of any tender points or fasciculatory response along the metacarpals and their interossei. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient’s hand and wrist in a supported position on your thigh or the treatment table. • While stabilizing the hand against your thigh or the table with your near hand, use one of the fingers for palpation while also extending the phalange with your far hand. • Using your far hand, abduct and adduct the opposing phalanges together for the area being treated. • Apply rotation to the phalanges with your far hand and fingers. • Corollary tissues treated: Wrist extensor tendons, metatarsophalangeal joints, CMC joints, extensor digitorum Innervation: C8-T1 (ulnar nerve) Dorsal interossei of the hand palpation procedure. Dorsal interossei of the hand PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 273 WRIST AND HAND: POSTERIOR STRUCTURES Wrist Extensor Tendons Compartment 1: Abductor pollicis longus Extensor pollicis brevis Compartment 3: Extensor pollicis longus Compartment 2: Extensor carpi radialis brevis Extensor carpi radialis longus Compartment 6: Extensor carpi ulnaris The wrist extensor tendons (extensor carpi radialis longus and brevis, extensor carpi ulnaris, and extensor digitorum) crossing at the wrist may also exhibit osteopathic lesions. Lesions of the extensor tendons are often the result of repetitive eccentric wrist flexion or an acute injury such as falling on an outstretched arm. Compartment 5: Extensor digiti minimi Extensor retinaculum Compartment 4: Extensor indicis Extensor digitorum communis Palpation Procedure E6296/Speicher/Fig. 11.08/532361/JG/R1 • Position the patient supine with the wrist in a relaxed position. • Start palpation at about 1 cm (just under 1/2 in.) medial to the radial styloid. The two tendons crossing the wrist at this location are the extensor carpi radialis longus and brevis. The lateral tendon is the longus, which can be followed to the base of the second metacarpal. The medial brevis tendon can be traced to its distal insertion on the third metacarpal. Moving medially across the wrist, the extensor digitorum tendon can be found almost at the center of the wrist, medial to the extensor pollicis longus tendon. The extensor carpi ulnaris can be found just lateral to the styloid process of the ulna. • Strum across the wrist extensor tendons with one or two fingers, moving to the next tendon. • Note the location of any tender points or fasciculatory response at the tendons and their attachments. • Determine the most dominant tender point or fasciculation (or both) and maintain light pressure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred. 274 PRT Clinician Procedure • Place the patient supine with the elbow flexed to approximately 90°. • With your far hand on the patient’s palm, apply marked wrist extension. • Apply wrist deviation and rotation with your far hand to target specific wrist tendons (e.g., radial deviation for the extensor carpi radialis). Wrist extensor tendons palpation procedure. Wrist extensor tendons PRT clinician procedure. • Using your far hand, apply light compression at the wrist toward the elbow. • Corollary tissues treated: Extensor group, common extensor tendon T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. WRIST AND HAND: POSTERIOR STRUCTURES Extensor Pollicis Longus and Brevis Tendons Extensor digitorum communis Abductor pollicis longus Extensor pollicis brevis Extensor pollicis brevis (tendon) The tendons of the extensor pollicis longus and brevis form the borders of the anatomic snuff box at the posterior thumb. The scaphoid bone, or navicular, is located within the snuff box and can be a site of tenderness when a fracture is present. Because the extensor pollicis longus and brevis tendons course upward to the middle of the posterior forearm, deep to the forearm extensors, these tendons are not accessible to palpation. Lesions of these tendons are often present with conditions such as osteoarthritis of the CMC joint of the thumb and de Quervain syndrome. Origin: Extensor pollicis longus: Ulna (middle of the posterior shaft) Extensor pollicis brevis: Radius (posterior shaft) Insertion: Thumb (base of the proximal dorsal phalange) Extensor indicis (tendon) Action: Extension of the interphalangeal joints of the thumb including the CMC and MP joints; assist with radial deviation of the wrist Innervation: C8-T1 (median nerve) Palpation Procedure • Place the patient’s hand in a neutral, supported E6296/Speicher/Fig. 11.09/532364/JG/R1 position with the thumb pointing up. • To visually identify both tendons, ask the patient to pull the thumb upward and back to reveal the border of the anatomic snuff box. • Starting at the MP joint of the thumb, strum over each of the tendons (the brevis is most medial when the hand is in a neutral position and is the smaller of the two) to the wrist joint. • Note the location of any tender points or fasciculatory response at the tendons and their attachments. • Once the most dominant tender point or fasciculation (or both) has been determined, maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • Place the patient’s wrist and hand in a neutral, supported position. • Apply marked thumb extension with your far hand or fingers. • Apply compression of the thumb toward the wrist with your far hand. • Using your far hand and fingers, apply rotation to the thumb. • Fine-tune the treatment by applying abduction and adduction to the thumb with your far hand. • Corollary tissues treated: Abductor pollicis longus, extensor carpi radialis tendon at the wrist Extensor pollicis longus and brevis tendons palpation procedure. Extensor pollicis longus and brevis tendons PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 4–Sport Medics. 275