1
Q
Bony landmarks of the wrist
A
- radial styloid
- ulnar styloid
- carpal bones
- metacarpals
- phalanges
- carpal bones
2
Q
Carpal bones
A
- proximal row = scaphoid, lunate, triquetrum, pisiform
- distal row = hamate, capitate, trapezoid, trapezium
- pisiform
- volar ulnar aspect of wrist
- attached to triquetrum
- insertion for FCU
- hook of hamate
- distal and radial to pisiform
- protects ulnar nerve as it passes through palm
- capitate
3
Q
Metacarpals
A
- first segment of each finger
- form the bone section of the palm
- form the transverse arches that enhance grasp and in hand manipulation
- longitudinal arch allows for radial and ulnar aspects of palm to come together
- metacarpal heads = knuckles
4
Q
Phalanges
A
- make up the fingers
- proximal, middle, and distal sections on digits 2-5
- the thumb only has proximal and distal
5
Q
Joints of the wrist
A
- distal radioulnar joint
- radiocarpal joint
- ulnocarpal complex
- intercarpal joint
- carpometacarpal (CMC) joint
- carpometacarpal (CMC) joint of thumb
6
Q
Distal radioulnar joint
A
Facilitates rotation of the forearm
7
Q
Radiocarpal joint
A
- movements = flexion/extension, radial deviation, ulnar deviation
- sustains 80% of force of the wrist
- radius, scaphoid, lunate, triquetrum
8
Q
Ulnocarpal complex
A
- ulna, lunate, triquetrum
- triangular fibrocartilage complex separates ulna and carpal bones
- sustains 20% of force
9
Q
Intercarpal joints
A
- complex arthrokinematic pattern (no set movements, just can mobilize them)
- bones slide and move against each other
- know that some patients may lack mobility here
10
Q
Carpometacarpal (CMC) joint
A
- gliding joints
- base of metacarpals articulate with distal row of carpals
11
Q
Carpometacarpal (CMC) joint of thumb
A
- saddle joint
- flexion/extension, abduction/adduction
- facilitates pinch and fine motor coordination
12
Q
ROM of wrist flexion
A
- primer movers = flexor carpi radialis, flexor carpi ulnaris
- patient position = sitting, forearm in pronation on tabletop, hand off table; fingers relaxed
- goniometer axis = dorsal wrist over capitate (goniometer upright)
- stationary arm = midline of dorsal forearm
- moving arm = 3rd metacarpal
- compensatory movement = elbow flexion and finger flexion
13
Q
Prime movers of wrist flexion
A
- flexor carpi radialis
- flexor carpi ulnaris
14
Q
Typical ROM of wrist flexion
A
80 degrees
15
Q
Compensatory movement of wrist flexion
A
- elbow flexion
- finger flexion
16
Q
ROM of wrist extension
A
- prime movers = extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris
- patient position = sitting with the forearm in supination on tabletop, hand off table; fingers relaxed
- goniometer axis = volar wrist crease
- stationary arm = midline of volar forearm
- moving arm = 3rd metacarpal
- compensatory movement = elbow flexion, finger extension
17
Q
Prime movers of wrist extension
A
- extensor carpi radialis longus
- extensor carpi radialis brevis
- extensor carpi ulnaris
18
Q
Typical ROM of wrist extension
A
70 degrees
19
Q
Compensatory movement
A
- elbow flexion
- finger extension
20
Q
ROM of radial deviation (wrist)
A
- prime movers = extensor carpi radialis longus, extensor carpi radialis brevis, flexor carpi radialis
- patient position = forearm in pronation on tabletop wrist neutral; fingers and thumb relaxed
- goniometer axis = capitate bone (base of 3rd metacarpal)
- stationary arm = midline of dorsal forearm
- moving arm = 3rd metacarpal
- compensatory movement = elbow flexion, finger/thumb abduction
21
Q
Prime movers of radial deviation (wrist)
A
- extensor carpi radialis longus
- extensor carpi radialis brevis
- flexor carpi radialis
22
Q
Typical ROM of radial deviation (wrist)
A
20 degrees
23
Q
Compensatory movement of radial deviation (wrist)
A
- elbow flexion
- finger/thumb abduction
24
Q
ROM of ulnar deviation (wrist)
A
- prime movers = extensor carpi ulnaris, flexor carpi ulnaris
- patient position = forearm in pronation on tabletop wrist neutral; fingers and thumb relaxed
- goniometer axis = capitate bone (base of third metacarpal)
- stationary arm = midline of dorsal forearm
- moving arm = 3rd metacarpal
