MECHANICS & PATHOMECHANICS OF HAND

Click to edit Master subtitle style By : Amrita Tomar Guided By: Dr.Manisha Rathi

8/26/12

Hand consist of :

8/26/12

4 fingers 1 thumb

Creases of hand:

8/26/12

Joints of hand :
Total 19 bones & 19 articulations by 29 muscles
Tm Tz

8/26/12

Cp H
L T

CMC JOINT OF FINGERS 8/26/12

q

2nd to 4th CMC joints Plain synovial joint Articular surfaces:

1) distal carpal row 2) proximal surface of base of 2nd to 4th metacarpal row

Ligaments

8/26/12

1) deep transverse metacarpal ligament It tethers the metacarpal heads together and provides CMC joint stability. 2) volar & dorsal longitudinal ligaments

5th CMC joint saddle joint

8/26/12

2 degrees of freedom -flexion -extension -abduction

CMC Joints of 2nd 3rd 4th digitsplane uniaxial joints.

8/26/12

CMC Joint of 5th digit-biaxial joint.

Flex of CMC and additional adduction of the 5th MC improves the ability of the hand to grasp the objects of various sizes. where as extn of MC helps to release those objects.

Palmar arches : 1) Proximal transverse arch 2) Distal transverse arch 3) Longitudinal arch

8/26/12

Proximal transverse arch is formed by trapezium, trapezoid, capitate and hamate.

8/26/12

Curve shape of the arch is still maintained when the hand is open by the lig.; i.e.

Distal transverse arch is present transversely across 8/26/12 the arch.

The adjustable position of 1st 4th and 5th MC heads around the relatively fixed 2nd and 43rd MC forms a mobile distal transverse arch at the level of MC heads that augments the fixed proximal transverse arch of the distal carpal rows.

8/26/12

Functions of palmar arches :-

It allow the palm and the digits to confirm optimally to the shape of the object being held.

It

maximizes

amount

of

surface

contact,

enhancing stability as well as sensory feedback

MCP JOINT OF FINGERS 8/26/12

Articular surfaces:

Proximallyconvex metacarpal head Distallyconcave base of the 1st phalanx

Joint is incongruent due to inappropriate articular

8/26/12 Flexion and extension increases from radially to

ulnarly

ROM: 1) index flexion- 90 degree 2) little finger flexion- 110 degree

Ligaments : Radial Collateral ligament Ulnar Collateral ligament

1)

2)

They provide stability through out 8/26/12MCP jt the ROM with part of fibres taut at various points in the range

Volar plate : It is an accessory joint structure to enhance the joint stability by increasing the joint congruency.

INTERPHALANGEAL JOINTS OF 8/26/12 FINGERS

True synovial hinge joint Articular surfaces: Proximally- pulley shaped head of phalanx (large)

Distally- base of phalanx having 2 shallow concave facets with a central ridge.(small)

8/26/12

Ligaments- radial collateral ligament 8/26/12 - ulnar collateral ligament

Lig. Remains taut and Provide stability and support to PIP and DIP Joint throughout.

Volar plates- reinforce each joint capsule and enhance stability and limit hyperextention.

ROM- 1 degree freedom (flexion- extention)

index PIP joint flexion - 100 degree index DIP joint flexion - 80 degree

8/26/12

5th PIP joint flexion 135 degree 5th DIP joint flexion 90 degree

Muscles: extrinsic- the finger muscles having proximal attachment above the wrist (radiocarpal jt)

8/26/12 MCP & IP joints of thumb are structurally and functionally identical to the MCP & IP joint of the finger MCP joint of thumb differs in that it is reinforced by the 2 sesamoid bones which improve the leverage of flexor pollucis brevis

CMC JOINT-THUMB

8/26/12

Articulation between trapezium and the base of 1st metacarpal Articular surfaces Trapezium - saddle shaped portion spherical portion

Saddle shaped portion is concave in sagittal plane and convex in frontal plane Spherical portion-convex in all direction

Base of 1st metacarpal has a reciprocal shape to

8/26/12 Flexion /extension and abduction/adduction are proposed to occur on saddle shape surfaces whereas axial rotation of the metacarpal that accompanies opposition is proposed to occur in the spherical surface

TYPE OF JOINT -biaxial , saddle Two degrees of freedom Flexion/ extension-around AP axis- 53 d Abd /add-around coronal axis- 42 d

8/26/12 Flexion /extension and abduction/adduction are

proposed to occur on saddle shape surfaces whereas axial rotation of the metacarpal that accompanies opposition is proposed to occur in the spherical surface

Type of joint: -biaxial , saddle

Two degrees of freedom:

8/26/12

Flexion/ extension-around AP axis- 53 d Abd /add-around coronal axis- 42 d Rotation 17 d

Capsule: Relatively lax, but it is reinforced by following ligaments.

