The Hand Complex

Joints involved are:

1. Carpometacarpal joint 2. Metacarpophalangeal joint.
3. Proximal inter phalangeal joint 4. Distal inter phalangeal joint.
CARPOMETACARPAL JOINT
Variety: Plane.
Type: Synovial joint.
Articular surfaces:
Proximally: Distal carpal row (Hamate, Capitate, Trapezoid, Trapezium)
Distally: Base of metacarpal (2nd – 5th)
• 2nd metacarpal articulates with trapezoid, trapezium and capitate.
• 3rd metacarpal articulates with capitate.
• 4th metacarpal articulates with capitate and hamate.
• 5th metacarpal with hamate.
Ligaments:
1. Deep transverse metacarpal ligament:
• It is spans the heads of the second through the
fourth metacarpals Volarly.
• It spans the heads of the second through fourth
metacarpals.
• It provides CMC stability, and is structurally part of
MCP Joint
• It controls the total ROM at each CMC joint.
2. Transverse carpal ligament:
• It is the portion of flexor retinaculum that attaches to pisiform and hook of hamate medially
and to scaphoid and trapezium laterally.
3. Intercarpal ligament:
• Proximal transverse carpal arch formed by distal carpal row.
• Maintains the transverse arch
Palmar Arches
❖ The function of the finger carpometacarpal joints and their segments overall is to contribute
(with the thumb) to the Palmar Arch System.
❖ The concavity formed by the carpal bones results in the
proximal transverse arch of the palm of the hand.
❖ The adjustable positions of the first, fourth and fifth
metacarpal heads around the relatively fixed on the
second and third metacarpals form a distal transverse
arch at the level of the metacarpal heads that augments
the fixed proximal transverse arch of the distal carpal
row.
❖ The longitudinal arch transverse the length of the digits
from proximal to distal.
❖ The deep transverse metacarpal ligament contributes to
stability of the mobile arches during grip functions.
❖ The palmar arches allow the palm and the digits to conform optimally to the shape of the object
being held.
Movements
One degree of freedom – Flexion /Extension.
Almost no movement at the CMCs of the 2nd and 3rd CMC jt., Slight movement at the 4th CMC.
Function of CMC joint:
❖ To contribute to palmar arch system.
❖ These arches will allow the palm and the digits to conform optimally to the shape of the object
being held thereby increasing surface contact.
Palmar Cupping – hollowing of palm + flexion of fingers and flattening causes extension of
fingers.
No muscles will act on CMC Joint alone. But only muscle acting is opponens digiti minimi.
It is attached proximally to hamate, TCL and distally to 5 th metacarpal.
It helps in flexion and rotation of 5th metacarpal
Flexor carpi ulnaris increases arching.

