Chapter 13: Hand

Quizlet link: https://quizlet.com/_94517z?x=1qqt&i=ajnew

1. Describe joint motions that occur at thumb in terms of appropriate plane and axis, and
the range of degrees of normal motion at these joints.

● The Carpometacarpal Joint

o The Carpometacarpal Joint is made up of the trapezium bone, which articulates with the base of
the first metacarpal 
o The carpometacarpal joint is most commonly described as a modified biaxial saddle joint.
o The shape of the inferior surface of the top chip is similar to the shape of the first metacarpal; the
shape of the superior surface of the bottom chip is similar to the trapezium bone.
▪ Each surface is concave in one direction and convex in the other.
o Rotation is an accessory movement
o CMC joint of the thumb allows more mobility than the other four fingers yet provides as much stability. 
o During flexion and extension concave base of the first metacarpal glides in the same direction as
the distal end of the metacarpal (concave-on-convex articulation).
▪ When flexion occurs, the base of the metacarpal glides medially while the distal end of
the metacarpal also glides medially.
▪ During extension, the base glides laterally, along with lateral movement of the distal
metacarpal.
o When abduction and adduction (sagittal plane motion) occur, the convex base of the first
metacarpal glides on the concave trapezium in the opposite direction from the distal end of the
metacarpal (convex-on-concave articulation).
▪ During abduction, the distal end of the metacarpal moves anteriorly while the base of the
metacarpal glides posteriorly
▪ During adduction, the posterior movement of the distal end of the metacarpal with an
anterior glide of the base.

● The Metacarpophalangeal Joint

o The MCP joint is a hinge joint that allows only flexion and extension, and is therefore a uniaxial
joint.

● The Interphalangeal Joint

o The IP joint, the only phalangeal joint of the thumb, also allows only flexion and extension. Note
that phalanx is singular, and phalanges is plural.

● Arthrokinematically
o Both the MCP and IP joints have a concave-on-convex articulation
▪ the concave base on the proximal end of the distal segment articulates with the convex
head on the distal end of the proximal segment.
▪ This concave-on-convex articulation causes the concave joint surface to glide in the same
direction as the distal end of the bony segment during movement.
2. Describe joint motions that occur at the fingers in terms of appropriate plane and axis,
and the range of degrees of normal motion at these joints.
● The second, third, fourth, and fifth digits, commonly known as the index, middle, ring, and little
fingers, respectively, have four joints each.
o These joints are the CMC joint, MCP joint, proximal interphalangeal (PIP) joint, and distal
interphalangeal (DIP) joint 

● The Carpometacarpal Joints

o The CMC joints of the fingers (digits 2 to 5) are classified as nonaxial, plane-shaped synovial joints
▪ The CMC joints of fingers 2-5 provide slight gliding motion.
▪ The CMC joints of fingers 2-5 provide more stability than mobility.
o The trapezoid articulates with the base of the second metacarpal,
o The capitate with the base of the third metacarpal
o The hamate with the bases of the fourth and fifth metacarpals
▪ The fifth CMC joint is the most mobile of the fingers because of its more condyloid shape,
which allows for a small amount of fifth finger opposition. 
▪ The fifth CMC joint does not, however, allow as much opposition as the thumb (the first CMC
joint).
● The Metacarpophalangeal Joints
o The Metacarpophalangeal Joints of the fingers are formed by the concave-shaped bases of the
proximal phalanges articulating with the convex, rounded heads of the metacarpals
o The Metacarpophalangeal Joints of the fingers are commonly referred to as the “knuckles.”
o The Metacarpophalangeal Joints of the fingers are biaxial condyloid joints with two degrees of
freedom, allowing flexion, extension, and hyperextension, plus abduction and adduction
o The middle finger is the point of reference for abduction and adduction. 
▪ Abduction occurs when the second, fourth, and fifth fingers move away from the middle (third)
finger. 
▪ Adduction is the return from abduction and occurs with the second, fourth, and fifth fingers.
● There is no adduction of the middle finger, only abduction occurring in either direction.
o The Metacarpophalangeal Joints have a concave-on-convex articulation
▪ Concave base of the proximal phalanges will move in the same direction as the distal end of the
proximal phalanges during movement.
▪ During Flexion, the base and distal end of the proximal phalanx glides anteriorly
▪ During Extension, the base and distal end of the proximal phalanx glides posteriorly
▪ During Adduction, the base and distal end of the proximal phalanx glides, medially
● (toward the midline of the hand)
▪ During Abduction, the base and distal end of the proximal phalanx glides laterally
● (away from the midline of the hand)
● The Interphalangeal Joints(2)
o The Proximal Interphalangeal Joint
▪ The Proximal Interphalangeal Joint is the articulation between the base of the middle phalanx
and the head of the proximal phalanx.
o Distal Interphalangeal Joint
▪ The Distal Interphalangeal Joint is formed by the base of the distal phalanx articulating with
the head of the middle phalanx.
o Both the Proximal Interphalangeal Joint and Distal Interphalangeal Joint are uniaxial hinge
joints allowing only flexion and extension, which occurs in the sagittal plane.
▪ Proximal and Distal Interphalangeal Joint are all concave-on-convex articulations, with the
mechanics of their arthrokinematic movements being identical to that of the IP joint of the
thumb.
1. Identify key bones and bony landmarks of the hand.

