Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_138_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

87 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 3738 / 5038 39 40 41 42 43 44 45 46 47 48 49 50 > Следующая >>>

Table 3.

https://t.me/med1917

Extrinsic Flexors of the Wrist and Hand

Muscle Origin Insertion

Flexor carpi radialis (FCR)

Flexor carpi ulnaris (FCU)

Medial epicondyle of humerus, deep fascia of forearm

2 heads: humeral head o humeral epicondyle, ulnar head o medial olecranon and proximal ulna

Flexor digitorum supercialis (FDS)

Humeral medial epicondyle, coronoid process of ulna, medial border of proximal radius

Flexor digitorum profundus (FDP)

Along proximal/middle ulna (anteromedial), interosseous membrane, deep fascia of forearm

Flexor pollicis longus (FPL)

Along anterior surface of the middle to distal radius, ulna coronoid and/ or medial epicondyle

Base of index metacarpal

Base of small metacarpal

2 slips on each middle phalanx

Base of each distal phalanx

Base of the thumb distal phalanx

Peripheral nerve

innervation

Primary action

Median Wrist exion

Ulnar Wrist exion

Median Finger proximal

interphalangeal (PIP) joint exion

Ring and small FDP–ulnar nerve; index and long

Finger distal interphalangeal (DIP)

joint exion FDP–anterior interosseous nerve (AIN)

AIN umb interpha-

langeal (IP) joint

exion

Table 4.

Intrinsic Muscles of the Hand

Muscle Origin Insertion

Abductor pollicis brevis (APB)

Tubercles of trapezium and scaphoid, exor retinaculum

Base of proximal phalanx radial side, extensor expansion

Opponens pollicis (OP)

Flexor pollicis brevis (FPB)

Adductor pollicis (AP)

Tubercle of trapezium, exor retinaculum

2 heads: supercial - exor retinaculum and trapezium; deep

- trapezoid and capitate

Oblique bers - capitate and

base of 2

and 3rd metacarpals;

transverse bers – length of the

Length of thumb metacarpal radial side

Base of thumb proximal phalanx radial border, extensor expansion

Base of thumb proximal phalanx ulnar border, extensor expansion

long nger metacarpal

Peripheral nerve

innervation

Recurrent branch of median

Recurrent branch of me-

Primary action

Palmar abduction of thumb carpometacarpal (CMC) joint*

Opposition of thumb CMC joint

dian

Supercial head – median; deep head – ulnar

umb metacarpophalangeal (MP) joint exion*

Ulnar umb adduction*

Table 4.

https://t.me/med1917

Continued

Muscle Origin Insertion

Dorsal interossei (DI)

1st - proximal border of thumb, ulnar side and radial border of index 2nd - ulnar border of index, radial border of long 3rd - ulnar border of long, radial border of ring

Base of proximal phalanx, extensor expansion. 1st - radial side of index 2nd - radial side of long 3rd - ulnar side of long

4th - ulnar side of ring 4th - ulnar border of ring, radial border of small

Palmar interossei (PI)

Note: some anatomy texts note a PI on the thumb and call this PI1 2nd - length of index metacarpal shaft, ulnar side 3rd - length of ring metacarpal, radial side 4th - length of small metacarpal, radial side

Primarily into extensor

expansion, may insert

on proximal phalanx of

associated digit.

1st - ulnar side of

thumb

2nd - ulnar side of

index

3rd - radial side of ring

4th - radial side of

small

Lumbricals From the FDP tendons.

1st - radial side of index exor digitorum profundus (FDP) 2nd - radial side of long FDP

Each insert onto radial

side of the extensor

expansion of the corre-

sponding nger 3rd - ulnar side of long FDP, radial side of ring FDP 4th - ulnar side of ring FDP, radial side of small FDP

Abductor digiti minimi (ADM)

Tendon of the FCU, pisiform Base of proximal

phalanx of small nger

ulnar border, extensor

expansion

Peripheral nerve

innervation

Primary action

Ulnar 1st – index nger

abduction 2nd – long nger radial abduction 3rd - long nger ulnar abduction 4th - ring nger abduction*

Ulnar Adduction toward the

long nger 1st - index to long nger 2nd - ring to long nger 3rd - small to ring nger*

Index and long

MP joint exion* digits–median; ring and small –ulnar

Ulnar Abducts the small

nger*

Flexor digiti minimi (FDM)

Opponens digiti minimi (ODM)

* 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.

