Wrist Anatomy Review & Evaluation Hand PDF

Anatomy Review & Evaluation : Hand and Wrist Sarah Maceda OTR/L CHT Dorsal Surface Anatomy Dorsal compartments wrist • Dorsal transverse carpal ligament • I: APL & EPB • II: ECRL & ECRB • III: EPL • IV: EDC and EI • V:EDM • VI: ECU Dorsal hand Landmarks • Lister’s Tubercle – Dorsal radial Tub...

Anatomy Review & Evaluation : Hand and Wrist Sarah Maceda OTR/L CHT Dorsal Surface Anatomy Dorsal compartments wrist • Dorsal transverse carpal ligament • I: APL & EPB • II: ECRL & ECRB • III: EPL • IV: EDC and EI • V:EDM • VI: ECU Dorsal hand Landmarks • Lister’s Tubercle – Dorsal radial Tubercle . Palpate with thumb extended, EPL turns around the radial side. • 1st Dorsal Interosseous- Sign of ulnar Nerve • Location of lunate(prox) and capitate (distal)depression between the radius and base of 3rd metacarpal. Extensor tendon zones Volar Landmarks Flexor Retinaculum Transverse carpal Ligament• Wrist Pulley forms carpal Tunnel • Radial attachment tubercle of the trapezium and scaphoid. • Ulnar side – hook of hamate and pisiform . • Median Nerve, FDP, FDS, FPL. Deep to PL tendon. • Distal Compression site of median nerve Finger Pulleys • 4-5 annular pulleys in between are cruciate bands (considered minor pulleys ). • A1 over MP joint . A2 largest (1/2 the proximal phalanx ) • What Pulleys are necessary for normal flexor tendon? Gliding A2 and A4 • Pulley most important in the thumb: oblique pulley • What pulley most often involved in Trigger finger? • What pulley most often involved in rock climbing injuries? Flexor tendon Zones Campers Chiasm Where FDS comes back together after it splits and inserts into middle phalanx . Vincula– attaches the tendon to the bone, gives blood supply to FDS and FDP tendons Function of Extrinsic Muscles • Muscle tendon unit effects every joint between origin and insertion . • Tendon function is augmented by the antagonist • Flexion of the DIP and PIP by the FDP is augmented by the Ext of the MPs by the long extensors. • Wrist extension augments profundus function at the MP and IP joints ( synergistic function) ex: tenodesis grasp Test for Flexor tendon Function • FDP is interdependent in ulnar 3 digits . If extend the FDP of any of these fingers function of the profundus in the other 2 is limited • Muscle bellies of FDS are separate and independent. https://youtu.be/JGX9P4Wkn24 • Test for superficialis function – Hold LF and SF in extension than only flexor of the PIP of RF is the FDS • Test for FDP function- isolate DIP in extension and flex tip of finger. • FPL is the only flexor of the thumb IP joint Function of Long extensors • Extrinsic extensors – Extend the MP joints of the hand primarily , secondarily wrist extensors. • Extensor mechanism in the fingers – If the MPs are flexed the long extensors through the extensor mechanism extend the IP joints (central slip and lateral bands) . • Interossei and lumbricals flex the MP joint , long extensors will augment the extension of the IP joints . loss of this intrinsic support results in claw deformity or intrinsic minus position Test for intrinsic vs extrinsic tightness • The MCP joint is held in extension and the PIP is passively flexed. Next the PIP Joint is passively flexed with the MCP in flexion. • (+) intrinsic tightness- If the PIP can be passively flexed more when the MCP joint is flexed than when it is extended. • (+) extrinsic tightness – PIP flexion increases with MCP extension Test for intrinsic tightness vs Intrinsic tightness stretch ? • Do not include DIP in test • Desired testing position of MP joint: Examine contralateral finger to test amount of MP hyperextension with PIP flexed . Intrinsic tightness due to stiff swollen digits will limit the patients ability to make a composite fist . Common