 The hand is made up of:

o One thumb and Four fingers
▪ Five metacarpals
▪ Five proximal phalanges
▪ Five distal phalanges
▪ Four middle phalanges
o The Hand has 8 different carpal bones

 Carpal bones in the Proximal Row

o Scaphoid
▪ The scaphoid is the #1 most commonly fractured carpal bone
▪ The scaphoid is the largest bone in the proximal row of carpals
▪ The scaphoid has a prominent scaphoid tubercle
o Lunate
▪ The lunate articulates proximally with the radius
o Triquetrum
▪ The triquetrum articulates proximally with the articular disc
o Pisiform
▪ The pisiform is located on top of the triquetrum

 Carpal bones in the Distal Row

o Trapezium articulates with the 1st metacarpal
o Trapezoid articulates with the 2nd metacarpal
o Capitate articulates with the 3rd metacarpal
o Hamate articulates with the 4th and 5th metacarpal
o Hook of Hamate

● There are no significant landmarks on these bones other than the bone ends.
o The proximal end of the metacarpals and phalanges is called the base
▪ It should be noted that the bases of all phalanges are concave
o The distal end the metacarpals and phalanges is called the head. 
▪ The heads of all phalanges and metacarpals are convex.

● Oblique Line
o There is one indistinct landmark on the forearm, the oblique line which is sometimes referred to
when describing muscle attachments.
o The oblique line located on the anterior surface of the radius from below the tuberosity, running
diagonally to approximately midradius
3. Recognize the joints, primary ligaments, and other structures that comprise the hand. 

● Flexor Retinaculum 
o The Flexor Retinaculum is a fibrous band of connective tissue that spans the anterior surface of the
wrist in a horizontal direction. 
o The Flexor Retinaculum attaches to the styloid processes of the radius and ulna and crosses over the
flexor muscle tendons. 
o Main function of the Flexor Retinaculum is to hold these tendons close to the wrist, preventing the
tendons from pulling away (bowstringing) when the wrist flexes. 
o The Flexor Retinaculum also prevents the two sides of the carpal bones from spreading apart or
separating. 
o The Flexor Retinaculum is known as a “Tie beam”.
o The Flexor Retinaculum distal border merges with the transverse carpal ligament. 
● Palmar Carpal Ligament
o The Palmar Carpal Ligament is more proximal and superficial than the transverse carpal ligament
o The Palmar Carpal Ligament attaches to the styloid processes of the radius and ulna and crosses over
the flexor muscle tendons. 
● Transverse Carpal Ligament
o The transverse carpal ligament lies deeper and more distally. 
o The transverse carpal ligament attaches to the pisiform and hook of the hamate on medial side and to
the scaphoid and trapezium laterally. 
o The transverse carpal ligament arches over the carpal bones, forming a tunnel through which the
medial nerve and nine extrinsic flexor tendons pass. 
● Cross section of the hand pic.
o Carpal tunnel: bottom is carpal bones and top is transverse carpal ligament. 
▪ Median nerve, flexor policis longus tendon, flexor digitorum superficialis tendons, and flexor
profundus tendons all pass through this carpal tunnel. 
● Extensor Retinaculum Ligament
o The Extensor Retinaculum Ligament fibrous band traversing the posterior side of the wrist in a
horizontal mediolateral direction. 
o The Extensor Retinaculum Ligament attaches medially to the styloid process of ulna and to the
triquetrum, pisiform, and lateral side of radius. 
o The Extensor Retinaculum Ligament holds the extensor tendons close to the wrist during wrist
extension.
● The Extensor Expansion Ligament
o The Extensor Expansion Ligament is also called the extensor hood
o The Extensor Expansion Ligament is a small, triangular, flat aponeurosis covering the dorsum and
sides of the proximal phalanx of each finger. 
o Extensor digitorum tendon blends into the Extensor Expansion Ligament. 
o The Extensor Expansion Ligament is wider at its base over the MCP joint, wrapping over the sides. 
o As the Extensor Expansion Ligament approaches the PIP joint, the extensor expansion is joined by
tendons of lumbricals and interosseous muscles. 
o The Extensor Expansion Ligament narrows toward the distal end at base of distal phalanx. 
o Extensor digitorum, lumbricals, and interosseous muscles form an attachment to middle or distal
phalanx by way of this expansion. 
o The extensor hood area, formed by extensor expansion proximally, covers the head of the metacarpal
and keeps the extensor tendon in the midline. 
●
● (From video) Extensor Hood (extensor mechanism)- 
o Extensor Hood covers the MCP, PIP, and DIP. 
o Sagittal bands on either side of MCP. 
o Central Slip crosses PIP and inserts into P2 and extends at PIP joint. 
o Soft tissue on either side of PIP joint called lateral bands that merge together and form terminal tendon
that cross DIP and inserts on P3 and is responsible for extension at DIP. 
o FDP and FDS on posterior side of fingers. 
o Extensor Hood Function- 
o flexion of MPJ and extension of IPJs

