Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_138_библиотеки_им_акад_М_И_Перельмана
.pdf
ACRONYM LIST
https://t.me/med1917
2PD: two-point discrimination
ADLs: activities of daily living
AIN: anterior interosseous nerve
AP: adductor pollicis
APB: abductor pollicis brevis
APL: abductor pollicis longus
AROM: active range of motion
CCH: collagenase clostridium histolyticum
CI: condence interval
CMC: carpometacarpal
CTQ: Carpal Tunnel Questionnaire
CTQ-SSS: Carpal Tunnel Questionnaire-Symptom
Severity Scale
CTQ-FS: Carpal Tunnel Questionnaire-Functional
Scale
CTR: carpal tunnel release
CTS: carpal tunnel syndrome
DASH: Disabilities of Arm, Shoulder, and Hand
DD: Dupuytren disease
DIC: dorsal intercarpal
DIP: distal interphalangeal
DISI: dorsal intercalated segmental instability
DRUJ: distal radioulnar joint
ECRB: extensor carpi radialis brevis
ECRL: extensor carpi radialis longus
ECU: extensor carpi ulnaris
ED: extensor digitorum
EDQ: extensor digiti quinti
EI: extensor indicis
EPB: extensor pollicis brevis
EPL: extensor pollicis longus
FCR: exor carpi radialis
FCU: exor carpi ulnaris
FDP: exor digitorum profundus
FDS: exor digitorum supercialis
FOOSH: fall on an outstretched hand
FPB: exor pollicis brevis
FPL: exor pollicis longus
IP: interphalangeal
LT: lunotriquetral
MP: metacarpophalangeal
MRI: magnetic resonance imaging
NLR: negative likelihood ratio
ODM: opponens digiti minimi
OP: opponens pollicis
ORIF: open reduction internal xation
PA: posterior-to-anterior
PIN: posterior interosseous nerve
PIP: proximal interphalangeal
PLR: positive likelihood ratio
PROM: passive range of motion
PRWE: Patient-Rated Wrist Evaluation
ROM: range of motion
RSC: radioscaphocapitate
SL: scapholunate
SLAC: scapholunate advanced collapse
SNAC: scapho-nonunion advanced collapse
STT: scaphotrapeziotrapezoid
TAM: total active motion
TFC: triangular brocartilage
TFCC: triangular brocartilage complex
UCL: ulnar collateral ligament
UTS: ulnar tunnel syndrome
VISI: volar intercalated segmental instability
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
5
https://t.me/med1917
6
The Wrist and Hand:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Mia Erickson, PT, EdD, CHT
Midwestern University
Physical erapy Department
College of Health Sciences
Glendale, Arizona
Carol Waggy, PT, PhD, CHT
West Virginia University School of Medicine
Department of Human Performance
and Applied Exercise Science
Division of Physical erapy
Morgantown, West Virginia
ABSTRACT
e purpose of this monograph is to provide the reader
with an overview of wrist and hand anatomy, biomechanics,
examination procedures, common pathologies, and interventions. Both skeletal and soft tissue injuries are covered including
fractures, tendon injuries, sprains, instability, and nerve lesions.
Evidence is integrated throughout to provide a rationale for
clinical decisions. In this edition, new evidence for examination
and management has been incorporated with the addition of
information from clinical practice guidelines. Also, the section
on tendon repair for both the exor and extensor surfaces have
been revised consistent with advances in surgical techniques allowing faster rehabilitation protocols.
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant will be able to:
Describe the anatomy and biomechanics of the wrist and
1.
hand.
2.
Perform a physical examination using evidence-based tests
and measures specic to the wrist and hand.
3. Integrate common wrist and hand outcome measures.
4. Interpret the results of a wrist or hand examination.
5. Explain the pathology and dierential diagnosis for wrist
and hand disorders.
6. Apply evidence-based interventions for wrist and hand con-
ditions.
7. Select appropriate orthoses for common diagnoses present-
ed.
8. Dierentiate between types of nerve injury.
9. Describe the process for sensory reeducation following nerve
injury.