Hook of the hamate, exor retinaculum

Base of proximal phalanx ulnar side

Length of small nger metacarpal ulnar side

Ulnar MP joint exion of the

small nger

Ulnar Opposition of the

small nger

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Figure 5.

https://t.me/med1917

Muscles and Tendons of the Dorsal Wrist and Hand

A, Dorsal view. B, Individual digit, lateral view.

Illustration provided courtesy of Brent Adrian, Midwestern University, Glendale, AZ.

ulnar direction. Once you recall the number of tendons in each compartment, you just need to place them correctly. e rst compartment contains the APL and the extensor pollicis brevis (EPB) tendons. ese 2 tendons are in a tight space lying over the radial styloid and is the location of De Quervain tendinopathy. e APL tendon inserts at the base of the rst metacarpal and only a small segment of the tendon can be seen on most people. As it is not as prominent as the other thumb extensors (EPB and extensor pollicis longus [EPL]), the APL muscle/tendon is easy to overlook, but can be found just radial and palmar to the EPB tendon. e APL tendon moves the thumb CMC joint into radial abduction while the EPB tendon extends the MP joint of the thumb.

e second compartment includes the ECRL and extensor carpi radialis brevis (ECRB) tendons. e tendons insert on the metacarpals of the index and long ngers, respectively. An important distinction here is that the ECRL is the only wrist extensor innervated proximal to the division of the radial nerve into the posterior interosseous nerve (PIN) and supercial sensory nerve branches. e third compartment holds only the EPL tendon. is tendon is quite visible when performing active thumb retropulsion, but its primary role is as the extensor

of the IP joint of the thumb. is tendon courses around the ulnar border of Lister’s tubercle at the wrist level and both acute and chronic ruptures of the EPL have been associated with fractures of the distal radi-

us.

e fourth compartment holds the 4 tendons from the ED as well as the tendon of the extensor indicis (EI). ere is 1 tendon of the ED to each nger, with the primary action being extension of the MP joints, though they also contribute distally, via the central slip, to the extensor expansion to assist in IP joints extension. e EI tendon, found on the ulnar side of the ED tendon of the index nger, performs the same functions for the index nger. e fth compartment holds 1 tendon, the extensor digiti quinti (EDQ) tendon, which assists the ED tendon to the small nger. ere are intertendinous connections called juncturae tendinae connecting the ED tendons to each other, most commonly between the ED tendon of the ring nger to the ED tendon of the small nger and between the ED tendon of the ring nger to the ED tendon of the long

Figure 5A). Functionally the junc-

nger ( turae tendinae assist the extensor tendons to work cohesively, but in doing so make independent MP joint extension dicult, particularly for the long and ring ngers. As the index and small ngers have an in-

dependent extensor in the EI and EDQ tendons, they are better able to extend the MP joint, even when the long and ring ngers are in a exed position. Try it moment: Make a full st and gently attempt to actively extend only your ring or your long nger at the MP joint. You should nd that it is both dicult and uncomfortable because you are lengthening the ED as a unit when you make a st, and then attempting to shorten only 1 tendon by actively moving 1 nger into extension. e juncturae tendinae is tethering the tendons making the above action uncomfortable and even impossible for some. In contrast, again make a full st but now extend the index or small nger MP joints. You should nd this much easier with the EI and EDQ to assist here.

e sixth compartment holds the tendon of the ECU muscle, the ulnar-most extensor tendon. Recall the sheath of this tendon is listed as a part of the ulnar-sided soft tissue complex, the TFCC. e ECU tendon may sublux palmarly with gripping and rotation activities causing a snapping sensation which may or may not be painful. e combination of ECRL, ECRB, and ECU muscles are the motors for wrist extension.

