Chapter 7

Structure and Function of the Hand

Copyright 2014, 2009 by Mosby, an imprint of Elsevier Inc.
Osteology: Metacarpals
Metacarpals are designated numerically as 1 through
5, beginning on the radial side
Each metacarpal has a base, shaft, head, and neck
First (thumb) metacarpal is shortest and thickest
Second is usually longest
Remaining three bones bone lengths decrease from
the radial to ulnar (medial) direction
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Osteology: Metacarpals contd
With hand in anatomic position, the thumb's
metacarpal is rotated almost 90 degrees medially,
relative to other digits
Second through fifth metacarpals are aligned
generally side by side, with palmar surfaces facing
anteriorly
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Osteology: Metacarpals contd
Terminology describing surfaces of carpal bones and
finger bones (except thumb) is standard: palmar
surface faces anteriorly, radial surface faces laterally,
etc.
Dorsal surface of thumb faces laterally
Palmar surface faces medially
Radial surface faces anteriorly
Ulnar surface faces posteriorly
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Osteology: Phalanges
The hand has 14 phalanges
Phalanges within each finger referred to as proximal,
middle, and distal
Thumb has only proximal and distal phalanx
Except for differences in sizes, all phalanges within a
particular digit have similar morphology
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Osteology: Arches of the Hand
Proximal transverse arch
Formed by distal row of carpal bones
Static, rigid arch that forms carpal tunnel
Capitate bone is keystone of this arch
Longitudinal arch
Follows general shape of second and third rays
Articulations provide longitudinal stability to hand

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Osteology: Arches of the Hand contd
Distal transverse arch
Passes through MCP joints
Sides of distal arch are mobile
Transverse flexibility occurs as peripheral metacarpals "fold"
around central metacarpals
Keystone formed by MCP joints of these central metacarpals
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Arthrology: Hand Terminology
Finger movements using cardinal planes
Flexion and extension occur in sagittal plane
Abduction and adduction occur in frontal plane
Abduction and adduction of fingers is described as motion
toward (adduction) or away (abduction) from middle finger


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Arthrology: Terminology for Thumb
Flexion is movement of palmar surface of thumb in
frontal plane across and parallel with palm
Extension returns thumb back to anatomic position
Abduction is forward movement of thumb away from
palm in a sagittal plane
Adduction returns thumb to plane of hand
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Arthrology:
Terminology for Thumb contd
Opposition describes movement of thumb across
palm, making direct contact with tips of any fingers
Terminology serves as basis for naming of thumb
muscles
e.g., opponens pollicis, extensor pollicis longus
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Arthrology: Carpometacarpal Joints
Form articulation between distal row of carpal bones
and bases of metacarpal bones
Positioned at proximal region of hand
Basis for all hand movements starts at CMC joints, at
most proximal region of each ray
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Arthrology:
Carpometacarpal Joints contd
First CMC joint is most mobile
Fourth and fifth CMC joints are next-most-mobile
CMC joints
Increased mobility of fourth and fifth CMC joints
improves grasp effectiveness and functional
interaction with opposing thumb
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Arthrology: Carpometacarpal
Joint of Thumb contd
CMC joint of thumb located at base of first ray,
between metacarpal and trapezium
Most complex of CMC joints, enabling extensive
thumb movements
Saddle shape allows thumb to fully oppose and
encircle objects held within palm
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Arthrology: Carpometacarpal
Joint of Thumb contd
Capsule surrounding joint is naturally loose, allowing
a large range of motion
Capsule is strengthened by stronger ligaments and
forces produced by overriding musculature
Ligament rupture often causes joint dislocation,
forming a hump at base of thumb

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Arthrology: Carpometacarpal
Joint of the Thumb contd
CMC joint of thumb is saddle joint
Each articular surface is convex in one dimension
and concave in otherlike saddle on horse
This shape allows a maximum of combined mobility
and stability
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Kinematics: Carpometacarpal
Joint of the Thumb contd
Motions occur primarily in 2 degrees of freedom
Abduction and adduction generally occur in sagittal
plane
Flexion and extension generally occur in frontal plane
Opposition and reposition of thumb incorporate two
primary planes of motion
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Kinematics: Abduction and Adduction
In neutral adduction position, thumb lies within plane
of hand
Maximum abduction positions thumb metacarpal
about 45 degrees anterior to plane of palm
Full abduction forms wide concave curvature, useful
for grasping objects
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Kinematics: Flexion and Extension
Performing flexion and extension of CMC thumb joint
is associated with varying amounts of metacarpal
spinning
During flexion, metacarpal rotates slightly medially
During extension, metacarpal rotates slightly laterally