INTRODUCTION
is monograph covers examination and management of
both the wrist and hand that include many joints and bony and
soft tissue structures. Comprehensive coverage of all conditions
is beyond the scope of this monograph, but it should provide
the physical therapist with an overview of common conditions
treated in outpatient physical therapy settings. In looking at
the pathologies described throughout this monograph, it is important to appreciate the form and function of our hands. e
small nature of the structures makes the region dierent than
any other body regions, and so even our palpation skills must
be adjusted accordingly. Swelling, scarring, and loss of sensation can result in major losses in joint range of motion (ROM)
and function and so emphasis will be placed on management
of these impairments throughout the monograph. Our hands
are a signicant part of our appearance and how we interact
with others, and so cosmesis can be an issue here more so than
in other regions. Also, consider the tasks our hands allow us to
accomplish, from activities of daily living (ADLs) to participation in work, school, and sports, our hands explore, manipulate, and maybe most importantly, provide sensory information
(feel). e information here was compiled by hand therapy experts with more than 20 years each of experience working with
world-renowned hand surgeons. We hope that, in this monograph, some clinical pearls are provided that will help you in
the management of individuals with wrist and hand conditions.
ANATOMY
Skeletal Anatomy
e bones within the hand are mostly miniature long
bones with the distal phalanges being the exception. Each of
the 5 metacarpals and 9 phalanges (5 proximal and 4 middle
phalanges) has a narrow shaft with a comparatively broad base
and head (Figure 1). e condylar portions of the base and
head serve as attachment sites for the collateral ligaments of the
neighboring joint. e base of each long bone of the hand is
concave while the head is convex. e unique distal phalanx
has a similar broad base and a short shaft with a broad crescent-shaped ridge of bone at the distal end called the tuft. e
tuft begins at the level of the proximal base of the nail and is
commonly fractured by crush injuries of the tips of the ngers.
e base of the distal phalanx serves as an attachment site for
the terminal extensor tendon dorsally and the exor digitorum
profundus (FDP) tendon volarly. Both are potential sites of
avulsion injuries, disruptions of which may be soft tissue only,
or involve a portion of the bone.
Each of the other phalanges have unique characteristics.
e middle phalanx, which serves as the bone spacer between
the distal interphalangeal (DIP) joint and the proximal interphalangeal (PIP) joint, has a long crest on both the medial and
lateral sides of the volar surface where the 2 exor digitorum
supercialis (FDS) tendon slips insert. Each proximal phalanx
in contrast, has a smooth shaft for passage of the exor tendons
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
7
Figure 1.
https://t.me/med1917
Bony Anatomy
A, Volar aspect. B, Dorsal aspect.
Illustration provided courtesy of Brent Adrian, Midwestern University, Glendale, AZ.
on the volar side and the extensor digitorum (ED) tendons on
the dorsal side. e base of the proximal phalanx articulates
with the associated metacarpal to form the metacarpophalangeal (MP) joint.
e metacarpals of the index and long ngers, along with
the distal carpal row form the stable base of the hand.
1
e intricate bone morphology and strong soft tissue support provide
inherent stability but minimal mobility in this region.
2
Figure
1 shows the articulations between the metacarpals and bones
of the distal carpus. e index metacarpal articulates with both
the trapezium and trapezoid and the long nger metacarpal
the articular surfaces provide stability but limited mobility.
3
In
contrast, the metacarpal bases of the ring and small ngers have
a relatively smooth articular border, allowing greater motion of
the CMC joints, particularly of the small nger. Duncan et al
reports small nger CMC joint motions of up to 25° in most
people. e ring and small ngers (along with the thumb) are
termed the mobile rays of the hand.
5
e additional motion
allows the cupping of the hand as the ring and small ngers oppose toward the thumb. is CMC joint motion of the ring and
small ngers can be easily observed if an individual rst makes
a light st, followed by a tight st. Note the freedom of motion
of the small nger CMC occurring with the rm st, illustrated
by a cupping of the lateral aspect of the hand, compared to the
stable radial side (index and long ngers). Limitations in CMC
motion may be subtle but can aect normal posturing of the
hand during functional activities.