e extrinsic exors of the wrist include the FCU and the exor carpi radialis (FCR) muscles. As noted previously, the

tendon of the FCU surrounds the pisiform, using it as a sesa-

https://t.me/med1917

moid on its way to insert upon the base of the fth metacarpal. e FCR tendon passes by the scaphoid tubercle on its way to insert upon the second metacarpal. e extrinsic exors of the digits all pass under the transverse exor retinaculum as they travel from the forearm into the hand passing through the carpal canal or tunnel. Within the tunnel, the 4 FDP tendons line up in a row along the carpal bones. ey are the most dorsal tendons within the carpal canal. e 4 FDS tendons stack on top of (anterior to) the FDP tendons in 2 rows of 2. e tendons to the index and small ngers are in the deeper row, and the tendons to the long and ring ngers are in the most supercial row. e exor pollicis longus (FPL) tendon, the extrinsic exor to the thumb, is the most radially located tendon in the carpal tunnel. It travels the length of the thumb to insert at the base of the distal phalanx.

e extrinsic exor muscles of the ngers diverge on the distal side of the exor retinaculum to travel to their designated ngers. At the level of the metacarpal heads, 1 FDP tendon and 1 FDS tendon for each digit pass into a brous sheath. In Fig-

entering an intact tendon sheath. In the same gure, the long nger shows the insertion sites of the FDS and FDP tendons onto the middle and distal phalanges, respectively. Each FDS tendon splits into 2 slips with each slip attaching to a ridge on the edges of the volar middle phalanx. e area between the

Figure 6.

Muscles and Tendons of the Volar Wrist and Hand

A, Volar view. B, Individual digit, lateral view.

Illustration provided courtesy of Brent Adrian, Midwestern University, Glendale, AZ.

2 slips is called the chiasm of Camper. e FDP tendon passes through the chiasm to insert on the volar base of the distal phalanx. e FDS tendon functions to ex the PIP joints of the ngers but is assisted by the FDP. e FDP tendon is the only exor of the DIP joint.

e intact tendon sheath includes areas where tissue bers are found to be oriented in a circular (annular) or crossed direction (cruciate). ese thickened, organized areas of the sheath, form the pulley system. e mechanical function of the pulleys is to hold the exor tendons close to the phalanges through the complete arc of IP joint motion. Without this support, the tendons would pull away (called bowstringing) from the bone. Bowstringing can occur with ruptures or lacerations of the pulley system. Figure 7A illustrates IP joint exion with an intact

pulley system and Figure 7B shows how this motion is dramatically altered if the tendons bowstring, separating away from their close proximity to the phalanges.

ere are 3 cruciate pulleys, C1, C2, and C3, and 5 annular pulleys, A1, A2, A3, A4, and A5. e most important are the A2 and A4 pulleys at the levels of the proximal and middle phalanges, respectively.

ese pulleys maintain the integrity of the system. Some surgical procedures require partial sacrice of the pulley system. But, if at least a portion of the A2 and A4 pulleys remain intact, the mechanics of the system remains functional. e A2 pulley is the area known to rupture in 75% of rock climbers’ nger injuries.

e A1 pulley is found at the level of the metacarpal head and is the most common location for a trigger nger to occur. Resecting the A1 pulley is a surgical option for a trigger nger because this pulley is not considered crucial for tendon function of the digit. Trigger nger pathology is further discussed in the soft tissue disorders section of this monograph.

e intrinsic muscles of the hand complement the extrinsic muscles allowing for rened and precise movements and actions. Intrinsic muscles, by denition, originate and insert within the hand. e intrinsic muscles include the lumbricals, palmar and dorsal interossei, and the muscles of the thenar and hypothenar groups. Table 4 provides more details re- garding the intrinsic muscles. In general, the lumbrical muscles arise from the FDP tendons to insert upon the radial side of the associated MP joint, contributing to the radial side of the extensor hood. e lumbricals perform MP joint exion and oer signicant contribution to IP joints extension, placing the hand in an intrinsic plus position, as seen in Figure 8. e

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

lumbrical muscles are numbered I to IV moving from the radial

https://t.me/med1917

to the ulnar side of the hand. Lumbricals I and II are unipennate while lumbricals III and IV are bipennate muscles arising from 2 neighboring FDP tendons.

Figure 7.

A, Intact pulleys. B, Ruptured A-2, A-3, and A-4 pulleys.