after hand/wrist trauma. Exercises to improve this include active and passive combined PIP and DIP flex with the MP in max extension /hyperextension. Extensor mechanism • Complex interaction between extrinsic extensors and intrinsic tendons • Extrinsic extensors (EDC) link to sagittal band – MP extension is primary function. Extends PIP and DIP secondarily if MP hyperextension is blocked. • Extensor tendon continues over PIP joint and attaches into the middle phalanx before it inserts it forms lateral bands with interosseous muscles which forms the terminal tendon . This extends the DIP . ----- Swan neck deformity vs Boutonniere • • • • • • • • • Hyperextension of PIP with Flex of DIP joint. Lateral bands move dorsally Can be caused by multiple pathologies: Mallet deformity- terminal tendon Rupture of Transverse Retinacular Ligament at PIP Intrinsic tightness – causes lateral band tightness Loss If FDS tendon- VP becomes lax Dorsal dislocation of DIP, FX of middle or distal phalanx Synovitis at DIP or PIP caused by RA. Boutonniere: • Volar Migration of the lateral bands due to central slip rupture • May be due to trauma, RA, Congenital to small fingers (rare) • Thumb most common deformity from RA • Causes Oblique Retinacular Ligament tightness . ORL moves dorsally which results in loss of flexion of DIP – arises from the volar lateral ridge of the proximal phalanx . Transverses distally and dorsally to attach at the dorsal apparatus near the dip joint. Wrist Anatomy Bony Anatomy • 8 carpal bones, pisiform a sesamoid bone in the tendon of the FCU • Proximal and distal carpal rows with 2 forearm bones and metacarpals (15 bones in all) • Radius articulates with the scaphoid and Lunate. • Ulna does not articulate with the carpal bones due to triangular disc. Joint anatomy • Radiocarpal Joint – concave distal articular surface or radius and the triangular fibrocartilage with convex Proximal carpal bones • Midcarpal joint (between proximal and distal carpal rows)– STT joint convex distal pole of scaphoid articulating with the concave proximal surfaces of trapezium and trapezoid. • “ball and socket joint” –convex head of the capitate and combined concave surfaces of scaphoid and lunate. • Traquetrohamate – complex both concave and convex regions Ligament Anatomy • Most are capsular ligaments, interosseous ligaments between the carpal bones are interarticular . • Palmar capsular ligaments are more numerous than the dorsal radial carpal ligament . Forms the entire capsule of radiocarpal and midcarpal joints. Wrist ligaments Palmar Radiocarpal • RSC- Radial styloid , forms radial wall of radiocarpal joint , passes palmar to the head of capitate and joins with the UC ligament . Very few fibers attach to capitate • LRL – pass palmar to the proximal pole of the scaphoid and SL ligament and attach to palmar horn of Lunate • RSL – not on picture is ulnar to the LRL . Comes from radius to SL ligament • SRL -palmar rim of lunate fossa to the lunate Ulnocarpal Ligaments • Arise from palmar aspect of TFCC runs obliquely towards the Lunate, Triquetrum and capitate. • UL – continuous with SRL forming a palmar capsule between the TFCC and Lunate • UT- TFCC to the triquetrum • UC – fovea of ulna to head of capitate, merges wit RSC ligament Distal Radioulnar ligaments Proximal Row interosseous ligaments • Interconnection between bones of proximal carpal row. • SL/LT ligaments • Dorsal and palmar regions are composed of collagen with blood vessels . Proximal regions are fibrocartilage without vascularization and collagen Examination of the wrist • Detailed history: hand dominance, work , leisure, single incident or progressive, localization of pain, clicking, grating, clunks. • Mechanism of injury : TFCC injury – acute rotation of the forearm