For example, look for decreased mobility of
the ring and small CMC joints following periods of
sustained hand immobilization such as with a shortarm or thumb spica cast. Functionally a patient may
have diculty grasping cylindrical objects, such as
tool handles, or completing full active opposition.
e shafts of the metacarpals have a gentle dorsal arch when viewed from the sagittal plane that
helps to maintain the longitudinal exion arch of
the hand. e arch extends into the phalanges of
each digit. e mid-point of the longitudinal arches
are the MP joints, which usually rest in 20° to 30° of
exion in a relaxed hand. e extrinsic and intrinsic
muscles surrounding the ngers balance this posture. e bases of the metacarpals are in close approximation while the shafts separate distally. is
allows space for the intrinsic muscles between the
bones and provides a wider distal palm for reaching and grasping objects. e supercial and deep
transverse metacarpal ligaments that run transversely between each of the heads of the metacarpals of
the 4 ngers assist in maintaining the position of
the metacarpal heads. e tension of the nger exor tendons, the thenar and hypothenar muscles, and
the transverse metacarpal ligaments also support the
distal transverse arch of the hand at the level of the
metacarpal heads. Injury to the local bony anatomy
or the neuromuscular system can aect this resting hand posture.
e thumb has a distal phalanx similar to that of the ngers, though it is broader. ere is no middle phalanx; therefore,
there is only an interphalangeal (IP) joint on the thumb (not a
DIP or PIP joint) between its distal and proximal phalanges,
and a MP joint between the proximal phalanx and the metacarpal. e most unique area of the thumb bony anatomy is found
at the CMC joint where the base of the thumb metacarpal, with
its saddle-shaped surface, articulates with the trapezium of the
distal carpal row. e thumb metacarpal rests in a exed and
pronated position of about 80° compared to the metacarpals of
4
the ngers.
e normal posterior-to-anterior (PA) and lateral
radiographs of a hand series demonstrate this posture (Figure
4
2). It should be noted that a lateral hand radiograph is needed
to provide a true PA view of the thumb metacarpal. e palmar
abduction and exion motions of the thumb CMC joint allow
this digit to oppose toward the ulnar-sided mobile rays of the
ring and small ngers as well as assume multiple positions for
pinch and grip activities.
4
e skeletal anatomy of the wrist includes the 8 carpal
bones as well as the distal radius and ulna (Figure 1). e carpals are divided into a distal and a proximal row. e distal
row, which is made up of the trapezium, trapezoid, capitate,
and hamate, articulates distally with the base of the metacarpals
to form the CMC joints. Overall, the distal row is stable, with
little intercarpal motion available. e proximal borders of the
Academy of Orthopaedic Physical erapy, APTA.
8
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 2.
30 to 60°
https://t.me/med1917
Plain Film Radiograph of the Wrist and
Hand
A
B
A, Posteroanterior view. B, Lateral view showing
normal scapholunate angle (30-60°). e arrow is
pointing to the scaphoid tuberosity.
bones of the distal row articulate with the distal border of the 3
major carpal bones of the proximal row (scaphoid, lunate, and
triquetrum) with the junction forming the midcarpal joint of
the wrist. e proximal border of the scaphoid and lunate articulate with the distal radius (in their respective fossa of the distal
radius), and the triquetrum with the triangular brocartilage
(TFC), collectively making the radiocarpal joint. e pisiform
is named as a carpal bone of the proximal row though it is a sesamoid for the exor carpi ulnaris (FCU) tendon. e pisiform
articulates with the triquetrum but plays little to no role in the
mechanics of the wrist. e pisotriquetral articulation can however be a source of ulnar-sided wrist pain.
e carpal bones do have some distinguishing characteristics. Reviewing the anatomy or architecture of the carpal bones
can enhance palpation skills at the wrist both for examination
and intervention techniques. Looking at a PA plain lm radiograph, one can see the geometry of the bones in the coronal
plane (Figure 2A). e scaphoid is long with a narrowed waist
giving it what has been described as a boat-shaped appearance.
It is an important stabilizer between the distal and proximal
carpal rows due to the sigmoid shape the midcarpal joint takes.
is alignment, for example, places the waist of the scaphoid
in line with the capitolunate joint line. Consider this position
of the scaphoid in the carpus, as you recall it is by far the most
susceptible carpal bone to fracture
(68% of all carpal fractures).
Scaphoid fractures occur most commonly due to falls onto the
outstretched hand (FOOSH) with the wrist in hyperextension
and slight radial deviation. As noted above, the scaphoid normally rests in some exion (compared to the longitudinal axis
of the forearm). Radial deviation exaggerates this exed posture.