Illustration by Kinstler Design.

Figure 8.

Bowstringing Tendons Due to Ruptured Flexor Pulleys

Intrinsic Plus Position

e dorsal interossei are a group of 4 bipennate muscles arising from the metacarpals, inserting on the proximal phalanges, and then continuing with a contribution to the extensor hood. ese muscles abduct the index and ring ngers away

from the long nger, and move the long nger away from center, both radially and ulnarly.

e palmar interossei are a group of 3 unipennate muscles arising from the metacarpals of the index, ring, and small ngers with each attaching to the base of its proximal phalanx as well as contributing to the IP joints extensor mechanism. e rst palmar interosseous is found on the ulnar side of the index metacarpal and acts to adduct the index to the long nger. e second and third palmar interossei arise from the radial side of the ring and small metacarpals, respectively, and adduct these ngers toward the long nger.

e hypothenar intrinsic muscles include the abductor digiti minimi, the exor digiti minimi, and the opponens digiti minimi (ODM). ese muscles arise from the pisiform, hook of the hamate, and ulnar side of the exor retinaculum. e ODM inserts along the length of the shaft of the fth metacarpal, the exor digiti minimi and abductor digiti minimi insert onto the base of the proximal phalanx, with the abductor digiti minimi having a second slip continuing as a contribution to the small nger’s extensor hood.

e thenar eminence is composed of a group of 4 muscles that help to position the thumb in its multiple orientations and

help with stability during ne motor tasks. e group consists of the abductor pollicis brevis (APB), the opponens pollicis (OP), the exor pollicis brevis (FPB), and the AP muscles. e APB muscle inserts on the radial side on the base of the proximal phalanx and provides the strong motor for palmar abduction of the thumb. Both the APB and the FPB contribute a slip on the radial side of the MP joint to the extensor hood of the thumb (the dorsal aponeurosis) while the AP contributes to the extensor hood from the ulnar side.

e extension mechanism for the IP joints of the ngers is complex and is probably best reviewed by studying the drawings in Figures 5B and 6B, as well as the dorsal view of the hand (Figure 5A). ough the contributors to the nger IP joints extension have already been named, focusing on the extensor hood alone should help to complete the understanding of this anatomy. e extrinsic ED tendons contribute the central slip to the middle phalanx of each digit and also send contributions

to the lateral bands of the intrinsic muscles. e lumbrical mus-

https://t.me/med1917

cles’ contributions are to the radial side of each nger’s extensor hood and are the most palmar portion of the lateral band. e tendons of the interossei make up the rest of the contribution into the lateral bands. e bands sit dorsal to the axis of rotation of the PIP joint in extension and must slide palmarly around the bony condyles when the PIP joint moves into exion.

Ligament support from a triangular ligament connect the edges of the bands on the dorsal surface over each middle phalanx (Figure 5A) and a transverse retinacular ligament connect to the palmar side of the bands (

Figure 6B). e balance be-

tween the triangular ligament and transverse retinacular ligament serves to maintain the proper position of the lateral bands. Disruption of the bands themselves or the ligaments that support them can result in abnormal PIP joint postures such as a Boutonnière (exion of the PIP joint and extension of the DIP joint) or swan-neck (PIP joint hyperextension and DIP joint exion) deformity. e conjoined lateral bands continue to the base of the distal phalanx and become the terminal tendon, the extensor of the DIP joint.

Neurovascular Structures

ree peripheral nerves (median, ulnar, and radial) originating from the brachial plexus (contributions from C5–8 and T1) supply the sensory and motor innervation to the wrist and hand. We recommend reviewing the pathways of these 3 major nerves as they come o the plexus. e median nerve passes through the antecubital fossa of the elbow, with the brachial artery, into the forearm to innervate the pronator teres, FCR, palmaris longus, and FDS muscles. An important branch o the median nerve then arises, the anterior interosseous nerve (AIN), which innervates the FPL, the FDP to the index and long ngers, and the pronator quadratus muscles. As the median nerve continues distally, a palmar cutaneous branch emerges that supplies sensation to the anterior skin of the radial distal forearm, the medial palm of the hand, and the thenar eminence. is branch does come o the nerve prior to the median nerve entering the carpal tunnel. e median nerve continues distally through the carpal tunnel to supply sensory innervation to the volar surfaces of the index, long, and half of the ring ngers as well as the thumb. e median nerve’s sensory distribution also includes a portion of the dorsal surface on each nger except the small nger and the thumb. Typically, this dorsal coverage includes the areas from the distal tips of these digits to the PIP joint creases. e branches of the median nerve supplying sensation to the ngers have a small motor component to them

innervating lumbricals I and II.