● Arches of The Hand

o When the hand is relaxed, the palm assumes a cupped position.
o This palmar concavity is due to the arrangement of the bony skeleton reinforced by ligaments.
o There are three arches that are responsible for this shape
o Proximal Carpal Arch
▪ The proximal carpal arch is formed by the proximal end of the metacarpals (base) and carpal
bones and is maintained by the flexor retinaculum
o Distal Carpal Arch
▪ The shallower distal carpal arch is made up of the metacarpal heads.
o Longitudinal Arch
▪ The longitudinal arch begins at the wrist and runs the length of the metacarpal and phalanges
for each digit. It is perpendicular to the other two arches.

 .

 Muscles of the Thumb and Fingers
o Any muscle spanning the anterior aspect of the finger or the anteromedial aspect of the thumb will pull
the anterior surfaces together, causing flexion.
o Muscles crossing the posterior aspect of the fingers or the posterolateral aspect of the thumb will cause
extension.
o It is helpful to keep some generalizations in mind when learning the muscles of the hand.
 First, their names give much information about function and location.
 For example, it is rather easy to distinguish the muscles having a function on the thumb
because pollicis means “thumb” and digitorum means “digits (fingers)” in Latin.
 Second, if the muscle has “longus” in its name, it implies that there is a counterpart “brevis”
muscle.
 The “longus” muscle either runs out to the distal phalanges or originates more proximally
than its “brevis” counterpart.
 Third, keep in mind that a muscle can only move the joints it crosses.
 By looking at the specific joints that each hand muscle crosses, we can determine at what
joints a muscle will have an action.
4. Describe the muscle origin, insertion, action, and nerve innervations of selected
extrinsic muscles of the hand. 

 Extrinsic Muscles
o These muscles are called extrinsic muscles of the hand because their proximal attachment is above,
or proximal to, the wrist joint.
 They have an assistive role in wrist function
 The primary function of the entrinsic muscles is at the thumb or finger.
 Because they cross the wrist, they could have a function there; however, any wrist function is
usually assistive at best.
 The prime function of the extrinsic muscles is in moving the fingers or thumb.
 Usually the muscle is strongest at the most distal joint it moves.
o Anterierior Extrensic Muscles
 Flexor Digitorum Superficialis Muscle
 Flexor Digitorum Profundus Muscle
 Flexor Pollicis Longus Muscle
o Posterior Extrinsic Muscles
 Abductor Pollicis Longus Muscle
 Extensor Pollicis Brevis Muscle
 Extensor Pollicis Longus Muscle
 Extensor Digitorum Muscle
 Extensor Indicis Muscle
 Extensor Digiti Minimi Muscle

 Flexor Digitorum Superficialis Muscle

o The flexor digitorum superficialis muscle lies deep to the wrist flexors and palmaris longus muscle
o The flexor digitorum superficialis muscle’s broad proximal attachment is part of the common
flexor tendon on the medial epicondyle of the humerus.
o The flexor digitorum superficialis muscle has an attachment on the coronoid process of the ulna
and the oblique line of the radius.
o The flexor digitorum superficialis muscle divides into four tendons and crosses the wrist with one
tendon going to each finger.
 Each distal attachment splits into two parts and attaches on each side of the middle phalanx of
each finger
o The primary action of the flexor digitorum superficialis muscle is to flex the PIP and then MCP
joints of the second through fifth fingers.
 This is an important muscle in the power grip.

 Flexor Digitorum Profundus Muscle

o The flexor digitorum profundus muscle lies deep to the flexor digitorum superficialis muscle;
these two muscles traverse the forearm and hand together
o The flexor digitorum profundus muscle has its proximal attachment on the ulna on the anterior and
medial surfaces, from the coronoid process to approximately three-fourths of the way down the ulna.
o The flexor digitorum profundus muscle  runs beneath the flexor digitorum superficialis muscle
until the superficialis tendon splits into two parts at its distal attachment.
o The flexor digitorum profundus muscle tendon passes through this split and continues distally to
attach at the base of the distal phalanx of the second through fifth fingers
o The action of the flexor digitorum profundus muscle is to flex the DIP, then the PIP and MCP
joints of the second through fifth fingers.
o The flexor digitorum profundus muscle is the only muscle that flexes the DIP joints.
 Flexor Pollicis Longus Muscle 
o The flexor pollicis longus muscle is a deep muscle that has its proximal attachment on the anterior
surface of the radius and interosseus membrane
o The flexor pollicis longus muscle’s distal attachment at the base of the thumb’s distal phalanx
o The flexor pollicis longus muscle is a prime mover in flexion of the IP joint of the thumb.
o The flexor pollicis longus muscle is the only muscle to do so.
o The flexor pollicis longus muscle also flexes the MCP and CMC joints of the thumb.