METACARPOPHALANGEAL JOINT
Variety: Condyloid
Type: Synovial
Articular surfaces:
Proximally: Convex metacarpal heads.
Distally: Concave base of the first phalanx.
Periarticular structures are:
Capsule: Surrounds the articular surfaces, lax in Extension.
❖ MCP joint is incongruent.
Ligaments:
1. Two collateral ligaments 2. Volar plate.
Ligaments:
1. Radial collateral ligament 2. Ulnar collateral ligament.
Ligament has two parts:
1. Collateral ligament proper (Dorsally)
2. Accessory collateral ligament (Volarly)
During flexion – accessory collateral ligament is shortened; collateral ligament is lengthened.
Volar plates:
• It is fibrocartilage.
• It is firmly attached to the base of proximal phalanx distally.
• Plate becomes membraneous proximally to blend with volar capsule that then attaches to the
metacarpal head.
• Plate + capsule blend with transverse metacarpal ligament.
• Plate is connected to the Extensor Communis tendon and extensor expansion by sagittal
bands.
• Sagittal bands help stabilize volar plates over 4 metacarpal heads.
• Note: Sagittal Bands connects Volar Plate to Extensor Digitorum Communis
Functions:
• It increases joint congruence.
• It provides stability to MCP Jt.
• It indirectly supports longitudinal arch.
• It takes up both tensile stresses and compressive forces.
• Plate glides proximally on volar surface of MC head there by preventing pinching of long
flexors.
Movements:
❖ Flexion /Extension in Sagittal Plane (Increases from radial to ulnar side)
❖ Abduction/Adduction in frontal plane (It is restricted in MCP flexion)
❖ Passive Hyper extension is used as a measure of generalized body flexibility.
❖ Closed Pack Position is Flexion, Rom – 90 degree
❖ For little finger ROM – 110 degree
 INTERPHALANGEAL JOINTS
Type: Synovial.
Variety: Hinge.
Articular Surfaces:
Proximally - Head of 1st (Proximal) phalanx and base of the 2nd (Middle) phalanx.
Distally - Head of 2nd (Middle) phalanx and base of 3rd (Distal) phalanx.
❖ They are incongruent.
Periarticular Structures:
➢ Capsule – It is weak and reinforced by ligaments.
➢ Ligaments – Two collateral ligaments
i. Radial Collateral Ligament
a. Collateral Ligament Proper
b. Accessory Collateral Ligament
ii. Ulnar Collateral Ligament
a. Collateral Ligament Proper
b. Accessory Collateral Ligament
➢ Volar plates:
- It is a fibrocartilage plate.
- It is firmly attached to the Head of phalanx to the base of another phalanx.
- Like MCP Joint, these volar plates are not connected by Deep Transverse Ligament.
Functions: They reinforce each of the interphalangeal joint capsule, enhance stability and
limits hyperextension.
Movements:
Osteokinematics:
- The total range of Flexion / Extension is greater at the PIP Joint (100° to 110°) than it is
at the DIP Joint (80°).
- The PIP Joint and DIP Joint flexion at each finger increase ulnarly, with the fifth PIP
Joint and DIP Joint achieving 135° and 90°.
- Frontal Plane, Coronal Axis.
- ROM – PROXIMAL INTERPHALANGEAL > DISTAL INTERPHALANGEAL.
- Increases ulnarly.

Arthokinematics:
- Concave Base moves on Concave Head, So the rolling and gliding(sliding) will be in the same
direction of that of movement.
- For Flexion: Flexion is Volarly(Anteriorly).
- For Extension: Extension is Dorsally(Posteriorly).

❖ Anti-Deformity position – MCP Joint is in Flexion and

Proximal Interphalangeal, Distal interphalangeal in Extension. This position minimizes the risk
of dysfunctional changes to the immobilized joints of hand.

MUSCLES OF INTERPHALANGEAL JOINTS

1. Extrinsic muscles –
Muscles that have proximal attachments above wrist joint. Ex: FDS
2. Intrinsic muscles – Muscles that have proximal attachments below wrist joint (distally)
Ex: Hypothenar muscle
EXTRINSIC MUSCLES
 Extrinsic muscles are divided into –
1. Extrinsic flexors.
2. Extrinsic extensors.
 EXTRINSIC FLEXORS
There are two extrinsic muscles that contribute to the finger flexors. They are –
1. Flexor digitorum superficialis – Muscle primarily flexes the PIP Joint, but it also
contributes to MCP Joint flexion.
(Flexion of PIJ + MCPJ)
2. Flexor digitorum profundus – Muscle can Flex the metacarpophalangeal, proximal
interphalangeal and the DIP Joints and is considered to be the more active of the two
muscles. (Flexion of Distal IPJ + Proximal IPJ + MCPJ).

❖ The Flexor digitorum profundus muscle alone will be active in gentle pinch or grasp.
 FDS has greater moment arm at MCP joint than FDP because it is superficial and it crosses
fewer joints.
 FDS crosses deep to FDP at PIP Joint.