e median nerve also has a very important motor branch, the recurrent motor branch, which courses radially after going through the carpal tunnel to supply the following thenar intrinsic muscles: APB, OP, and the supercial head of the FPB.

e ulnar nerve travels through the cubital tunnel at the

level of the elbow joint, and then between the heads of the FCU

into the forearm. e nerve innervates only 2 extrinsic muscles, the FCU and the 2 ulnar components (to the ring and small ngers) of the FDP muscle as it courses distally towards the wrist. Two sensory branches arise from the ulnar nerve prior to entering the hand, the palmar and dorsal cutaneous branches. ese dedicated sensory portions of the nerve supply the anterior and posterior portions of the ulnar half of the hand and distal forearm. e ulnar nerve continues toward the hand dividing into a supercial sensory branch and a deep motor branch as it enters the ulnar tunnel (Guyon canal), found between the pisiform and the hook of the hamate. e supercial branch primarily provides sensation to the small nger and the ulnar half of the ring nger. e deep branch is the very important motor branch, which innervates many of the intrinsic muscles of the hand. Ulnar-innervated intrinsic muscles include all 3 of the hypothenar intrinsic muscles, all palmar and dorsal interossei muscles, lumbricals III and IV, the AP, and the deep head of the FPB muscle.

e only muscle that is a primary hand or wrist motor innervated by the radial nerve is the ECRL. e radial nerve then divides into a motor branch (the PIN) and a supercial sensory branch. is division of the radial nerve occurs just proximal to the heads of the supinator. e PIN (motor nerve only) provides innervation to the remaining wrist extensor muscles (ECRB and ECU), the nger extensors (ED, EI, EDQ), and all the extrinsic extensor muscles to the thumb (APL, EPB, EPL). e supercial branch of the radial nerve (sensory nerve only) is the sensory branch that travels distally under the brachioradialis to the level of the radial styloid where it emerges to supply sensation to the dorsoradial side of the hand.

e arterial blood supply to the hand arises from the brachial artery, which diverges into the radial and ulnar arteries. Each artery separates into supercial and deep branches. e 2 supercial branches communicate in the palm of the hand as the supercial palmar arch and the 2 deep branches ultimately communicate together to form the deep palmar arch. Both arches contribute 3 branches that combine as they progress distally to ultimately result in the radial and ulnar arteries for each digit. e deep branch of the radial artery dives dorsally by the rst metacarpal under the APL and EPB tendons to create the dorsal metacarpal branches and the princeps pollicis (branch to the thumb) before re-emerging in the palm and connecting

with the deep branch of the ulnar artery.

Both the supercial and deep branches of the radial artery send blood supply to the distal scaphoid.

EXAMINATION

Interview and Relevant History

e examination begins by taking a thorough history and performing a systems review. Relevant historical data include the following

• demographic information,

• history of the current injury or illness,

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

• date and mechanism of injury,

https://t.me/med1917

• prior treatment,

• relevant surgical history,

• chief complaint(s),

• lifestyle (eg, living environment, social support),

•

functional status and activity level (eg, work activities, recreational activities),

• general health status,

• prior medical history,

• family medical history,

• medications,

• growth and development,

• social and health habits,

• diagnostic tests and measures, and

• patient’s goals for therapy.

If the patient has primary complaints of pain, discuss specic aspects of the pain, including the location, frequency, intensity, type, duration, and activities that increase or decrease the pain. Also, note the location, frequency, intensity, and duration of any numbness, tingling, temperature or color changes, and abnormal clicks, clunks, or sounds, as these may be indicative of injuries to specic tissues.