 Adductor Pollicis Longus Muscle

o The abductor pollicis longus muscle is located deep on the posterior forearm
o The abductor pollicis longus muscle attaches to the radius just distal to the supinator, the
interosseus membrane, and the middle portion of the ulna.
o The abductor pollicis longus muscle becomes superficial just proximal to crossing the wrist
and attaches to the base of the first metacarpal on the radial side.
o Although the abductor pollicis longus crosses the thumb’s MCP joint, the abductor pollicis longus
muscle it only abducts the CMC joint because the MCP joint allows only flexion/extension.
o The thumb moves as one unit in the direction of abduction and adduction.
o Similarly, abduction of the thumb’s CMC joint adducts the entire thumb.
o Therefore, in this text, when referring to thumb abduction, adduction, opposition, and reposition, it is
implied that the action occurs at the CMC joint.
o Without the abductor pollicis longus, the thumb cannot be moved away from the palm
o The abductor pollicis longus muscle also has a secondary action of extending the thumb.

 Extensor Pollicis Brevis

o The extensor pollicis brevis muscle is also located deep on the posterior forearm and spans the
wrist just medial to the abductor pollicis longus muscle.
o The extensor pollicis brevis muscle’s proximal attachment is on the posterior radius near the distal
end and just below the abductor pollicis longus muscle.
o The extensor pollicis brevis muscle’s distal attachment is on the posterior surface at the base of the
thumb’s proximal phalanx (Fig. 13-16).
o The extensor pollicis brevis muscle functions to extend the MCP and CMC joints of the thumb.
 Without the function of the extensor pollicis brevis muscle muscle, the thumb MCP joint
remains in a flexed position.

 Extensor Pollicis Longus Muscle

o The extensor pollicis longus muscle is located near the two previously mentioned muscles, deep on
the posterior forearm.
o The extensor pollicis longus muscle’s proximal attachment is on the middle third of the ulna and
interosseus membrane
o Like the other two muscles, the extensor pollicis longus muscle  becomes superficial just before
crossing the wrist.
o The extensor pollicis longus muscle’s distal attachment is at the base of the thumb’s distal phalanx,
on the posterior side.
o The extensor pollicis longus muscle functions to extend the IP, MCP, and CMC joints of the
thumb.
o We use The extensor pollicis longus muscle to pull the thumb back when a flat and open hand is
needed.
 An example of this is clapping.
 Anatomical Snuffbox
o If you extend your thumb, you will notice that a depression is formed between what appears to be
two tendons.
o Actually, there are three tendons.
o The abductor pollicis longus and extensor pollicis brevis muscles form the lateral border, and the
extensor pollicis longus muscle forms the medial border.
o This depression is called the anatomical snuffbox 

 Extensor Digitorum Muscle

o The extensor digitorum muscle is a superficial muscle on the posterior forearm and hand.
o The extensor digitorum muscle attaches proximally to the lateral epicondyle of the humerus as part
of the common extensor tendon.
o The extensor digitorum muscle passes under the extensor retinaculum to attach distally on the
distal phalanx of the second through fifth fingers via the extensor expansion
o In the area of the metacarpals are interconnecting bands joining the four extensor digitorum tendons.
 These interconnecting bands limit independent finger extension.
o The extensor digitorum muscle is the only common extensor muscle of the fingers.
o The extensor digitorum muscle extends the DIP, PIP, and MCP joints of the second, third, fourth,
and fifth fingers.

 Extensor Indicis Muscle

o The extensor indicis muscle is a deep muscle that has its proximal attachment on the posterior
surface of the distal ulna
o The extensor indicis muscle  crosses the wrist under the extensor retinaculum medial to the
extensor digitorum muscle
o The extensor indicis muscle attaches into the extensor expansion of the second finger along with
the extensor digitorum muscle.
o The extensor indicis muscle extends the DIP, PIP, and MCP joints of the index finger.
 This allows us to point with our index finger while the other fingers are in a fist.