MECHANISMS OF FINGER FLEXION

 Optimal functioning of FDS and FDP muscles depend on –
1. Stabilization by the wrist musculature.
2. Intact flexor gliding mechanisms.
 Flexor gliding mechanisms consist of –
1. Flexor retinaculum.
2. Bursae
3. Digital tendon Sheaths
❖ The fibrous retinacular structures (proximal flexor retinaculum, transverse carpal ligament
and Extensor Retinaculum) tether the long flexor tendons to the hand.
❖ The bursae and the tendon sheaths facilitates friction - free excursion of the tendons on the
fibrous retinaculum.
Function: It prevents bowstringing of the tendons that would result in loss of excursion and
work efficiency in the contracting muscles.
❖ The tendon of the FDS and FDP muscles cross the wrist to enter the hand, they first pass
beneath the proximal flexor retinaculum and through the carpal tunnel under the transverse
carpal ligament.
❖ The tendons on the overlying transverse carpal ligament are prevented by the RADIAL and
ULNAR bursae that envelop the flexor tendon at this level. This prevents friction of the
tendon and tendon on transverse carpal ligament.
❖ All 8 Tendons of FDS and FDP are enveloped in Ulnar bursae and FPL (Flexor Pollicis
Longus) tendon alone is enveloped in radial bursae.
❖ The bursae are compartmentalized to prevent friction of tendon on tendon.
❖ Ulnar bursae is continues with the digital tendon sheath for the little finger.
❖ For other fingers - ulnar bursae ends just distal to proximal palmar crease, and digital
tendon sheaths will start from distal palmar crease.
❖ Radial bursae is continues with the digital tendon sheath of FPL.
❖ Digital tendon sheaths will end at distal aspect of middle phalanx.
❖ FDS and FDP tendons of each finger pass through fibro-osseous tunnel.
- This fibro – osseous tunnel comprises of:
1. 5 transversely oriented annular pulleys.
2. 3 obliquely oriented cruciate pulleys.
Annular pulleys:
They are longer than the roof and roof has a slight concavity Volarly.
1. It prevents the pulleys from pinching each other in extremes of flexion.
2. Minimizes pressure on Tendons.
 - Annular Pulleys are designated as A1, A2, A3, A4, A5.
A1 – located at metacarpal head.
A2 – located at volar midshaft of proximal phalanx.
A3 – located at distal most part of proximal phalanx.
A4 – located centrally on the middle phalanx.
A5 – located at the base of distal phalanx.
Cruciate pulleys:
Cruciate pulleys are designated as C1, C2, C3.
C1 – located between A2 and A3.
C2 – located between A3 and A4.
C3 – located between A4 and A5.
- C3, A4, A5 contain only FDP.
- Additional annular pulley proximal to A1 – “Palmar Aponeurosis Pulley.”
Functions of Annular pulley:
- It prevents bowstringing of tendons.
- It enhances both tendon excursion efficiency and work efficiency of the long flexors.
- Trigger finger: It is created when repetitive trauma to a flexor tendon results in the
formation of nodules on the tendon and thickening of an annular pulley,

Vascular supply to gliding mechanism –

1. Through vessels that reach tendon via the vincula tendinum. (Folds of the synovial
membrane)
2. Directly from synovial fluid within the sheaths.