With a FOOSH, hyperextension motions will occur at both the
radiocarpal and midcarpal joints. e proximal scaphoid is then
locked into the scaphoid fossa of the radius, leaving the extreme
posturing of the wrist to create potentially overwhelming tensile
forces on the midportion of the scaphoid.
e length of the scaphoid can be appreciated from Fig-
ures 1 and 2. e proximal edge of the scaphoid is found about
half-way across the width of the articulating surface of the distal
radius; the waist of the scaphoid in the base of the anatomical
snubox; and the tubercle on the volar surface just proximal to
the CMC joint of the thumb. From a lateral radiograph, the
normal resting alignment of the scaphoid is in a exed position
of 30-60° compared to the neighboring lunate. e proximal
portion of the bone is more dicult to discern on the radiograph with the overlap of neighboring carpals; however, the distal end of the bone in the exed position is normally easily seen
(Figure 2B). An exaggerated exed posture of the scaphoid in
this view is one of the radiographic signs of scaphoid instability
(or dissociation) indicative of ligament disruption within the
carpus.
e lunate on a PA view has a quadrangular appearance
but on the lateral view, has a crescent shape. An alteration in
either shape or alignment of the normal lunate can be an indicator of local pathology. For example, a lunate that has avascular necrosis not associated with obvious trauma, Kienböck disease, may over time lose its shape from a quadrangular look on
the PA view to more of a triangular appearance, or a attened
8
A second example, visible from the lateral view, is where
bone.
the lunate may be seen tilting in an exaggerated dorsal or volar
direction indicative of local ligamentous disruption. is will be
addressed again when discussing ligaments in the carpus. Recall
that the lunate, more than any other carpal bone, is dependent
upon surrounding ligamentous support. An inherently weak
area of the volar ligaments makes the lunate the most frequently
dislocated carpal bone.
6
7
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
9
e triquetrum is a large triangular shaped bone on the ul-
https://t.me/med1917
nar side of the proximal row and is the second most commonly
7
fractured carpal bone (18%).
e triquetrum articulates with
the hamate, the most ulnarly located bone of the distal row.
e hamate has a characteristic hook extending volarly from its
body. e hook is an attachment point for the exor retinaculum on the ulnar side of the wrist and can be the site of an undiagnosed fracture resulting in ulnar-sided wrist pain particularly
with gripping activities, or end-range wrist exion.
e capitate is the largest of the carpal bones and is described as the keystone of the transverse arch of the wrist.
Many of the extrinsic ligaments of the wrist attach upon the
capitate. e trapezoid has very stable articulations with the second metacarpal, the capitate, and the trapezium, making it the
most stable carpal bone. e trapezium found at the base of the
thumb contributes to the mobile rst CMC joint. e distal
surface of the trapezium is a saddle joint matching the base of
the metacarpal of the thumb. Within the distal row, the trapezium has the most mobility in relation to the surrounding bones.
e articulations between the proximal surfaces of the
proximal carpal row and the distal radius and ulna make up the
radiocarpal joint. e lateral border of the radius has a distally
extending styloid. One may easily palpate the prominent radial
styloid on the radial border of the wrist just proximal to the
snubox. e distal articular surface of the radius has a gentle
slope, known as radial inclination, from the styloid to its ulnar-most border. is slope may be viewed on a PA radiograph
of the wrist. Normal inclination is 15° to 20° when the slope
line is compared to a line drawn perpendicular to the mid-shaft
8
of the radius (Figure 2A).
Medial to the radius is the distal end of the ulna, which
articulates in a shallow impression on the radius called the ulnar notch (or sigmoid notch). is forms the bony articulation
of the distal radioulnar joint (DRUJ). e normal length of
the ulna (ulna neutral or neutral variance) would have the radial border of the distal articulating surface of the ulna on a
line parallel to the ulnar border of the distal radius. A negative
ulnar variance, or ulnar minus, is present if the distal ulna is
proximal to the ulnar surface of the radius. A positive ulnar
variance, or ulnar positive, is noted if the articular surface of
9
the ulna is distal to the radius.
been inconsistently associated with Kienböck disease.