 Extensor Digiti Minimi Muscle

o The extensor digiti minimi muscle is a long, narrow muscle that is deep to the extensor digitorum
and extensor carpi ulnaris muscles near its proximal attachment.
o The extensor digiti minimi muscle becomes superficial before crossing the wrist.
o The extensor digiti minimi muscle comes off the common extensor tendon on the lateral
epicondyle of the humerus, crosses the wrist under the extensor retinaculum
o The extensor digiti minimi muscle attaches to the base of the distal phalanx of the fifth finger via
the extensor expansion.
o The extensor digiti minimi muscle is a prime mover in extending the DIP, PIP, and MCP joints of
the fifth finger.
o The extensor digiti minimi muscle  makes possible isolated extension of the fifth finger.
5. Describe the muscle origin, insertion, action, and nerve innervations of selected
intrinsic muscles of the hand. 

● The intrinsic muscles of the hand are located in five compartments

● In the thenar compartment:
● Abductor pollicis brevis
● Flexor pollicis brevis
● Opponens pollicis.
● In the adductor compartment
● Adductor pollicis
● In the hypothenar compartment
● Abductor digiti minimi,
● Flexor digiti minimi brevis
● Opponens digiti minimi
● In the central compartment
● Short muscles of the hand
● Lumbricals
● Long flexor tendons
● In the interosseous compartment
● The dorsal and palmar interossei in separate compartments between the metacarpals.

 Intrinsic Muscles
o Intrinsic muscles have their proximal attachment at or distal to the carpal bones and have a function
on the thumb or fingers.
o Intrinsic muscles  are responsible for the hand’s fine motor control and precision movement.
o The Intrinsic muscles  can be further divided into the thenar, hypothenar, and deep palm muscles.

 Thenar Muscles
o The thenar muscles are those that function to move the thumb.
o The thenar muscles form the thenar eminence, or ball of the thumb.

 Deep Palm Muscles

o The deep palm muscles are located deep in the palm of the hand between the thenar and hypothenar
muscles.
o The deep palm muscles perform some of the more intricate motions that usually involve multiple
muscles.
o The deep palm muscles are the adductor pollicis, the interossei (of which there are four dorsal and
three palmar), and the lumbricals (of which there are also four muscles)
o The muscles located in the area between the thenar and hypothenar muscle groups are often called
the deep palm group, or the intermediate group. 
o The adductor pollicis muscle is sometimes placed in this group because it is located deep within the
palm.
 Other sources place the adductor pollicis muscle with the thenar group because of its action
on the thumb.
 The adductor pollicis muscle is placed here in the deep palm group for perhaps no other
reason than to discuss the intrinsic muscles in groups of three!
 Hypothenar Muscles
 The hypothenar muscles, forming the hypothenar eminence, act primarily on the little finger
 Flexor Pollicis Brevis Muscle
o The flexor pollicis brevis muscle is a relatively superficial muscle.
o The flexor pollicis brevis muscle attaches proximally to the trapezium and the flexor retinaculum
and distally to the base of the proximal phalanx of the thumb
o The primary actions of the flexor pollicis brevis muscles are to flex the MCP and CMC joints of the
thumb.

 Abductor Pollicis Brevis Muscle

o The abductor pollicis brevis muscle lies just lateral to the flexor pollicis brevis muscle
o The abductor pollicis brevis muscle attaches proximally to the flexor retinaculum, scaphoid, and
trapezium, and distally to the base of the thumb’s proximal phalanx
o The abductor pollicis brevis muscle  acts to abduct the CMC joint of the thumb.
o The abductor pollicis brevis muscle also has a secondary role in flexing the thumb at the MCP and
CMC joints.
o Note that the attachments of the oblique head of the adductor pollicis on the bases of the second and
third metacarpals and the capitate cannot be seen as they are deep to the opponens pollicis.

 Opponens Pollicis Muscle

o The opponens pollicis muscle lies deep to the abductor pollicis brevis muscle.
o The opponens pollicis muscle attaches proximally to the trapezium and flexor retinaculum and
distally to the entire lateral surface of the first metacarpal
o The primary function of the opponens pollicis muscle  is to oppose the thumb. Remember, this
action occurs at the CMC joint.
o Loss of thumb opposition is caused by damage to the median nerve and is referred to as “ape hand
deformity.”
o Thumb opposition is perhaps the most important function of the hand.
 Because it is a combination of flexion, abduction, and rotation of the thumb, other muscles
such as the flexor pollicis brevis and abductor pollicis muscles assist in this function.