- compensatory movement = elbow extension, finger abduction
25
Prime movers of ulnar deviation (wrist)
- extensor carpi ulnaris
- flexor carpi ulnaris
26
Typical ROM of ulnar deviation (wrist)
30 degrees
27
Compensatory movement of ulnar deviation (wrist)
- elbow extension
- finger abduction
28
MMT of wrist flexion
- against gravity = forearm in supination on tabletop, wrist in midrange flexion; fingers relaxed
- stabilizing hand = forearm stabilizing against tabletop (more distal/medial forearm)
- resistive hand = mid-volar palm
- force application = against flexion
- gravity eliminated = sitting with forearm neutral (thumb up) and ulnar forearm and hand resting on tabletop
- stabilization = radial forearm
- palpation = flexor carpi radialis and flexor carpi ulnaris at volar wrist
29
Palpation of wrist flexion
Flexor carpi radialis and flexor carpi ulnaris at volar wrist
30
MMT of wrist extension
- against gravity position = forearm resting in pronation on tabletop; wrist in midrange extension; fingers relaxed
- stabilizing hand = mid-dorsal forearm stabilizing against tabletop
- resistive hand = dorsal metacarpals
- force application = against extension
- gravity eliminated = sitting with forearm neutral (thumb up) and ulnar forearm and hand resting on tabletop
- stabilization = radial forearm against tabletop
- palpation = extensor carpi ulnaris, extensor carpi radialis longus, and extensor carpi radialis brevis at dorsal wrist
31
Palpation of wrist extension
Extensor carpi ulnaris, extensor carpi radialis longus, and extensor carpi radialis brevis at dorsal wrist
32
Palpation of radial deviation (wrist)
Extensor carpi radialis longus and brevis at dorsal wrist; flexor carpi radialis at volar wrist (MMT not tested in practical)
33
Palpation of ulnar deviation (wrist)
Extensor carpi ulnaris at dorsal wrist; flexor carpi ulnaris at volar wrist
34
Clinical implications
- carpometacarpal osteoarthritis (CMC OA) of thumb
- flexor tendon injuries
- extensor tendon injuries
- carpal tunnel syndrome
- distal radius fracture
- peripheral nerve injuries
- ulnar nerve injury
- median nerve injury
- radial nerve injury
35
Carpometacarpal osteoarthritis (CMC OA) of thumb
- common place for osteoarthritis due to activity demands
- interventions = activity modifications, adaptive grips, orthoses, surgical intervention
36
Flexor tendon injuries
- often result from a laceration from a sharp object
- categorized into zones of injury
- intervention = surgical repair, dorsal blocking orthosis, early motion to promote tendon gliding, one handed techniques
- difficulty bending fingers
37
Extensor tendon injuries
- less common than flexor tendon injuries
- interventions = one handed techniques, orthoses
38
Carpal tunnel syndrome
- carpal tunnel contains 9 tendons and median nerve
- occurs with increased pressure caused by repetitive motion
- reduces blood flow to arteries that supply the median nerve
- intervention = surgical intervention, orthosis, task modification, education
39
Distal radius fracture
- 25% of all fractures in pediatrics
- 18% of all fractures in older adults
- occurs most often from a FOOSH
- complications = edema, swelling, scar tissue, nerve compression, joint stiffness
- post-op interventions = scar management, edema management, adjacent joint mobility, ADL modifications, balance/fall assessment
40
Peripheral nerve injuries
- vision, touch, and proprioception guide the movement and place of our hands
- stereognosis
- somatosensation
- both are important for safety
- intervention = orthoses
41
Stereognosis
Ability to identify an object using hands alone
- no visual input
42
Somatosensation
Ability to determine temperature and pain
43
Ulnar nerve injury
- may present with sensory and motor deficits
- motor = interossei muscles, ADPL, lumbricals of ring and small finger
- ring and small fingers may begin to claw = claw hand
- hyper extension in MCPs and loss of IP extension in ring and small fingers
44
Median nerve injury
- also called the Hand of Benediction
- unable to flex thumb , pointer finger, and middle finger
- loss of webspace of thumb
45
Radial nerve injury
- wrist drop = loss of wrist and digit extension