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Kinematics: Flexion and Extension contd
Axial rotation is evident by watching change in
orientation of thumbnail between full extension and
full flexion
In anatomic position, CMC joint can be extended an
additional 10-15 degrees
From full extension, thumb metacarpal flexes across
palm about 45-50 degrees
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Kinematics: Opposition
First, thumb metacarpal abducts
Next, abducted metacarpal flexes and medially
rotates across palm toward small finger
Muscle force helps guide and rotate metacarpal to
extreme medial side of articular surface of trapezium
Small finger contributes indirectly to opposition,
allowing tip of thumb to more easily contact tip of
small (little) finger

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Metacarpophalangeal Joints: Fingers
Knuckles of fingers are articulations formed
between convex heads of metacarpals and shallow
concave proximal surfaces of proximal phalanges
Motion at MCP joint occurs predominantly in two
planes: flexion and extension in sagittal plane, and
abduction and adduction in frontal plane
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Metacarpophalangeal Joints:
Supporting Structures
Capsule
Connective tissue that surrounds and stabilizes MCP joint
Radial and ulnar collateral ligaments
Cross MCP joints in an oblique palmar direction; limit
abduction and adduction; become taut on flexion
Fibrous digital sheaths
Form tunnels or pulleys for extrinsic finger flexor tendons;
Contain synovial sheaths to help lubrication
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Metacarpophalangeal Joints:
Supporting Structures contd
Palmar (or volar) plates
Thick fibrocartilage ligaments crossing palmar side of each
MCP joint
Limit hyperextension of MCP joints
Deep transverse metacarpal ligaments
Merge into wide, flat structure that interconnects and loosely
binds second through fifth metacarpals
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Finger Kinematics: Flexion
Controlled by flexor digitorum superficialis and flexor
digitorum profundus
Stretches and increases tension in dorsal part of
capsule and collateral ligaments, stabilizing joint in
flexion, useful during grasp
Kinematics of extension occurs in reverse
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Finger Kinematics: Abduction
Proximal phalanx rolls and slides in radial direction
Kinematics of adduction of MCP joints occurs in
reverse fashion
Radial collateral ligament becomes taut
Ulnar collateral ligament slackens
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Thumb Kinematics
Active and passive motions at MCP joint of thumb are
significantly less than fingers
MCP joint of thumb allows only 1 degree of freedom:
flexion and extension within frontal plane
Active abduction and adduction of thumb MCP joint is
limited and considered an accessory motion
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Interphalangeal Joints
Proximal interphalangeal (PIP) joints
Formed by articulation between heads of proximal
phalanges and bases of middle phalanges
Distal interphalangeal (DIP) joints
Formed through articulation between heads of middle
phalanges and bases of distal phalanges
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Interphalangeal Joints contd
Articular surface appears as tongue-in-groove
articulation
Articulation helps limit motion at PIP and DIP joints to
flexion and extension only
Same ligaments that surround MCP joints also
surround PIP and DIP joints
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Interphalangeal Joints: Kinematics
Flexion at PIP and DIP joints is greater in more ulnar
digits
Similarities in joint structure cause similar roll-and-
slide arthrokinematics at PIP and DIP joints
Passive tension in collateral ligaments remains
constant throughout range of motion

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Interphalangeal Joint:
Thumb Kinematics
Motion is limited primarily to 1 degree of freedom,
allowing active flexion to about 70 degrees
IP thumb joint can be passively hyperextended
beyond neutral to about 20 degrees
This motion is often employed to apply force between
pad of thumb and object
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Innervation to Hand
Radial, median, and ulnar nerves innervate skin,
joints, and muscles of hand
Normal sensory innervation is essential for protection
of hand against mechanical and thermal injury
Persons with peripheral neuropathy are thus
vulnerable to injury