EXTRINSIC FINGER EXTENSORS

 Extrinsic finger extensors are:
1. Extensor Digitorum Communis 2. Extensor indicis Proprius 3. Extensor digiti minimi.
 Each of these muscle passes from the forearm to the hand beneath the Extensor
Retinaculum, which maintain proximity of the tendons to the joints and improves excursion
efficiency.
 At the level of MCP Joint, EDC tendon of each finger merges with broad aponeurosis
known as Extensor expansion or Dorsal hood or Extensor hood.
 EDC tendon of one finger may also be connected to the tendons of adjacent fingers by
“Junctura Tendinae”, which are fibrous inter connections.
Use: Active extension of one finger will cause passive extension of the other.
 Distal to the extensor hood, EDC tendon at each finger splits into 3 bands –
1. Central tendon – inserts on the base of middle phalanx.
2. Two lateral bands – The lateral bands rejoin as the terminal tendon to insert into
the base of distal phalanx.
• MCP Joint extension is by EDC muscle.
 IP Joint extension is by lateral bands, terminal tendon and Dorsal Interossei, Volar
Interossei.
Mechanism of Finger Extension
1. The foundation of the extensor mechanism is formed by the tendons of the extensor
Digitorum Communis Muscle (with Extensor Indicis Proprius and extensor digiti minimi).
2. Extensor hood
3. The Central Tendon and the lateral Bands that merges into the Terminal tendon.
✓ The first two components that will add to the Extensor mechanism are the passive components
of the Triangular ligament and the Sagittal Bands.
 4. Triangular ligament or dorsal retinacular ligament – lateral bands are interconnected
dorsally by triangular band of fibers known as triangular ligaments.
Function: Triangular ligament stabilizes lateral bands to dorsum of fingers.
5. Sagittal bands: These bands connect volar plates to transverse metacarpal ligament to
Extensor hood. These bands 1. Help to stabilize MCP Joint.
2. Prevents bowstringing of extensor mechanism during active extension.
3. Helps in transmission of forces to proximal phalanx.
4. Helps in centralization of EDC tendon over MCP Joint, preventing tendon subluxation.
6. Dorsal Interossei (DI), Volar Interossei (VI) and Lumbricals muscles are the active
components of the Extensor Mechanism.
✓ Dorsal Interossei & Volar Interossei muscles arise proximally from sides of the MCP jt.
✓ Insertion – directly into proximal phalanx where as others join with hood and wrap around
proximal phalanx, others also contribute to central tendon, lateral bands.
7. Lumbricals: Proximally To FDP
Distally to lateral bands.
8. Oblique retinacular ligaments:
Arise from both sides of proximal phalanx, sides of annular & cruciate pulleys Volarly.
It continues distally as band and inserts on the lateral bands, distal to PIP joint.
Origin – From lateral bands, Insertion – To the Terminal tendon.
Extensor Mechanism Influence on MCP Joint.
 EDC lies dorsal to the MCP JOINT axis.
 Active contraction of the muscle will create tension on the sagittal bands and will pull these bands
proximally over MCP joint, and extends PIP Joint.
 Isolated contraction of EDC will cause hyper extension of
MCP Joint and flexion of IP Joint (Passive tension of
FDP, FDS)
 This position is called as clawing.
 “Collapse” (Excessive extension) of the Proximal
phalanx is prevented by active tension in the lumbricals or Interossei muscles that pass Volar to
the MCP joint Axis.
 In order to simultaneously extend PIP, DIP Joint, EDC requires active assistance of DI, VI &
LUMBRCALS.
 These muscles cross MCP Joint axis Volarly but crosses IP JOINT dorsally.
 When EDC, VI, DI & LUMBRICALS contract simultaneously, MCP Joint will extend along with IP
Joint.
 When intrinsic muscles are weak, EDC muscle is unopposed, and fingers not only claw with active
MCP Joint extension but at rest also.
 This clawed position is also known as Intrinsic minus position.
 This is because passive tension in EDC muscle exceeds passive tension in remaining MCP Joint
flexors.
EXTENSOR MECHANISM INFLUENCE ON IP JOINT.
 Active and passive forces are arranged in such a way that extension of PIP JOINT will cause
extension of DIP JOINT.
 This is because:
1. PIP JOINT is crossed dorsally by central tendon and two lateral bands.
2. Interossei and lumbricals all have attachment to central tendon, lateral bands.
3. All these muscles (EDC, Interossei, lumbricals) are capable of producing extensor force on IP
JOINTS.
 Interossei, lumbricals alone cannot extend both MCP JOINT and IP JOINTS.
 Active contraction of these muscles cannot extend MCP Joint as these muscles pass Volarly to
MCP JOINT.
 But these muscles would not be able to produce sufficient tension to cause independent IP JOINT
extension if EDC tendon was completely slack.
For full IP, Joint Extension, the following are necessary:
1. Active contraction of intrinsic finger muscles.
2. Active contraction or passive stretch of EDC muscle.
(Active contraction of EDC – MCP JOINT extension & passive stretch – flexion of MCP JOINT.)
3. Due to passive tension in oblique retinacular ligaments – PIP JOINT extension will cause
extension of DIP JOINT.
 Flexion of PIP JOINT will cause flexion of DIP JOINT because of FLEXOR DIGITORUM
PROFUNDAS muscle action.
 But to achieve this extensor forces at PIP JOINT should be released at same time
When DIP JOINT flexion is initiated by FLEXOR DIGITORUM PROFUNDAS muscle, terminal
tendon and its lateral bands are stretched over the dorsal aspect of DIP JOINT.
 The stretch of these bands will pull extensor hood distally.
 Distal migration of hood will cause central tendon to relax, releasing PIP JOINT extensor
influence.
 When PIP JOINT is flexed, tension increases in central tendon which pulls extensor hood
distally.
 Thereby releasing tension in lateral bands.
 This will relieve tension in terminal tendon.
 This eliminates extensor force on DIP and hence DIP JOINT will flex and it cannot extend.