 Adductor Pollicis Muscle

o The adductor pollicis muscle is a thumb muscle, although it is not usually considered part of the
thenar group.
 This is because it is located deep and does not make up the muscle bulk of the thenar
eminence.
o The adductor pollicis muscle actually has two heads.
 The oblique head of the adductor pollicis muscle has its proximal attachments on the
capitate and bases of the second and third metacarpals.
 The transverse head of the adductor pollicis muscle arises from the distal two-thirds of the
palmar surface of the third metacarpal.
 The fibers of the oblique and transvers heads of the adductor pollicis muscle unite to attach
on the ulnar side of the base of the proximal phalanx of the thumb
 As its name implies, its function is to adduct the thumb (at the CMC joint). It gives
much power to grasp.
 Interosseus Muscles
o There are two sets of interosseus muscles: dorsal and palmar.
o Like the dorsal interosseus muscles, the palmar interosseus muscles are innervated by the ulnar
nerve.
 Both the dorsal and palmar interossei play an important role in such activities as typing and
playing the piano.
 Dorsal Interosseus Muscles
o DAB- abduction
o There are four dorsal interosseus muscles.
 The dorsal interosseus muscles each attach proximally to two adjacent metacarpals and
distally to the base of the proximal phalanx
o The action of the dorsal interosseus muscles is to abduct the second, third, and fourth fingers at the
MCP joint.
o The third digit has two dorsal interosseus muscles, one on either side of the proximal phalanx.
 This allows the third digit to abduct in either direction.
o The fifth finger is abducted by the abductor digiti minimi.
o The ulnar nerve innervates all dorsal interosseus muscles

 Palmar Interosseus Muscles

o PAD-adduction
o There are three palmar interosseus muscles.
o The palmar interosseus muscles attach proximally to the palmar surface of the second, fourth, and
fifth metacarpals.
o The palmar interosseus muscles do not attach to, or have a function on, the middle finger.
o Distally, the palmar interosseus muscles attach to the base of the phalanx of the same finger as the
proximal attachment
o The palmar interosseus muscles pull the digits toward the midline of the hand, creating an
adduction motion.

 Lumbricals
o The lumbricals are the last muscle group to be discussed is rather unique.
o The lumbricals, of which there are four, have no bony attachment.
o The lumbricals are located quite deep and attach only to tendons.
o Proximally, the lumbricals attach to the tendon of the flexor digitorum profundus muscle, spanning
the MCP joint anteriorly
 This allows them to flex the MCP joint.
o The lumbricals then pass posteriorly at the dorsal proximal phalanx to attach to the tendinous
expansion of the extensor digitorum muscle
 This allows them to extend the PIP and DIP joint.
o Therefore, the action of the lumbricals is to flex the MCP joint and extend the PIP and DIP joints of
the second through fifth fingers.
 This combined motion is referred to as the “tabletop position.”
 Incidentally, the plural of lumbrical can be spelled with an “s” or “es.”
o Loss of lumbrical function will result in “claw hand,” characterized by MCP hyperextension and PIP
and DIP flexion (opposite positions from the lumbricals’ actions).
o The lumbricals are innervated in part by the median and ulnar nerves.
 If the median nerve is involved affecting the first and second lumbricals, then only the
second and third fingers will be involved.
 If the ulnar nerve is affected involving the third and fourth lumbricals, then the fourth and
fifth fingers will assume this posture.
 o Note that the middle finger abducts in two directions and therefore does not adduct.
 Flexor Digiti Minimi Muscle
o The flexor digiti minimi muscle serves the same function on the little finger as the flexor pollicis
brevis does on the thumb.
o The flexor digiti minimi muscle is attached proximally to the hook of the hamate and the flexor
retinaculum, and distally to the base of the little finger’s proximal phalanx
o The flexor digiti minimi muscle flexes the MCP joint of that finger.
o Remember, although most thumb motion occurs at the CMC joint, most finger motion occurs at the
MCP joint.

 Abductor Digiti Minimi Muscle

o The abductor digiti minimi muscle lies superficially, just medial to the flexor digiti minimi muscle
on the ulnar border of the hypothenar eminence.
o The abductor digiti minimi muscle attaches proximally to the pisiform and to the tendon of the
flexor carpi ulnaris muscle
o The abductor digiti minimi muscle attaches distally to the base of the proximal phalanx of the fifth
finger
o The abductor digiti minimi muscle  abducts the MCP joint of that finger.
o By being able to abduct the fifth digit, one is able to increase one’s grasp.