Use self-report measures that are reliable, valid, and responsive to change to help better understand the overall impact of the condition on the patient’s lifestyle. Common self-report measures for the wrist and hand include the Disabilities of the

Arm, Shoulder, and Hand (DASH), the Patient-Rated Wrist Evaluation (PRWE).

the QuickDASH,29 and

e Carpal Tunnel Questionnaire (CTQ) is a disease-specic instrument for individuals with carpal tunnel syndrome (CTS). It includes 2 scales, one for measuring symptom severity (CTQ-SSS) and an-

other for assessing function (CTQ-FS).

Observation

First, observe how the patient presents in the clinic or the department, how they are holding the extremity, and whether they seem apprehensive. Also specically look at the patient’s resting hand posture; the ngers should rest in slight exion, with more exion in the ulnar than radial ngers. Note if there are any obvious or gross deformities. One should be aware of typical presentations caused by injuries or disease processes. For example, bony or joint malalignment may be indicative of a fracture or malunion. Loss of the resting hand position could indicate a tendon laceration, contracture, or peripheral nerve in-

Flattening of the palmar arches or muscle atrophy could

jury. be due to a nerve injury. Common sites of atrophy include the thenar and hypothenar eminences as well as the intrinsic muscles between the metacarpals and in the rst dorsal web span. An ulnar claw-hand (hyperextension of the ring and small ngers MP joints with exion of the corresponding IP joints) is the result of an injury to the ulnar nerve, while an ape hand

- loss of the ability to abduct the thumb away from the palm - is

caused by an injury to the median nerve or long-standing CTS. Ulnar drift at the MP joints is a pattern typically seen in individuals with rheumatoid arthritis. Boutonnière and swan-neck deformities are brought on by soft tissue imbalances that occur after an injury or by disease process.

Observe the skin for wounds (surgical and nonsurgical), scars, nodules, and cysts. When abnormalities exist, perform a more detailed assessment including wound type, size, status, and drainage. Assess scar characteristics such as tenderness or sensitivity, size, thickness, color, and height. e Vancouver Scar Scale can be used for an objective assessment of the patient’s scar.

Excessive scar tissue, or scar that is adhered to the subcutaneous tissue, could interfere with tendon glide and ROM, and hypersensitivity could interfere with functional activities. Note the size and location of any nodules or cysts as they may be indicative of arthritic conditions.

Observe the skin for abnormal coloration, moisture, tone, texture, and creases. Redness may be a sign of inammation or infection; whereas pallor in a nger may be indicative of a vascular disorder such as Raynaud’s disease (or phenomenon) or digital artery injury or occlusion. Bluish, dusky, or cyanotic coloring is a result of venous occlusion. Venous occlusion can occur after soft tissue surgery and result in edema or ischemia. Dry skin may indicate a peripheral nerve lesion and hyperhidrosis may signify increased sympathetic activity.

Trophic changes resulting from inadequate tissue nourishment may aect skin texture (making it appear soft, hard, brotic, smooth, or atrophic) and produce changes in the nails (ridges, blemishes, curves) and hair (length, thickness).

Trophic changes occur when there is sympathetic involvement such as in complex regional pain syndrome. Skin creases or ridges may be diminished or absent in the presence of edema or trophic changes associated with nerve injury.

Fingernail abnormalities can be present in a variety of hand

or systemic conditions.

Clubbing of the nails often suggests pulmonary or inammatory bowel disease, whereas spoonshaped nails (longitudinal concavity) may be present in patients with iron deciency, Raynaud’s disease, or lupus erythemato-

sus.

e appearance (clean, dirty, callus formation, etc) of the skin and nails may also provide information on how the patient is using their hands.

e presence of edema or atrophy, whether gross or localized, warrants objective bilateral measurements. Either volumetric or circumferential measurements can detect abnormalities in size, and both are reliable assessments. be preferred in the presence of general hand edema,

Volumetry may

whereas circumferential measurements may be best in the presence of more local edema or joint eusion. Circumferential measurements can be made at specic landmarks (eg, wrist crease, distal palmar crease, phalanges, IP joints) or a gure-of-eight method (Figure 9) may be used.