Intrinsic Muscles of Interphalangeal Joint

Dorsal Interossei Muscle (Four in number)
Origin: From the sides of the Metacarpals (Between)
Insertion: Proximal: Few fibres will get inserted into proximal phalanx, few will get
attached to Extensor Hood.
Distal: Attachment to Central Tendon and Lateral bands.

Volar Interossei Muscle {four (thumb having first VI)}

Origin: Sides of the metacarpals.
Insertion: These muscles will get attached to central tendon and lateral bands.
Proximal attachment will have predominated effect at MCP JT.
Distal attachments will have predominated effect at IP JT.

ROLE OF INTEROSSEI AT MCP JT AND IP JT:

When MCP JT is in extension, these muscles will produce little torque as MCP JT flexors but act
as effective joint stabilizers and prevent clawing of fingers.
When MCP JT is in extension, these muscles act as abductors & adductors.
Those having proximal attachments act as abductors of MCP JT.
At IP JT, these muscles will cause extension.
All Interossei are MCP joint flexors.
Lumbricals:
Origin: From tendon of FDP
Insertion: To the lateral bands
Action: Regardless of MCP joint position, Lumbricals act as Interphalangeal joint
extension.
✓ Intrinsic Plus Position
When Lumbricals, Interossei contract together without any extrinsic muscle activity, these muscles
produce flexion at MCP Joints and Extension of Interphalangeal joint.
STRUCTURE OF THUMB
Joints involved are:
1. First CMC joint of thumb.
2. MCP joint of thumb.
3. IP joint of thumb.

CMC JT OF THUMB: (TRAPEZIOMETACARPAL JT)

Type: Synovial joint.
Variety: Saddle.
Articular surfaces: 1. Trapezium
2. Base of first metacarpal.
• Saddle shape of trapezium is Concave in Sagittal plane (Abduction /Adduction) & Convex in
frontal plane (Flexion /Extension)
Capsule: Lax and reinforced by ligaments.
Ligaments:
1.Volar & Dorsal radial, Ulnar collateral ligaments.
2. Inter metacarpal ligament.
3.Anterior oblique ligament.
Movements:
Flexion /Extension – Oblique AP axis, Frontal plane.
Abduction /Adduction – Oblique coronal axis, Sagittal plane.
Opposition – Sequentially abduction, flexion, adduction with simultaneous rotation.

Arthrokinematics:
Flexion:
Concave surface of 1st base of the metacarpal moves on convex trapezium.
So, rolling and sliding is in the same direction as that of the movement
(Sliding & Rolling Volarly)
Extension:
Concave surface of the 1st base of metacarpal moves on convex trapezium.
So, rolling and sliding is in the same direction as that of the movement.
(Sliding & Rolling Dorsally)
Abduction:
Convex surface of base of the 1st metacarpal moves on concave trapezium.
So, Rolling and sliding is in the opposite direction.
For Abduction, rolling radially and sliding ulnarly.

Adduction:
Convex surface of base of 1st metacarpal moves on concave
trapezium.
So, rolling & sliding is in the opposite direction.
For Adduction, rolling ulnarly & sliding radially.

METACARPOPHALANGEAL JOINT:
Variety: Condyloid.
Type: Synovial.
Articular Surfaces: Base of first proximal phalanx and head of 1st metacarpal.
Ligaments:
1. Collateral ligaments.
2. Volar plate.
Movements: Flexion /Extension, Adduction /Abduction.

INTERPHALANGEAL JOINT:
Articulation between head of proximal phalanx & base of distal phalanx.