 Opponens Digiti Minimi Muscle

o The opponens digiti minimi muscle lies deep to the other hypothenar muscles.
o The opponens digiti minimi muscle’s proximal attachments, the hook of the hamate and the flexor
retinaculum, are similar to the proximal attachments of the flexor digiti minimi muscle.
o Distally, the opponens digiti minimi muscle attaches to the ulnar border of the fifth metacarpal
o The primary action of the opponens digiti minimi muscle is in opposition of the fifth finger.
 This action occurs at the CMC joint.
Functions of the Hand
 The primary function of the hand is grasp, or prehension. 
o This means that the hand is designed to hold or manipulate objects.
o There are basically two types of prehension: power grips and precision grips
 There are also many nonprehensile hand functions, such as expressing emotions, scratching, using a fist as a
club, and using the open palm, as in pushing down on an armrest to assist in standing.
 Because no manipulative movement occurs with these types of activities, no further description of
nonprehensile function will be made here.
 With prehension (grasping or holding an object), the manner in which the hand is used depends on the size,
shape, and weight of the object, how that object will be used, and the involvement of the proximal segments
of the upper extremity.
o Generally speaking, the shoulder girdle and shoulder joint position the hand in space.
o The elbow allows the hand to move closer or farther away from the body, especially the face.
o The wrist provides stability while the hand is manipulating objects and is important in the tenodesis
action
 Although much attention tends to focus on the grasping aspect of hand function, release is equally
important.
o Release is the role of the MCP, PIP, and DIP extensors.
o Without the ability to release, the hand’s function is greatly diminished.
 Hand Sensation
o Of paramount importance to hand function is sensation.
 Without intact sensation, an individual must compensate with visual clues to find items,
know what is being held, and how hard the object is being grasped.
 For example, if you were presented with a laundry bag full of clothes and told to find
the small box of soap, you could feel around inside the bag until locating the soap.
 However, if your hand’s sensation were not intact, you would have to empty the bag
and visually search for the box.
 A person with an upper extremity amputation who uses a prosthetic device is a good example
of having hand function without sensation.
 That person would need visual feedback to find the soap and to know if the terminal device
had grasped it.
 Hand sensation is provided by the radial, ulnar, and median nerves. Figure 13-31 shows the
pattern of sensory distribution.
 This distribution varies somewhat between individuals and is therefore presented with some
variations between authors.
o There is an optimal wrist and hand position for the hand to be most effective in terms of strength and
precision.
 This position helps to maintain the optimal length of the extrinsic multijoint muscles and is
called the functional position of the hand. 
 In the functional position of the hand position
 The wrist is in a slightly hyperextended (dorsiflexed) position
 The MCP and PIP joints of the fingers are slightly flexed
 The thumb is in opposition
 The transverse and longitudinal arches are normal. 
 Maintenance of the thenar web is vital to thumb opposition.
 There are basically two types of prehension: power grips and precision grips. 
6. Differentiate between the two basic types of prehension (power and precision) and
demonstrate examples of each based on a desired activity. 

● Power Grips
o The power grip is used when an object must be held forcefully while being moved about by more
proximal joint muscles (holding a hammer or doorknob)
o Often a power grip involves an isometric contraction with no movement occurring between the hand
and the object being held.

● Types of Power Grips

o Cylindrical grip has all the fingers flexed around the object, which usually lies at a right angle to the
forearm.
▪ The thumb is wrapped around the object in the opposite direction, often overlapping the fingers.
▪ Examples of a cylindrical grip would be holding a hammer, a racquet, or a wheelbarrow handle.

o Spherical grip has all the fingers and thumb abducted around an object
▪ Unlike the cylindrical grip, the fingers are more spread apart.
● The palm of the hand is often not involved
▪ Activities involving a spherical grip include holding an apple or a doorknob or picking up a
glass by its top.

o Hook grip involves the second through fifth fingers flexed around an object in a hooklike manner
▪ The MCP joints are extended
▪ The PIP and DIP joints are in some degree of flexion.
▪ The thumb is usually not involved.
▪ The Hook Grip this is the only power grip possible if a person has a median nerve injury and
loses the ability to oppose the thumb.
▪ Examples of a hook grip are seen when holding on to a handle, such as on a suitcase, a wagon,
or a bucket.

● Precision Grips
o The precision grip often referred to as precision prehension,
o The precision grip is used when an object must be manipulated in a finer type movement, such as
holding a pen or threading a needle

● Types of Precision Grips

o Pad-to-Pad Grip
▪ Pad-to-Pad Grip occurs when the MCP and PIP joints of the finger(s) are flexed, the thumb is
abducted and opposed, and the distal joints of both are extended, bringing the pads of the
finger(s) and thumb together.
▪ A pinch Grip is when the pad-to-pad grip involves the thumb and one finger, usually the
index finger, it is called a pinch grip
▪ A tripod grasp occurs when the pad-to-pad grip involves the thumb and two fingers, usually
the index and middle fingers.
▪ A tripod grasp is also called a three-jaw chuck.
▪ If you observe how a power drill holds the drill bit in place, you will see the similarity to this
grip
▪ There are three “jaws” pinching in on the drill bit; the entire holding mechanism is called a
chuck.
▪ Holding a pen or pencil would be an example of a tripod grasp grip.
▪ The tripod grasp is by far the most common precision grip
o Tip-to-Tip Grip
▪ Tip-to-tip grip involves bringing the tip of the thumb up against the tip of another digit, usually
the index finger, to pick up a small object such as a coin or a pin
▪ The tip-to-tip grip is also called pincer grip.
▪ The tip-to-tip grip type of grip becomes difficult with very long fingernails.