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Extrinsic Flexors of Digits
Extrinsic flexor muscles of digits are flexor digitorum
superficialis, flexor digitorum profundus, and flexor
pollicis longus
These muscles originate primarily from medial
epicondyle of humerus and palmar surfaces of radius
and ulna
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Extrinsic Flexors of Digits:
Flexor Digitorum Superficialis
Proximal attachments
Common flexor tendon on medial epicondyle of humerus,
coronoid process of ulna, and radius
Distal attachment
Four tendons, each to the sides of middle finger phalanges
Innervation
Median nerve
Actions
MCP and PIP joint flexion
Wrist flexion
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Extrinsic Flexors of Digits:
Flexor Digitorum Profundus
Proximal attachments
Anterior ulna and interosseous membrane
Distal attachment
By four tendons, each to the base of the distal phalanx of
digits 2-5
Innervation
Medial half: ulnar nerve; lateral half: median nerve
Actions
MCP, PIP, and DIP joint flexion, wrist flexion
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Extrinsic Flexors of Digits:
Flexor Pollicis Longus
Proximal attachments
Middle anterior portion of radius and interosseous
membrane
Distal attachment
Base of distal phalanx of thumb
Innervation
Median nerve
Actions
CMC, MCP, and IP joint flexion, wrist flexion
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Flexor Pulleys
Embedded within each fibrous digital sheath
Surround flexor tendons, providing them with nutrition
and lubrication
Following tendon injury, adhesions may develop
between tendon and adjacent digital sheath or
between adjacent tendons
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Passive Finger Flexion
via Tenodesis Action
Extrinsic flexors of digits cross over anterior side of
wrist, and wrist position alters amount of stretch
placed on these muscles
Stretching multi-articular muscle at one joint creates
passive movement at another joint and is referred to
as tenodesis action of muscle
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Extrinsic Extensors of Fingers
Extensor tendons do not attach directly to phalanges
but blend with extensor mechanism
Proximal end of extensor mechanism is the dorsal
hood, which wraps completely around MCP joint
Extensor mechanism serves as primary distal
attachment for both extensor muscle tendons and
intrinsic muscles of fingers
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Extrinsic Extensors of Fingers:
Extensor Digitorum
Proximal attachments
Lateral epicondyle of humeruscommon extensor tendon
Distal attachment
Four tendons, each to base of extensor mechanism and base
of proximal phalanx of all four fingers
Innervation
Radial nerve
Actions
Extension of MCP, PIP, and DIP joints
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Extrinsic Extensors of Digits:
Extensor Indicis
Proximal attachments
Posterior surface of distal ulna and interosseous membrane
Distal attachment
Blends with index tendon of extensor digitorum
Innervation
Radial nerve
Actions
Extension of MCP, PIP, and DIP joints of index finger
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Extrinsic Extensors of Fingers:
Extensor Digiti Minimi
Proximal attachments
Ulnar side of belly of extensor digitorum
Distal attachment
Joins tendon of extensor digitorum to little finger
Innervation
Radial nerve
Actions
Extension of MCP, PIP, and DIP joints of little finger
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Extrinsic Extensors of Thumb
Extrinsic extensors of thumb are extensor pollicis
longus, extensor pollicis brevis, and abductor pollicis
longus
Tendons of these muscles make up anatomic
snuffbox on radial side of wrist
Tendons attach to different regions of dorsal side of
thumb; may have secondary actions
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Extrinsic Extensors of Thumb:
Extensor Pollicis Longus
Proximal attachments
Posterior surface of mid-ulna and interosseous membrane
Distal attachment
Dorsal base of distal phalanx of thumb
Innervation
Radial nerve
Actions
Extension of IP, MCP and CMC joints of thumb
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Extrinsic Extensors of Thumb:
Extensor Pollicis Brevis
Proximal attachments
Posterior aspect of distal radius and interosseous membrane
Distal attachment
Dorsal base of proximal phalanx of thumb
Innervation
Radial nerve
Actions
Extension of MCP and CMC joints of thumb
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Extrinsic Extensors of Thumb:
Abductor Pollicis Longus
Proximal attachments
Posterior surface of mid-radius, ulna, and interosseous
membrane
Distal Attachment
Base of the metacarpal of the thumbdorsal-radial aspect
Innervation
Radial nerve
Actions
Abduction and extension of CMC joint of thumb
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Intrinsic Muscles of Hand
Muscles of thenar eminence
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
Muscles of hypothenar eminence
Flexor digiti minimi
Abductor digiti minimi
Opponens digiti minimi

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Intrinsic Muscles of Hand contd
Adductor pollicis
Lumbricals and interossei (intrinsic muscles of
fingers)