or fall on pronated outstretched upper extremity. Scaphoid FX – load to radial side of palm with wrist in extreme dorsiflexion. • Functional ROM of the Wrist : 40 deg wrist ext/flex ; radial ulnar dev 15/15 Radial Dorsal Zone • Radial Styloid, scaphoid, scaphotrapezial, trapezium, base of 1st metacarpal , CMC joint , Tendons of 1st and 3rd extensor compartments, and DRSN (Wartenberg’s syndrome). • Radial styloid- palpate with ulnar dev . Tenderness= contusion, fx or radioscaphoid arthritis. • Scaphoid- distal to Radial styloid in the snuff box. Evaluate with wrist ulnarly deviated. Acute pain = FX , nonunion, or scaphoid instability . Clamp sign – patient grasp volar and dorsal aspect of scaphoid when asked where wrist hurts (+ fx of scaphoid). • ST joint – distal to scaphoid. wrist in ulnar dev with opposition of thumb to sf. • CMC joint – Grind test ( 70% )– axial compression of 1st metacarpal with rotation. Positive with pain and crepitus. Pressure sheer test 98% accurate for DX Finkelstein Test EPB , APL tendon 1st dorsal compartment – thumb flexed and wrist radially deviated. Nodule often noted in 1st dorsal compartment . Tx involves CSI, Immobilization with thumb and wrist orthotic . Surgery to release 1st dorsal compartment . • EPL tendonitis (Drummer’s palsy) or rupture around lister’s tubercle. • Intersection syndrome – tenderness and crepitus 4 to 5 cm proximal to radial styloid . Friction point where EPB and APL cross over ECRL and ECRB . Pain with resisted thumb MCP extension , often have a Positive Finkelstein’s test . Caused by clenched fist with thumb abduction (rowing). Wrist flex/ext with radial dev. Test :Passive Wrist flex, thumb flex, Radial dev . Central dorsal zone • Dorsal Rim of distal radius, Lister’s tubercle, lunate, SL interval, capitate, base of the 2nd and 3rd Metacarpals. • Dorsal Rim of Radius – dorsal to radial styloid – tenderness caused by impingement of radius on scaphoid. Gymnastics cause osteophyte in this area. • Lunate palpate distal and ulnar to lister’s tubercle with wrist flexed. Pain = Keinbock’s disease avascular necrosis of the lunate. • SL- interval distal to Lister’s tubercle between the 3rd and 4th Extensor compartments . • Dorsal wrist ganglion • Pain in this area = SL injury , Dorsal wrist syndrome – SL synovitis from stress on the ligaments . Test with resisted finger extension with the wrist in flexion . • SL ligament injury causes rotary subluxation of the scaphoid. Clinical signs of rotary subluxation of the Scaphoid • Watson 5 clinical signs: Tenderness over the scaphoid in the snuff box, Scaphoidtrapezial – trapaezoid (STT) synovitis, Dorsal scapholunate synovitis, positive finger extension test , abnormal scaphoid shift test (Watson’s test). • Scaphoid Shift Test only 69% sensitive , 66% specific • Other tests : scaphoid thrust test (dorsal shift of scaphoid tubercle, SL ballottement test ( scaphoid moves volar/dorsal on lunate) Ulnar Dorsal Zone • Ulnar styloid, ulnar head, DRUJ, TFCC, Hamate, Triquetrum, LT interval, 4th and 5th CMC joints, and the ECU • DRUJ- sigmoid notch of radius and ulnar head. Palpate radial to the ulnar head . Pain here may be due to DRUJ arthritis. • Prominence of the distal ulnar head is sign of DRUJ instability . Piano Key sign (pain), Piano Key test ( Extremes of Pro and sup distal ulna moved volar and dorsal) TFCC • Palpate between the head of the Ulna and Triquetrum . • Fovea- deep an palmar to the radial styloid . Attachment of the TFCC. (Fovea Sign- pain and tenderness with palpation indicates a TFCC injury) • Ulna carpal abutment- Ulna Positive Variance causes impaction of the TFCC . TFCC Load Test – (ulnar carpal abutment and TFCC tears) ulnar deviation with an axial load to the wrist and moving it volarly and dorsally or by