8/26/12

These ligaments are important stabilizers of the CMC 8/26/12 joint. As a group they resist the tendency of CMC to dislocate

The large functional demands placed on the CMC joint of thumb results in a painful condition called BASILAR JOINT ARTHRITIS

When the ligaments are weakened by arthritis, the

Functions of the CMC joint

8/26/12

It has a unique range & direction of motion that produces opposition (abd+ flex+add+ simultaneous rot.) of thumb

This opposition occurs in all forms of prehensions

8/26/12

8/26/12

EXTRINSIC MUSCLES FLEXORS OF THE DIGITS..

FLEXOR DIGITORUM SUPERFICIALIS.. 8/26/12

Medial epicondyle of humerus Coronoid process Middle anterior radius Four tendons separating into two parts that insert into sides of bases of middle 2-5 phalanx Median MCP flexion digits 2-5

FLEXOR DIGITORUM PROFUNDUS..

Antero-medial surface of ulna Interosseus membrane Four tendons inserting into distal phalanxes of digits

2-5

Median 2-3 digits Ulna 4-5 digits

FLEXOR POLLICIS LONGUS..

Anterior middle of radius Interosseus membrane Palmar surface of base of distal 1st phalanx Median IP Flexion of thumb

EXTENSORS OF THE FINGERS..

EXTENSOR DIGITORUM COMMUNIS..

8/26/12

O: Common extensor tendon from lat.epicondyle of humerus, and deep antebrachial fascia. I: By 4 tendons, each penetrating a membranous expansion of the dorsum of the 2-5 digits and dividing over the proximal phalanx into a medial and 2 lateral bands. The medial band inserts into the base of the middle phalanx while the lateral bands reunite over the middle phalanx and insert into the base of the distal phalanx. N: Radial, C6, 7, 8 A: Extends the MCP joints and, in conjunction with the lumbricals and interossei, extends the IP joints of the 2-

EXTENSOR INDICIS..

Dorsal surface lower body of ulna Interosseus membrane Ulnar side of index fingers EDC tendon Radial (posterior interosseus) MCP and IP Ext of 2nd

EXTENSOR DIGITI MINIMI..

Lateral epicondyle of humerus Extensor expansion of 5th digit Radial (posteior interosseus) MCP and IP extension of 5th digit

8/26/12

EXTENSORS OF THUMB..

EXTENSOR POLLICIS LONGUS..

Posterior 1/3 ulna Interosseus membrane Posterior surface of base of thumb distal phalanx Radial (posterior interosseus) CMC, MCP and IP Ext of 1st digit

EXTENSOR POLLICIS BREVIS..

Dorsal 2/3 of radius Dorsal surface of base of proximal 1st phalanx Radial (posterior interosseus) CMC & MCP Ext of thumb CMC ABD of thumb

ABDUCTOR POLLICIS LONGUS..

Posterior distal 2/3 of ulna Posterior middle 1/3 of radius Interosseus membrane Radial side of base of 1st metacarpal Radial (posterior interosseus) CMC ABD & Ext of thumb

8/26/12

INTRINSIC MUSCLES THENAR EMINENCE..

ABDUCTOR POLLICIS BREVIS..

Scaphoid tuberosity Trapezium ridge Transverse carpal ligament Lateral base f proximal 1st phalanx Median

FLEXOR POLLICIS BREVIS..

Superficial head trapezium Deep head trapezoid, capitate and palmar ligaments of distal carpal bones Base of prximal 1st phalanx on radial side Extensor expansion Superficial median Deep Ulnar

OPPONENS POLLICIS..

Trapezium Transverse Carpal Ligament Radial side of 1st metacarpal shaft Median Opposition

8/26/12

HYPOTHENAR EMINENCE..

Abductor Digiti Minimi..

Pisiform

Ulnar side base of 5th proximal phalanx

Ulnar

MCP ABD of 5th digit

Flexor Digiti Minimi..

Hamate bone Transverse carpal ligament Ulnar side of proximal 5th phalanx Ulnar MCP Flexion of 5th digit

Opponence Digiti Minimi..

Hook of hamate Transverse carpal ligament

Ulnar border of entire 5th metacarpal bone

Ulnar

MCP flexion & rotation of 5th digit

Palmaris Brevis..

Flexor retinaculum Palmar surface skin on ulnar side of hand Ulnar Wrinkles skin of hand on ulnar side

Adductor Pollicis..

1.Oblique Head

Capitate bone of 2-3 metacarpals

Bases

2.Transverse Head
Proximal

2/3 of palmar surface of 3rd metacarpal

Ulnar side of base of 1st proximal phalanx Ulnar

Lumbricals..

Tendons of FDP Extensor expansion on dorsal aspect of each digits radial side 1 and 2 median 3 and 4 ulnar MCP flexion 2-5 digits

Palmar Interossei..

1st ulnar side base of 1st metacarpal bone 2nd ulnar side of 2nd MC bone 3rd radial side of 4th MC bone 4th radial side of 5th MC bone Extensor expansion of 2,4 and 5th digits Ulnar

Dorsal Interossei..

1st lateral head ulnar side of 1st metacarpal bone 1st medial head radial side of 2nd metacarpal bone 2nd, 3rd, 4th space between metacarpal bones 1st radial side 2nd proximal phalanx 2nd radial side of 3rd 3rd Ulnar side of 3rd 4th ulnar side of 4th

To learn..