11
and Mitchell
note that wrists with a positive ulnar variance are
A negative ulnar variance has
10
Adams
associated with thinner brocartilaginous disk that may lead to
an increased risk of TFC degeneration. A comparison lm of
the uninvolved wrist should be reviewed because while length
changes between the radius and ulna may be seen after trauma
(for example, loss of height of the radius following a distal radius fracture), a positive or negative ulna variance may also be
congenital.
e natural 15° volar tilt of the distal radius compared to
the line of the radius diaphysis can be seen on a lateral radiograph (Figure 2B). Loss of this normal volar tilt is common
following distal radius fracture and is one of the major considerations in reduction of such fractures. On the lateral view,
with the wrist in a neutral position, the distal radius, lunate,
and capitate stack up in a near horizontal line that bisects each
bone. Ligament disruption should be suspected if the lunate has
an exaggerated tilt, either dorsally or volarly, compared to the
alignment of the radius and capitate. A tilt of the lunate indicating either a dorsal intercalated segmental instability (DISI) or
a volar intercalated segmental instability (VISI) is an important
radiographic indicator of soft tissue disruption within the prox-
6
imal carpal row.
e articular surface of the distal ulna has a small at area
covered by the brocartilaginous disk, the TFC. e TFC is a
meniscus-like structure in the center of the triangular brocartilage complex (TFCC). e TFC is found between the distal surface of the ulna and the carpus, making it susceptible to
degenerative changes, and it may also be involved with acute
injuries. e TFC attaches medially to the base of the ulna styloid, and the dorsal and volar attachments blend into the radioulnar ligaments. e ulna styloid is a location where fractures
frequently occur in combination with distal radius fractures.
Joints
e DIP and PIP joints of the ngers as well as the IP joint
of the thumb are hinge-like joints allowing exion and extension motion. Table 1 provides normal ROM values for each of
the joints of the hand. Appreciate that the amount of motion
12
can be quite variable among individuals. Norkin and White
provide a summary table of normal active and passive nger
and thumb motions from several sources. Articular capsules, brous collateral ligaments, thinner fan-like accessory collateral
ligaments, and a palmar (volar) plate support the joints. e
volar plates are thick and broad on the base of the distal bone of
each joint but form thinner long extensions, called check reins,
inserting onto the proximal bone. e volar plate of the PIP
joint can avulse from its distal insertion with hyperextension
injuries or dorsal joint dislocations. e collateral ligaments of
the DIP and PIP joints provide medial and lateral support with
ligamentous tension being uniform throughout the full range
of exion and extension movements. e accessory collateral ligaments are located slightly palmar to the axis of motion
and therefore will have a small amount of laxity as the IP joints
move into exion.
A common nding at the DIP and PIP joints, which is an
indicator of osteoarthritis, is the development of osteophytes,
called Heberden’s and Bouchard’s nodes, respectively (Figure
3). ese are dierent than inammatory nodules that may develop at these same joints secondary to rheumatoid arthritis.
In the upper extremity, the DIP joints of the ngers and the
thumb CMC joint are the most commonly symptomatic joints
involved with osteoarthritis.
13
e MP joints of the ngers, which connect the metacarpals and proximal phalanges, are biaxial joints that allow ex-
10
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Table 1.
https://t.me/med1917
Normal Active Range of Motion Values of the Wrist and Hand
Joint Motion Normal value
Forearm Pronation 85-90°
Supination 85-90°
Wrist Flexion 90°
Extension 70°
Radial deviation 15-20°
Ulnar deviation 30-45°
Metacarpophalangeal joint Flexion 85-90°
Extension 30-45°
Abduction 20-30°
Adduction 0°
Proximal interphalangeal joint Flexion 100-110°
Extension 0°
Distal interphalangeal joint Flexion 80-90°
umb carpometacarpal joint Flexion 20°
Radial abduction 50-55° total from start to end position
Palmar abduction 50-55° total from start to end position
umb metacarpophalangeal joint Flexion 50-55°
Extension 0°
umb interphalangeal joint Flexion 80-85°
Extension 0°
ion and extension as well as abduction and adduction motion.