o Pad-to-Side Grip
▪ Pad-to-side grip is also called lateral prehension
▪ Pad-to-side grip has the pad of the extended thumb pressing an object against the radial side of
the index finger
▪ Pad-to-side grip is a strong grip, but it allows less fine movements than the other two types.
▪ The terminal device of upper extremity prostheses adapts this type of grip.
▪ Because the pad-to-side grip does not require an opposed thumb, a person who has lost
opposition but has retained thumb adduction can grasp and hold small objects.

o Side-to-Side Grip
▪ The side-to-side grip is somewhat similar to pad-to-side grip
▪ The side-to-side grip requires adduction of the index finger and abduction of the middle finger
▪ The side-to-side grip is a weak grip and does not permit much precision.
▪ The side-to-side grip is most frequently used to hold a cigarette.
▪ The side-to-side grip is also used to hold an object, like a pencil, between two fingers while
using another pencil or pen.
▪ Because the thumb is not involved, the side-to-side grip could be used in the absence of the
thumb.

o Lumbrical Grip
▪ The lumbrical grip is sometimes referred to as the plate grip
▪ The lumbrical grip has the MCP flexed and the PIP and DIP joints extended.
▪ The thumb opposes the fingers holding an object horizontal
▪ The lumbrical grip is usually used when something needs to be kept horizontal, such as a plate
or a tray.
▪ The lumbrical grip is called a lumbrical grip because the action of the lumbrical muscles is to
flex the MCP joints while extending the IP joints.
7. Define common pathologies of structures around the wrist and hand. Describe
potential impact on occupational performance.

● Carpal Tunnel Syndrome 

o Carpal tunnel syndrome is an extremely common condition caused by compression of the median
nerve within the carpal tunnel.
o Symptoms include numbness and tingling in the hand, which often begins at night.
o Patients often complain of tingling, pain, and weakness in the hand, particularly in the thumb, index,
and middle fingers.
o Tapping over the carpal tunnel often produces symptoms.
o Some, but not all, fibers of the transverse carpal ligament are often surgically cut to relieve the
symptoms.
o If all fibers were cut, it would allow bowstringing of the extrinsic tendons on the flexor surface.
● De Quervain’s Disease
o De Quervain’s disease is caused by an inflammation and thickening of the sheath containing the
extensor pollicis brevis and abductor pollicis longus, resulting in pain on the radial side of the wrist.
o Because it is an inflammation of tendons and their surrounding sheaths, it is called a tenosynovitis. 
o Making a fist with your thumb inside and then moving the wrist into ulnar deviation can elicit pain in
those tendons and is considered a positive test. Care should be exercised in doing this test because it
often causes some discomfort in a normal wrist.
● Dupuytren’s Contracture 
o Dupuytren’s contracture occurs when the palmar aponeurosis undergoes a nodular thickening.
o Dupuytren’s contracture is most common in the area of the palm
▪ Often those fingers will develop flexion contractures. 
● Stenosing Tenosynovitis
o Stenosing tenosynovitis commonly known as trigger finger, 
o Stenosing tenosynovitis is a problem with the sliding mechanism of a tendon in its sheath.
o When a nodule or swelling of the sheath lining or the tendon develops, the tendon can no longer slide
in and out smoothly.
o It may pass into the sheath when the finger flexes, but it becomes stuck as the finger attempts to
extend.
o The finger can become locked in that position, and it must be manually extended.
o The flexor tendons of the middle and ring fingers are most commonly involved. 
● Skier’s Thumb
o Skier’s thumb, a common hand injury among athletes, involves an acute tear of the ulnar collateral
ligament of the thumb. 
● Gamekeeper’s Thumb 
o Gamekeeper’s thumb is an old term referring to a stretching injury of this same ligament developed
over time by English gamekeepers as they twisted the necks of small game.
o Most injuries to the ulnar collateral ligament occur with a fall on an outstretched hand.
● Swan Neck Deformity 
o Swan neck deformity is characterized by flexion of the MCP joint, (hyper)extension of the PIP joint,
and flexion of the DIP joint.
● Boutonnière Deformity
o With a boutonnière deformity, the deformity is in the opposite direction—extension of the MCP
joint, flexion of the PIP joint, and extension of the DIP joint. 
● Ulnar Drift 
o Ulnar drift results in ulnar deviation of the fingers at the MCP joints. 
● Mallet Finger
o Mallet finger is caused by disruption of the extensor mechanism of the DIP joint, either because the
tendon was severed or because the portion of bone where the tendon attached has avulsed from the
distal phalanx.
o In either case, the distal phalanx remains in a flexed position and cannot be extended. The scaphoid is
the most frequently injured carpal bone.
● Scaphoid Fracture
o A scaphoid fracture usually results from a fall on the outstretched hand of a younger person. Because
of a poor vascular supply, it has a high incidence of avascular necrosis. 
● Kienböck’s Disease 
o Kienböck’s disease refers to the necrosis of the lunate, which may develop after trauma.