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Intrinsic Muscles of Hand:
Muscles of Thenar Eminence
All three muscles are proximally attached on
transverse carpal ligament and adjacent carpal bones
Short abductor and flexor attach to base of proximal
phalanx of thumb
Deeper opponens muscle attaches along radial
border of first metacarpal
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Intrinsic Muscles of Hand:
Muscles of Thenar Eminence contd
Primary responsibility of muscles of thenar eminence
is to position thumb in varying amounts of opposition
Each muscle within thenar eminence is prime mover
for at least one component of opposition
Opponens pollicis is especially important in its ability
to medially rotate thumb toward fingers
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Intrinsic Muscles of Hand:
Muscles of Hypothenar Eminence
Flexor digiti minimi, abductor digiti minimi, and
opponens digiti minimi
Proximal attachments on transverse carpal ligament
and adjacent carpal bones
Short abductor and flexor attach distally on base of
proximal phalanx of small finger
Opponens digiti minimi has its distal attachment
along ulnar border of fifth metacarpal
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Intrinsic Muscles of Hand:
Muscles of Hypothenar Eminence contd
Common function of hypothenar muscles: raise and
curl ulnar border of hand
This action deepens distal transverse arch and
enhances contact with held objects
Injury to ulnar nerve can completely paralyze
hypothenar muscles
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Intrinsic Muscles of the Hand:
Adductor Pollicis
Two-headed muscle lying in the web space of the
thumb
Proximal attachments
The capitate bone, second and third metacarpals
Distal attachment
Base of the proximal phalanx of the thumb
Important for activities involving pinching objects
between the thumb and index finger, and for actions
used to close a pair of scissors
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Intrinsic Muscles of Hand:
Lumbricals
Four very slender muscles originating from tendons
of flexor digitorum profundus
Distally, lumbricals do not attach to bone but to lateral
bands of extensor mechanism
These muscles flex MCP joints and extend PIP and
DIP joints
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Intrinsic Muscles of Hand:
Interossei
Named according to their location between
metacarpal bones
Include palmar and dorsal sets
Both sets contain four individual muscles, originating
on medial or lateral shafts of metacarpals
Dorsal interossei are larger and responsible for
fullness of shape of dorsal side of hand
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Intrinsic Muscles of Hand:
Interossei contd
All eight are innervated by ulnar nerve
Primary function is to abduct or adduct fingers
Dorsal interossei abduct fingers at MCP joint away
from an imaginary reference line through middle digit
Middle digit has two dorsal interosseous muscles:
one that radial deviates and one that ulnar deviates

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Intrinsic Muscles of Hand:
Interossei contd
Palmar interossei adduct fingers at MCP joints
toward middle digit
Palmar and dorsal interossei have line of force that
passes palmar to MCP joints
They flex MCP joints and extend PIP and DIP joints
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Opening Hand: Finger Extension
Extensor digitorum exerts force on extensor
mechanism, pulling MCP joint toward extension
Flexion torque is produced at MCP joint
This flexion torque prevents extensor digitorum from
hyperextending MCP joint
Only with MCP joint blocked from being hyperextended can
extensor digitorum effectively tense bands of extensor
mechanism
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Closing Hand: Finger Flexion
Flexing fingers against resistance or at high speed
requires activation of flexor digitorum profundus,
flexor digitorum superficialis, and, to a lesser extent,
interossei muscles
Force produced by flexor digitorum profundus and
superficialis flex all three joints of fingers
Lumbricals may exert a passive flexion torque at
MCP joint
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Functional Consideration:
Wrist Extensors during Finger Flexion
Making a strong fist requires equally strong
synergistic activation from wrist extensor muscles
Wrist extensor activity can be verified by palpating
dorsum of forearm while making fist
If wrist extensors are paralyzed, attempts at making
fist result in posture of wrist flexion and finger
flexiona weak and ineffective action
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Common Deformities
Deformity of hand is often caused by disease or
trauma that disrupts balance of forces around joints
Three types of deformities are typical in hand with
severe rheumatoid arthritis
Ulnar drift
Swan-neck deformity
Boutonniere deformity
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Summary
Joints of hand are organized into three sets of
articulations: carpometacarpal, metacarpophalangeal,
and interphalangeal
MCP joints form base of each digit
IP joints flex and extend only; other potential planes
of motion are blocked by bony fit of joint and by
periarticular connective tissues
Simultaneous extension of all three joints of fingers
requires coordinated interplay among muscles
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