e collateral ligaments of each of the MP joints are attached
dorsolaterally on the metacarpal head and travel distally to the
volar lateral surface of the proximal phalanx. Due to the orientation of the ligaments and the shape of the metacarpal head,
the collateral ligaments are taut in exion but relaxed in extension. is dierence can be demonstrated by contrasting the
ability to perform MP joint abduction/adduction motion with
the MP joint in extension versus in exion. e tension in the
collateral ligaments in a exed position eliminates the ability to
perform abduction/adduction motions. Prolonged immobilization of the MP joints in extension can result in shortening of
the collateral ligaments, and therefore, diculty in recovering
MP joint exion. When immobilization of the MP joints is required, when possible, the patient’s MP joints should be placed
14
in or near full
exion (ie, 70-90° of exion).
Each MP joint has accessory collateral ligaments found volar to those described above. ey assist with stabilization of the
volar plate and the exor tendon sheath. e volar plate at the
MP joint does not have the long check rein extensions onto the
metacarpal; instead, if present at all, they are shorter. is in
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
part explains the ability to hyperextend the MP joints as much
as 45°.
e MP joint of the thumb has anatomically more in common with the PIP than the MP joints of the ngers. It is a uniaxial joint that only allows exion and extension motion. Two
sesamoids, easily seen on a plain radiograph, accompany the volar plate at this location. e collateral ligaments of this joint are
supported by the expansions of the intrinsic muscles aponeurosis, the stronger of which is on the ulnar side as the expansion
from the adductor pollicis (AP) muscle. is is an important
stabilizer of the thumb for functional activities involving pinch
with the neighboring digits. An acute disruption of the ulnar
collateral ligament (UCL) of the thumb at the MP joint is often called skier’s thumb, while a UCL disruption secondary to
degenerative changes is called gamekeeper’s thumb. A complete
ligament disruption may result in what is called Stener lesion, a
condition where the torn ligament is now seated supercial to
the adductor aponeurosis. Surgical repair to restore stability to
the thumb MP joint is required for a Stener lesion.
e rst CMC joint, between the rst metacarpal and the
trapezium allows biaxial motions including movement from
11
15
Figure 3.
https://t.me/med1917
Radiographic Evidence of Heberden (Distal Interphalangeal Joint) and Bouchard (Proximal
Interphalangeal Joint) Nodes
palmar abduction into retropulsion (a term describing hyperextension of the thumb metacarpal beyond the level of the dorsum
of the hand) and from exion across the palm into radial abduc-
16
tion (thumb extension).
ere are several supportive ligaments
that connect the 2 bones of this joint, but the 2 strongest stabilizers are: (1) the palmar oblique ligament running from the
trapezium to the base of the metacarpal, and (2) the dorsoradial
ligament running from the trapezium to insert on the dorsoradial base of the rst metacarpal. e dorsoradial ligament is an
extracapsular ligament found under the abductor pollicis lon-
16
gus (APL) tendon.
e palmar oblique ligament tightens in
radial abduction and retropulsion. In contrast, the dorsoradial ligament tightens in adduction motions of the metacarpal.
e mobility of this joint combined with its natural instability
(being the only digit on the radial side of the wrist, therefore
with little bony stabilization), places it at risk for degenerative
changes secondary to repetitive compressive forces such as that
which occurs during pinch and grasp activities. Gottschalk and
17
report that thumb CMC joint osteoarthritis is the sec-
Kakar
ond most common site of arthritis in the hand, following only
DIP joint osteoarthritis in frequency.
Intrinsic and extrinsic ligaments rmly support the bones
within the distal carpal row, thus allowing minimal independent motion among bony structures. e midcarpal (also called
intercarpal) and radiocarpal joints allow for wrist exion/extension. Approximately 50% of the total wrist exion and exten-
18
sion occurs at each of these joints.
During radial deviation,
the carpal bones of the proximal row move into a slightly greater exion (compared to the resting position) and slide ulnarly,
while the distal row moves radially with the hand. Consider that
as the hand moves into radial deviation, if the proximal row
moved with it in that direction, then the radial styloid would
become a roadblock. Instead, the scaphoid bows out of the way
(exes forward and slides ulnarly). e opposite occurs in ulnar
deviation with the distal row sliding ulnarly with the hand and
the proximal row moving into extension and sliding radially.