8/26/12

PULLEYS
5 ANNULAR

8/26/12

&

3 CRUCIATE C1 C2 C3

A1 -MINOR A2 -MAJOR A3 -MINOR A4 -MAJOR A5 -MINOR

8/26/12

8/26/12

ZONES OF THE HAND 8/26/12

Dorsum of the hand, wrist, and forearm are divided into 8 anatomic zones to facilitate classification and treatment of extensor tendon injuries

Zone 1 (distal interphalangeal [DIP] joint) Zone 2 (middle phalanx) Zone 3 (proximal interphalangeal [PIP] joint) Zone 4 (proximal phalanx) Zone 5 (metacarpophalangeal [MCP] joint) Zone 6 (dorsum of hand)

Extensor tendon zones; dorsal aspect of the hand and wrist 8/26/12

flexor tendon zones; volar aspect of the hand and 8/26/12 wrist.

TENODESIS

8/26/12

As the wrist is extended , the thumb & fingers automatically flex due to the stretch placed on the extrinsic digital flexors. The flexion occurs passively, without effort from the subject..

8/26/12

A person with c6 level qudriplegia using tenodysis action to grasp a cup of water.

8/26/12

SWAN NECK DEFORMITY8/26/12

Commonly seen in Rheumatoid arthritis It causes PIP joint hyperextension and DIP joint flexion It can be a result of musculotendinous imbalance or joint laxity It can originate from abnormalities at the DIP jt, PIP jt.

At DIP joint

MALLET FINGER

8/26/12

Rupture of the terminal extensor tendon attachment causes flexion at the DIP joint Because of which there is inadequate extensor force at DIP jt, causing flexion at the joint. The extensor force concentrates more proximally causing PIP joint

Boutonnieres deformity

8/26/12

It has got three components flexion of PIP jt and hyperextension of DIP jt

8/26/12

This is because of Syonovial proliferation within the PIP jt Contracture of the oblique retinacular ligament

8/26/12

The central band ruptures and the lateral band slips into the palmar direction.. To the PIP joint ,thus proximal interphalangel joint looses its only means of extension.. Any tension in lateral bands produces flexion at the PIPand hyperextention at DIP

GAMEKEEPERS 8/26/12 THUMB of the ulnar collateral ligament It is caused by rupture

It is characterised by radial deviation deformity of the MCP joint with secondary adduction of the thumb at the metacarpal

ZIG-ZAG DEFORMITY OF 8/26/12 THUMB RA. Commonly seen in

The thumb metacarpal dislocates laterally at the CMC jt. Causing hyperextention at MCP jt. The IP jt. Remains partially flexed owing to the passive tension in the stretched and taut flexor pollicis longus. The bow string of the tendon of the EPL across the MCP jt creates a large extensor moment arm,thereby magnifying the mechanics of the deformity.

Ulnar Drift

8/26/12

It leads to ulnar deviation of the digits at the metacarpo-phalangeal joint. Mainly due to weakning of the capsuloligamentous structures as seen in RA.

8/26/12

ULNAR CLAW HAND

8/26/12

caused due to injury to ulnar nerve. It causes MCP joint hyperextension and PIP jt and DIP jt flexion Ulnar nerve injury can be at the wrist or elbow level At the wrist level the muscles that may be

affected are hypothenar muscles, dorsal and palmar interrosei, ulnar two lumbricals, adductor pollicis, deep head of

If these muscles are paralysed the ulnar two8/26/12 have fingers no intrinsic support And the extrisic muscle pull predominates. The extensor digitorum has a larger moment arm at MCP joint and consequently pulls the joint in hyperextension. As a result FDP is stretched and results in PIP and DIP jt flexion. At the elbow level injury The muscles affected are flexor carpi ulnaris, flexor digitorum profundus to ring and little finger This causes slight alteration in the claw hand deformity, where DIP joint remains in extension due to paralysis of flexor digitorum profundus.

APE THUMB

8/26/12

Due to injury to the median nerve CMC jt of the thumb goes in to ext. and add. And MCP jts and IP jts in to flex. Injury at the wrist causes paralysis of the thenar muscles and lumbricals of the index and ring fingers. Hence there is insufficient balance to the extrisic muscles of the thumb And the EPL has a large adductor moment arm at the CMC joint causing adduction and extension.

PALMAR DISLOCATION OF MCP JOINT 8/26/12

8/26/12

Advanced stages of osteoarthritis in the hands of an 86-yearold 8/26/12 pianist. Note the carpometacarpal joint subluxation at the base of each thumb. Atrophy of the first dorsal interossei as well as nodules and joint enlargements are apparent, but the individual is still functional.

Click below to know what your hands8/26/12 do can

REFERENCES..

8/26/12

CAROL OATIS ELIZABETH KENDALL DONALD NEUMANN CYNTHIA NORKIN CALLIET www.googleimages.com

THANK YOU

8/26/12