Note if the patient is wearing an orthosis, prosthesis, assis-

tive or adaptive device, or wound dressing. If present, note the

Figure 9.

https://t.me/med1917

Figure-of-eight Method for Wrist Girth

type and purpose of the device. Evaluate the t, condition, and appropriateness of the device based on the patient’s injury/condition.

A B

A, Begin at the distal aspect of the ulnar styloid and move the tape dorsally across the hand and through the thumb web span. B, Move the tape horizontally across the hand at the distal palmar crease and then dorsally across the hand (A). Move the tape horizontally across the wrist to join back at the ulnar styloid (B).

Palpation

Using palpation, examine skin temperature, texture, and mobility and compare with the opposite hand. Palpate any scars to evaluate stiness, adherence, and sensitivity. Also, palpate specic bony and soft tissue areas for point tenderness that might indicate an injury or pathology, such as a fracture or tenosynovitis (Table 5).

Range of Motion

When appropriate, rst perform a general screening of active movement to initiate the tests and measures portion of the examination. With certain conditions, such as a recent tendon repair, active and even potentially passive motion could be contraindicated, so one must thoroughly understand the patient’s medical and surgical history prior to performing the movement assessment. General screening includes observation of gross movement patterns. As the patient actively moves the wrist between extension and exion, with the ngers relaxed, tenodesis moves the ngers proportionate-

Table 5.

Areas to Palpate During a Wrist and Hand Examination and eir Signicance

Pain with palpation Suspected conditions

Radial aspect

Radial styloid Fracture

De Quervain syndrome Arthritis Radial nerve (supercial sensory branch) neuritis

Scaphoid (in the anatomical snu box) Fracture

Avascular necrosis Scapholunate ligament injury

umb: rst metacarpal, phalanges, MP and IP joints Fracture

Sprain/tendon injury Gamekeeper thumb (ulnar aspect of thumb MP joint)

First CMC joint Osteoarthritis

Scaphotrapeziotrapezoid joint Scaphotrapeziotrapezoid synovitis or arthritis

First dorsal compartment (APL and EPB tendons) De Quervain tendinopathy

Tendon rupture

ird dorsal compartment (EPL tendon) EPL tendon rupture or tendinopathy

Central dorsal aspect

Lister tubercle Fracture

EPL tendon rupture or tendinopathy

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Table 5.

https://t.me/med1917

Continued

Lunate Kienböck disease

Dislocation, subluxation, instability, or fracture

Capitate and capitolunate joint Fracture

Subluxation or dissociation Dissociation with or without arthritis

Index, long, and ring ngers: second, third, and fourth metacarpals, phalanges, CMC, MP, PIP, and DIP joints

Fracture Sprain/ligament injury Volar plate injury (volar PIP joint) Bossing (CMC joints)

Scapholunate joint Scapholunate ligament injury or dissociation

Ganglion cyst

Second and fourth dorsal compartments (ECRB/L and ED/ EI tendons)

Tenosynovitis or impingement beneath the extensor retinaculum Tendon rupture

Ulnar aspect

Ulnar styloid and ulnar head Fracture

Distal radioulnar joint injury

Triquetrum Fracture

Lunotriquetral ligament injury Triangular brocartilage complex injury

Hamate Fracture

Small nger: fth metacarpal, phalanges, CMC, MP, PIP, and DIP joints

Fracture Sprain or ligament injury Volar plate injury (volar PIP joints)

Distal radioulnar joint Arthritis

Instability Triangular brocartilage complex injury

Triangular brocartilage complex Triangular brocartilage complex injury including tear of

articular disk Ligament disruption Distal radioulnar joint disruption

Lunotriquetral joint Lunotriquetral ligament injury or dissociation

Fifth and sixth dorsal compartments (EDM and ECU tendons)

Tendinopathy or tendon rupture ECU subluxation

Volar aspect

Scaphoid tubercle Fracture

Pisiform Fracture

Pisotriquetral arthritis

Hook of hamate Fracture

Distal ulnar tunnel Ulnar tunnel syndrome

Nerve or artery injury

Wrist and nger exor tendons (palpable as a group proximal to the carpal tunnel or individually in the palm, palpated best during nger active motion)