19
Clinical application: A scaphoid spot view is a PA radiograph
taken with the wrist in neutral exion/extension but full ulnar
deviation. During ulnar deviation, because the scaphoid moves
into extension, its entire length becomes visible, giving the examiner a better opportunity to view a fracture line within the
body of the bone.
e proximal carpal row is considered the weak link of the
wrist as there is no secure bony articulation. Compare the proximal carpal row against the stability of the distal row and the
base of the metacarpals. Distally, the carpals of the proximal row
articulate with the distal carpal bones, and proximally with the
radius and TFC. Both intrinsic and extrinsic ligaments support
the proximal carpal row yet it is the site of the most common
20
ligamentous disruptions within the carpus.
e proximal surface of the proximal carpal row is convex and articulates with
the concave distal radius with the scaphoid and lunate sitting
within their respective fossae of the radius. e ulnar border of
the proximal row articulates with the TFC. Weight bearing or
strong grip forces are transferred through the carpus into the
forearm with approximately 20% of the forces across the TFC
21
and ulna, while 80% are transferred through the radius.
e
TFC separates the lunate and triquetrum from the ulna head.
e TFC has only a small area of vascularity close to the attachment to the ulnar styloid. Although acute injuries can occur,
22
most injuries to the TFC are degenerative in nature.
e TFC
is part of the group of structures known as the TFCC. is
soft-tissue complex provides stability to the ulnar side of the
wrist but can be a cause of ulnar-sided pain if injury occurs. e
complex is made up of the articular disk itself, a fan-like structure called the meniscus homologue, the wrist UCL, the sheath
of the extensor carpi ulnaris (ECU) tendon, and the dorsal and
volar radioulnar ligaments. e latter 2 structures are important
stabilizers of the DRUJ. e volar radioulnar ligament is taut
when the forearm is in supination. During forearm pronation,
the radius pivots around the distal ulna, and the radius slides
slightly proximally. In this position, the dorsal radioulnar ligament is taut. Disruption of the ligaments supporting the DRUJ
may result in excess anterior/posterior translation of the ulna
head on the radius, called piano key sign.
11
Ligaments within the carpus are extensive and variable
18
(Figure 4).
Ligament names reect the bones the ligaments
span, either proximally to distally or laterally to medially. An
example is the radioscaphocapitate (RSC) ligament, one of the
12
Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Figure 4.
https://t.me/med1917
Wrist Ligaments
A
B
A, Volar view. Ligaments: LRL, long radiolunate; LT, lunotriquetral; RSC,
radioscaphocapitate; SC, scaphocapitate; SRL, short radiolunate; STT,
scaphoid-trapezium-trapezoid; TC, triquetrocapitate; UL, ulno-lunate; UT,
ulnotriquetral. B, Dorsal view. Ligaments: DCH, dorsal capitohamate; DCT,
dorsal trapezocapitate; DIC, dorsal intercarpal; DRC, dorsal radiocarpal.
Illustration by Kinstler Design.
extrinsic ligaments originating from the radius and inserting on
a carpal bone. An example of a ligament named for its lateral
to medial orientation would be the dorsal intercarpal (DIC)
ligament. Ligaments are formed of tightly packed bundles of
collagen bers and provide mechanical stability and proprioception. Generally, the ligaments on the dorsal surface of the
wrist are thinner and fewer compared to the palmar ligaments.
A reasonable way to identify these ligaments is to divide
them into intrinsic and extrinsic groups.
23
e intrinsic ligaments are intercarpal ligaments, found either between 2 neighboring carpal bones on the same row, such as the scapholunate
extensor expansion (hood) assist with extension of the IP joints
of the ngers (Figure 5). e tendons of the extrinsic extensor muscles are nicely organized within compartments made
by vertical bands from the extensor retinaculum that cross the
dorsum of the wrist (Figure 5A). Knowing the contents within
each compartment allows naming each of the extrinsic extensors for this area. A mnemonic that may be helpful is 221211.
e mnemonic describes the number of tendons found within
each of the 6 extensor compartments moving from a radial to
(SL) ligament, or between the bones of the
distal and proximal rows, such as the DIC
ligament. Contrast these with the extrinsic
ligaments that originate from the radius or
ulna into the carpus, or from the carpus to
the metacarpals.
