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(15-20), and its posterior margin projects more distally to provide a buttress effect Lunate and triquetrium also articulate with the triangular cartilaginous disc and not the ulna. (the disc extends from the ulnar side of the distal radius and attaches to the ulna at the base of the ulnar styloid process) The disc adds stability to the wrist; creates a close relation between the ulna and carpal bones and binds together the distal ends of the radius and ulna.
ulna bears 40%. If the disc is removed, the radius transmits 95% of the axial load and the ulna transmits 5% Therefore, the cartilaginous disc acts as a cushion for the wrist joint and as a major stabilizer of the distal radioulnar joint; the disc can be damage by forced extension and pronation Distal end of radius is concave and the proximal row of carpals is convex Has two degrees of freedom Resting position: neutral with slight ulnar deviation Close packed position: extension Capsular pattern: flexion and extension equally limited
Intercarpal Joints
Include the joints between the individual bones of the proximal
row of carpal bones (scaphoid, lunate, and triquetrium) and the joints between the individual bones of the distal row of carpal bones (trapezium, trapezoid, capitate and hamate). Bound together by small intercarpal ligaments (dorsal, palmar and interosseus), which allow only a slight amount of gliding movement between the bones. Close packed position: extension Resting position: neutral or slight flexion Capsular pattern is none Pisotriquetral joint is considered separately because the pisiform sits on the triquetrium and does not take a direct part in the other intercarpal movements
Midcarpal Joints
Form a compound articulation between the proximal and distal
rows of carpal bones with the exception of pisiform On the medial side, the scaphoid, lunate, and triquetrium articulate with capitate and hamate, forming a compound sellar (saddle-shaped joint). On the lateral aspect, the scaphoid articulates with the trapezoid and trapezium, forming another compound sellar joint These articulations are bound together by dorsal and palmar ligaments; however, there are no interosseus ligaments between the proximal and distal rows Therefore, greater movement exists at the midcarpal joints than at the intercarpal joints Close packed position: extension with ulnar deviation Resting position: neutral or slight flexion with ulnar deviation Capsular pattern: equal limitation of flexion and extension
Carpometacarpal Joint
Sellar joint that has 3 degrees of freedom (thumb) Plane joint for 2nd to 5th CMC joints Capsular pattern of CMC jt (thumb): abduction is most limited,
followed by extension Resting position (thumb): midway between the abduction and adduction and midway between flexion and extension Close packed position (thumb): full opposition Capsular pattern (2-5): equal limitation in all directions Bones of are held together by dorsal and palmar ligaments Thumb articulation has a strong lateral ligament extending from the lateral side of the trapezium to the radial side of the base of the 1st metacarpal, and the medial four articulations have an interosseus ligament similar to that found in the carpal articulation CMC articulations of fingers allow only gliding movements CMC articulations of thumb is unique that it allows flexion, extension, abduction, adduction, rotation, and circumduction
Intermetacarpal Joints
Have only a small amount of gliding movements between
them and do not include the thumb articulation They are bound together by palmar, dorsal and interosseus ligaments
Metacarpophalangeal Joints
Condyloid joints 2nd and 3rd MCP joints tend to be immobile and are the primary
stabilizing factor of the hand, whereas the 4th and 5th joints are more mobile. Collateral ligaments of these joints are tight on flexion and relaxed on extension These articulations are also bound by palmar ligaments and deep transverse metacarpal ligaments Has two degrees of freedom 1st CMC has 3 degrees of freedom Close packed position: maximum opposition (thumb); maximum flexion (fingers) Resting position: slight flexion Capsular pattern: more limitation of flexion than extension
Interphalangeal Joints
Uniaxial hinge joints with one degree of freedom
that the pulp of the fingers face more fully the pulp of the thumb Cascade sign if the MCP jts and PIP jts of the fingers are flexed, they converge toward the scaphoid tubercle If one or more fingers do not converge, it usually indicates trauma to the digits that has altered their normal alignment