rotating the forearm . Pain and crepitus • Ulnocarpal instability – Relocation test- in pronation relocate carpus on ulna reduced pain , Pisiform Boost test – dorsally gliding pisiform to lift carpus causes pain and crepitus Midcarpal instability • Pain, swelling, tenderness in the dorsal triquetralhamate area. Volar sag on the ulnar side of the wrist . Clunk as the wrist moves from radial to ulnar dev • Midcarpal shift test ( Catch-up clunk test, midcarpal shift test) Palmar load is placed over the capitate and ulnarly deviating the wrist with simultaneous axial load. Positive test if a painful clunk (abrupt change of PCR from flex to extension with ulnar dev) LT Interval • Palpate ulnar to the lunate in line with the 4th ray Tenderness indicates possible LT instability . • LT Ballottement test – stabilizing the lunate and attempt to displace the triquetrum volarly and dorsally. Positive test pain, clicking, laxity • Shear test for LT instability - loading the Pisotrquetrial complex in a dorsal direction and with the lunate stabilized and then deviating the wrist in an ulnar and radial direction ECU tendon • Palpate between ulnar styloid and base of 5th Metacarpal when forearm is pronation and ulnar dev. • Pain with resisted motion can indicate ECU tendonitis • ECU subluxation – ECU is held in ulnar groove of distal ulna by a tendon sheath, With disruption of the sheath it will sublux and snap during forearm rotation • Test : forearm supinated , wrist ulnarly deviated subluxation noted Volar wrist • Scaphoid Tuberosity- volar aspect of the distal radius at the base of the thenar crease. More prominent in radial Deviation. Tenderness may indicate disease of Scaphoid. • STT Joint – distal to scaphoid tuberosity . Pain indicates arthritis (limited radial dev and painful). Volar wrist ganglion. • FCR tendonitis- ulnar to the scaphoid tuberosity . Pain with resisted motion. • Phalen’s, Tinel’s for median and Ulnar Nerves • Allen’s test for radial and ulnar arteries Median Nerve Sites of Median N Compression • Median nerve enters the forearm between the 2 heads of the Pronator teres (pronator syndrome)and deep to the bicipital aponeurosis (lacertus fibrousa). • AIN nerve – deep to the interosseous membrane motor branches to FPL, PDF to IF and Pronator Quadratus. Damage to this nerve can result from surgery in the forearm. Patient unable to flex the tip of thumb and IF . Normal sensation noted. • Main Trunk of median nerve passes through superficial muscles and lies deep to superficialis muscle and tendons. • Gives off motor branches to FDS and FCR • Palmar cutaneous branch arises 5to 7 cm proximal to the wrist crease • Becomes most superficial structure in CT . Between transverse carpal lig and ulnar bursa • After CT it splits into Sensory branch ( Thumb – RF radial side), motor branches of radial 2 lumbricals and recurrent Motor Branch (thenar muscles) Carpal Tunnel syndrome • Most common upper extremity compression. 8% prevalence in US. • Due to inc pressure in CT, using hands “forcefully” at work. • Hypertrophy of Lumbricals :Lumbrical muscle move into the CT with >50% Flexion of the digits. • Studies do not promote acute flexor tenosynovitis but fibrosis and the development of scar tissue. Risk Factors or CT • Obesity- doubles with BMI greater than 30 kg/m2. • Female 2x as likely as men • Increase with age 3.7% in those younger than 30 yo. 11.9% in those over 50. • Those less significant: DM, OA, previous musculoskeletal disorder, estrogen replacement therapy, Cardiovascular disease risk factors, Hypothyroidism, family hx of CT , wrist ratio greater than 0.70, wrist -palm ratio greater than 0.39, a short, wide hand, and short stature Symptoms of CT • • • • Paresthesia in median nerve distribution . Worse at night/ Night waking