Extrinsic and intrinsic palmar ligaments form inverted “V” shapes that reinforce the wrist, although the terms describing this arrangement vary in the literature.
e capitate is the apex of the distal “V”
(referred to as the arcuate ligament) and
the lunate is the apex of the proximal “V”.
e space between these 2 complexes, the
space of Poirier, is inherently weak. is is
the location of lunate dislocation, the most
common carpal bone to dislocate.
Muscles
e strength, dexterity, and grace of
the human hand are largely attributed to
the delicate balance of its intrinsic and extrinsic muscles working in a coordinated
manner. is is perhaps best appreciated
when observing the loss of resting posture
or functional movements secondary to pathology. Tables 2-4 describe the extrinsic
extensors, extrinsic exors, and intrinsic
hand muscles, respectively, providing origins, insertions, innervations, and primary actions of each muscle. In general, the
extrinsic muscles supplying movement to
the wrist, ngers, and thumb, originate in
the forearm or from the medial and lateral
epicondyles of the humerus with their tendons inserting on the metacarpals or phalanges. One exception is the extensor carpi
radialis longus (ECRL) which originates
from the supracondylar ridge of the lateral
distal humerus.
e dorsal extrinsic extensors extend
all joints of the thumb and the wrist and
MP joints of the ngers, and through the
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
13
Table 2.
https://t.me/med1917
Extrinsic Extensors of the Wrist and Hand
Muscle
Abductor
pollicis longus (APL)
Extensor
pollicis
brevis
(EPB)
Extensor
carpi radialis longus
(ECRL)
Extensor
carpi radialis brevis
(ECRB)
Extensor
pollicis longus (EPL)
Extensor
digitorum
(ED) - or
communis
(EC)
Extensor
compartment
Origin Insertion
1st Posterior surface of
ulna, interosseous
membrane, middle
shaft of radius
1st Distal shaft of
radius, interosseous
membrane
2nd Distal supracondy-
lar ridge of lateral
humerus
2nd Common extensor
tendon from lateral
humeral epicondyle,
deep forearm fascia
3rd Middle shaft of
ulna, interosseous
membrane
4th Common extensor
tendon from lateral
humeral epicondyle,
deep forearm fascia
Peripheral
nerve
innervation
Base of thumb metacarpal Posterior inter-
osseous nerve
Primary
action
umb radial
abduction
(PIN)
Base of thumb proximal phalanx
PIN umb meta-
carpophalangeal
(MP) joint
extension
Base of long metacarpal Radial Wrist extension/
radial deviation
Base of index metacarpal PIN Wrist extension/
radial deviation
Base of thumb distal phalanx PIN umb retropul-
sion and interphalangeal (IP)
joint extension
Tendon to each of the 4 ngers.
Attach at base of the proximal
PIN Finger MP
joint extension
phalanx with a central slip contributing to the extensor hood
for proximal interphalangeal
(PIP) joint extension. Contrib-
Contributes
to IP joint
extension*
utes to lateral bands to end as
the terminal tendons on the
distal phalanges of each nger
Extensor
indicis (EI)
Extensor
digiti quinti
(EDQ) - or
minimi
(EDM)
Extensor
carpi ulnaris
(ECU)
* Contributes to the extensor expansion of the PIP joints continuing to the distal phalanges as the terminal tendon. Refer to Figures 5 and 6 regarding the
orientation of the contributors into the extensor expansion of the ngers and for a depiction of the orientation of the lateral bands distal to the PIP joint
inserting into the distal phalanx as the terminal tendon.
4th Distal shaft of ulna,
interosseous membrane
5th Common extensor
tendon from the
lateral epicondyle,
deep forearm fascia
6th Common extensor
tendon from the
lateral epicondyle,
deep forearm fascia
Same as ED on the index nger
only. Found on the ulnar side of
the ED
Same as ED on the small nger
only. Found on the ulnar side of
the ED
PIN Same as ED but
only to the index
nger
PIN Same as ED but
only to the small
nger
Base of the 5th metacarpal PIN Wrist extension
Academy of Orthopaedic Physical erapy, APTA.
14
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Соседние файлы в папке Библиотека им академика М.И. Перельмана