Tenosynovitis Trigger nger Tendon rupture Dupuytren disease in the palmar fascia

Abbreviations: APL, abductor pollicis longus; CMC, carpometacarpal; DIP, distal interphalangeal; ECRB/L, extensor carpi radialis brevis and longus; ECU, extensor carpi ulnaris; ED, extensor digitorum; EDM, extensor digiti minimi; EI, extensor indicis; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; IP, interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal

ly. Note if one nger appears out of alignment, if movement

https://t.me/med1917

is not synchronized, or if movement substitutions are present. When making a st, the ngertips should point toward the scaphoid tubercle at the base of the thenar eminence. Compare all observations with the uninvolved side. Other functional movements include the following:

•

ability to open the hand (MP and IP joints extension) (Fig- ure 10A), hook st: requires lumbrical muscle extensibility and maxi-

• mal dierential gliding between the FDS and FDP tendons

(Figure 10B),

• straight st: elicits maximum FDS tendon gliding

(Figure

10C),

• full (composite) st: elicits maximum FDP tendon gliding in

relation to surrounding structures

•

cylindrical (holding a can) and spherical (holding a ball) grips, key (lateral), tip, and 3-point pinch (require ulnar, AIN, and

•

(Figure 10D),

median nerve function, respectively), and

Figure 10.

Four Stage Tendon Gliding

A B

C D

A, Open hand/start position. B, Hook st. C, Straight st. D, Full st.

• opposition of the thumb to the ngertip of each nger and the distal palmar crease (requires median nerve function).

Following the general movement screening, continue with a more detailed examination using goniometric measurements. e ROM assessment should provide data on overall joint mobility, muscle and tendon function, tendon excursion, tendon length or tightness, and associated symptoms. Compare values to the opposite side and published normal values and compare active ROM (AROM) values with passive ROM (PROM) values. Normally, PROM is slightly greater than AROM. If PROM exceeds AROM by more than 10°, there is likely weakness or tendon adhesions. Other reasons could be due to pain or fear of movement. When AROM and PROM are similar and accompanied by a capsular end-feel, there may be a joint or capsular restriction. e absence of exion AROM at a DIP joint could be a result of a exor tendon rupture, such as a jersey nger, whereas absent extension AROM at the DIP joint may be indicative of an extensor tendon rupture.

One may also choose to measure isolated, or single joint motion to eliminate the inuence of soft tissue structures (eg, tendons) that cross multiple joints. Measure isolated or single joint ROM by positioning the joints adjacent to the one being measured in positions that relax the interconnecting soft tissue structures. To measure nger ROM, the therapist uses a nger goniometer on the dorsum of the nger or hand with the axis over the joint being measured and asks the patient to ex and extend the nger. If using a small standard goniometer, rather than a nger goniometer, one may choose to place it on the radial or ulnar aspect of the nger, aligning the goniometer axis with the axis of the joint being measured and the stationary and moving arms with the adjacent phalanges. Document the position of the goniometer if there is any deviation from the standard goniometric measurement procedures.

Measure wrist exion and extension with the ngers relaxed to avoid confounding results due to tightness of the nger extensors (which limits wrist exion) or nger exors (which limits wrist extension). e most accurate goniometric method to measure wrist exion and extension is the dorsal/volar method (Figure 11).

Additional measures include ulnar and radial deviation and forearm supination and pronation. Researchers have reported dierent methods for measuring forearm supination

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 3738 / 5038 39 40 41 42 43 44 45 46 47 48 49 50 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
05.09.202618 Мб0Книга_1157_Библиотеки_им_академика_М_И_Перельмана.pdf
#
05.09.202618 Мб0Книга_1158_Библиотеки_им_академика_М_И_Перельмана.pdf
#
05.09.202618 Мб0Книга_1160_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.2026101 Мб0Книга_136_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.202691 Мб0Книга_137_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.202687 Мб0Книга_138_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202674 Мб0Книга_139_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202672 Мб0Книга_140_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202671 Мб0Книга_141_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202665 Мб0Книга_142_библиотеки_им_акад_М_И_Перельмана.pdf
#
30.08.202656 Мб0Книга_143_библиотеки_им_акад_М_И_Перельмана.pdf