Pain in wrist area Pt reports dropping objects or inability to manipulate small objects. • Wasting thenar muscles • Progression of symptoms from mild to moderate to severe.night time only and less than 1 year (mild); Day time numbness also, clumsiness, dec pinch and grip(moderate) , thenar atrophy (severe). • Tests: Phalen's, Tinel’s at the wrist, WEST monofilament nerve test, Berger’s test, EMG, R/O higher level of compression Evaluation of CT • Self reported questionnaire: Katz hand diagram: 72-75% specificity • Boston Carpal Tunnel Questionnaire- CTQ-SSS (only this for no sx), CTQ-FS ,DASH. • Phalen’s, Tinel’s, Carpal compression , Semmens Weinstein, 2pt discrimination, • Baseline grip strength/pinch- Grade C evidence • Test combination: >45yo, shaking hands provides relief, wrist ratio greater than 0.67, CTQ-SS >1.9, Diminished light touch. Ulnar Nerve C7-T1 • Passes through the cubital tunnel (Osborne’s lig site of compression) • Thru 2 heads of FCU • Motor Branches to the FCU and ulnar 2 or 3 FDP Muscles • Enters the hand beneath the palmaris brevis muscle into Guyon’s tunnel splits into deep an superficial branches (Sensory innervation to the SF and ulnar RF ) • Deep motor branch - interossei, ulnar 2 lumbricals , adductor pollicis, FPB , palmaris brevis, and abductor digiti minimi ,Flexor digiti minimi brevis, opponenes digiti minimi. Sensory innervation to the SF and ulnar RF Ulnar Nerve Injury Appearance of Hand with Ulnar Nerve injury: loss of normal arches of the hand , wasting of is dorsal interosseous and 1st web space muscles , wasting of hypothenar muscles Look for These signs: • Fromet- Hyperflexion of the MCP of the thumb with pinch Grip • Wartenberg- Inability to adduct the extended SF to the extended RF • Duchenne- clawing of RF and SF • Masse- flattening of metacarpal arch • Inability to perform true opposition to tips of digits. The patient will perform a lateral pinch Additional tests Test : Tinel’s at elbow and hand, WEST monofilament test Claw deformity • Paralysis of the interosseous muscles , long flexors are unopposed and cause hyperextension of MCP joints with finger ext. • Bouvier Test – determine if the PIP joint capsule and extensor mechanism are working. • By placing MCP joint in slight flex during active ext result is in transfer of force to long extensors Bouvier test High Vs low Ulnar nerve injury • Clawing of the RF and SF will be more dramatic in the low Ulnar Nerve palsy due to intact FDS • High Ulnar nerve palsy ( at the elbow level) clawing less noticeable due to noninnervated FDP which limits the clawing at the IP joint Anticlaw orthotic Anticlaw orthotic- allows for functional use of the hand. Prevents over stretch of ligaments, joint capsule and tendons while nerve regenerates. Radial nerve C5-T1 • Enters forearm deep to brachioradialis, • Motor branches - brachioradialis, FCRL , FCRB . • Dorsal sensory branch – radial dorsal aspect of hand and proximal dorsal hand Th, IF, LF and variable RF • Posterior Interosseous Nerve – radial nerve splits and becomes this as it passes thru the Arcade of Froshe (where radial nerve goes thru 2 heads of supinator) . EDC, ECU, EI, EDM Radial Nerve Entrapment • Radial Tunnel syndrome – Where nerve emerges from the Arcade of Froshe. • Pain without palsy in the dorsal forearm. 4-5cm distal to the lateral epicondyle. Night time and resting pain common. • Test – elbow and hand extended resist middle finger extension. Radial Nerve Neurodynamic tests. Resisted supination with the elbow extended. • Radial nerve disruption common during elbow surgery causing wrist drop. Hand and wrist surgery can cause injury to the dorsal sensory branch. • Wartenberg’s syndrome – DRSN irritation . Burning and numbness over Dorsal Radial wrist with passive wrist flex.