Patient History
Lunate dislocation fall on the outstretched hand Dislocation of fingers extension of fingers Galleazzi fx fracture of the radius and dislocation of the distal end of
the ulna Wrist is commonly injured by weight bearing, by rotation stress combined with ulnar deviation, by twisting, and by impact loading If flexor tendons (which are round, have synovial sheaths, and have a longer excursion that the extensor tendons) are injured, they respond much more slowly to treatment than do extensor tendons (which are flat or ovoid) Surgical no mans land region between the distal palmar crease and the midportion of the middle phalanx of the fingers; damage to the flexor tendons in this area that requires surgical repair usually leads to the formation of the adhesive bands that restrict gliding. In addition, the tendons may become ischemic, being replaced by scar tissue. Because of this, the prognosis after surgery in this area is poor
Observation
Skin creases occur because of movement at the various joints Note of any muscle wasting on the thenar eminence (median nerve),
1st dorsal interosseus mm (C7 nerve root), or hypothenar eminence (ulnar nerve) that may be indicative of nerve or nerve root injury Note of any localized swelling In the wrist and hand, effusion and synovial thickening are most evident on the dorsal and radial aspects Swelling of MCP and IP jts are most obvious on the dorsal aspects Dominant hand tends to be larger than the non dominant Any vasomotor, sudomotor, pilomotor, and trophic changes should be recorded; indicative of PNI, PVD, DM, reynauds dse, or reflex neurovascular syndromes such as shoulder-hand syndrome or sudecks atrophy Note any hypertrophy; may be indicative of pagets dse, neurofibromatosis, AV fistula
Observation
Presence of heberdens or bouchards nodes Heberdens nodes appear on the dorsal surface of the DIP jts
and are associated with OA Bouchards nodes are on the dorsal surface of the PIP joints; associated with gastrectasis and rheumatoid arthritis Any ulcerations may indicate neurological or circulatory problems Any alteration in the color of the limb with changes in position may indicate a circulatory problem Ulnar drift may be seen in RA Spoon-shaped nails are often result of fungal infection, anemia, iron deficiency, long term DM, local injury, developmental abnormality, chemical irritants or psoriasis. Clubbed nails associated with COPD, congenital heart defects, or cor pulmonale
median nerve palsy Thumb falls back in line with the fingers as a result of the pull of the extensor mm Px is unable to oppose or flex the thumb
Bishops hand or Benediction hand deformity
Wasting of the hypothenar mm of the hand, the interossei mm, and the
2 medial lumbrical mm Occurs because of the ulnar nerve palsy Flexion of the 4th and 5th fingers is the most obvious resulting change
Drop-wrist deformity Extensor mm of the wrist are paralyzed as a result of the radial nerve palsy, and the wrist and fingers cannot be extended
Types of Grip
Power Grip Requires fine control and gives greater flexor asymmetry to the hand Used whenever strength or force is the primary consideration Digits maintain the object against the palm Thumb may or may not be involved, and the extrinsic mm are more important For a power grip to be formed, fingers are flexed and the wrist in ulnar deviation and slightly extended
Hook grasp in which all or the second and third fingers are used as a hook
controlled by the FA flexors and extensors; involve the IP and MCP jts (thumb not involved) Cylinder grasp type of palmar prehension, thumb is used, and the entire hand wraps around an object Fist grasp/digital palmar prehension - hand moves around a narrow object Spherical grasp type of palmar prehension, in which there is more opposition and the hand moves around the sphere
Precision or prehension grip An activity limited mainly to the MCP joints and involves primarily the radial side of the hand Used whenever accuracy and precision are required Radial digits (index and long fingers) provide control by working in concert with the thumb to form a dynamic tripod for precision handling There is pulp to pulp contact between the thumb and fingers, and the thumb opposes the fingers. Intrinsic mm are more important Types of pinch grip
Three point chuck, three fingered, or digital prehension, in which palmar