THUMB MUSCULATURE
EXTRINSIC MUSCLES INTRINSIC MUSCLES
Flexor Pollicis Longus. Opponens Pollicis
Extensor Pollicis Longus Flexor Pollicis Brevis
Extensor Pollicis Brevis. Abductor Pollicis Brevis
Abductor Pollicis Longus First Volar Interossei
Adductor Pollicis Brevis.
PREHENSION
Prehension activities of hand involve:
1. Grasping
2. Taking hold of an object between any two surfaces in hand.
Prehension can be categorized into:
1. Power grip – forceful act resulting in flexion at all finger joints including thumb.
2. Precision handling – skillful placement of an object between fingers and between finger &
thumb (palm is not involved)
POWER GRIP
Sequence:
1. Opening of hand.
2. Positioning of fingers.
3. Bringing fingers to the object.
4. Maintaining a static phase that actually constitutes the grip.
✓ Thumb acts as stabilizer to the object between fingers and palm.
Types of power grip
1. Cylindrical grip.
2. Spherical grip.
3. Hook grip.
4. Lateral prehension.
Cylindrical grip:
It involves:
✓ Wrist is neutral and slight ulnar deviation.
✓ MCP JT Flexion, Ulnar deviation (adduction of index finger & abduction of middle, ring,
little fingers), IP JT Flexion of fingers
✓ Thumb – flexion & abduction.
✓ Muscles involved are:
✓ Flexor Digitorum Profundus, Flexor Digitorum Superficialis, Interossei, lumbricals – for fingers.
✓ Flexor Pollicis Longus, Thenar muscles – for thumb.
✓ Even HYPOTHENAR muscles are also active – Flexor Digiti Minimi, Abductor Digiti Minimi.
Spherical grip:
✓ It is similar to that of cylindrical grip but with greater spread of the fingers to encompass the
object.
✓ Other difference is – MCP JT is not ulnarly deviated but abducted, increase in Interossei
activity.
Hook grip:
✓ It includes only palm but not thumb.
✓ Muscles involved are: Flexor Digitorum Profundus, Flexor Digitorum Superficialis.
✓ Thumb is held in moderate to full extension by thumb extrinsic muscles.
Lateral prehension:
✓ Here contact occurs between two adjacent fingers.
✓ MCP JT, IP JT will be in extension as contiguous MCP JTS abduction & adduction.
✓ Only power grip in which extensor activity predominates.
✓ Muscles involved are: Extensor Digitorum Communis, Lumbricals, Interossei.

PRECISION HANDLING
Sequence:
1. Opening of hand.
2. Positioning of fingers.
3. Bringing fingers to the object
4. In Precision handling, the fingers & thumb grasp the object for the purpose of manipulating
it within hand.
Two jaw chuck –
1. one jaw is formed by thumb (abducted &rotated)
2. Other jaw is formed by distal tip, pad, side of a finger.
3. When two fingers oppose thumb, it is three jaw chuck
Types of precision handling are:
1. Pad to pad prehension.
2. Tip to tip prehension.
3. Pad to side prehension.

Pad to pad prehension:

✓ Involves opposition of pad or pulp of thumb to the pad/pulp of the fingers.
✓ 80% of precision handling falls under this category.
✓ In two jaw chuck – thumb &index finger
✓ In three jaw chuck – thumb, index &middle finger.
✓ Wrist is held in Neutral/ulnar dev/Ext.
✓ Finger MCP JT, PIP JT will be in slight flexion but DIP JT will be in slight flexion or in extension
depending on the size of the object.
✓ Thumb – CMC JT – Flexion, Opposition, MCP JT, IP JT – May be partially flexed or fully
extended.
✓ Muscles involved are: Flexor Digitorum Profundus, Flexor Digitorum Superficialis, Dorsal
Interossei, Volar Interossei.
✓ For thumb movement – THENAR muscles – Flexor Pollicis Brevis, Opponens Pollicis,
Abductor Pollicis Brevis, Adductor Pollicis Brevis.
Tip to tip prehension:
✓ Similar to that of pad to pad prehension but with slight difference
✓ Here IP JT of fingers and thumb must be in full flexion and Finger MCP JT – abduction.
✓ Muscle activity is same as that of pad to pad prehension.

Pad to side prehension:

✓ Also, called as key grip/lateral pinch
✓ Thumb is adducted and less rotated at CMC JT and IP JT is slightly flexed.
✓ So, adductor pollicis muscle activity increases compared to opponens pollicis.
✓ Wrist will be in neutral position.
✓ Forearm will attain supination and pronation.
✓ This can be performed even when all hand muscles are paralyzed.

Functional position of the wrist & hand:

It is the position of hand from which optimal function is most likely to occur.
The functional position is:
1. Wrist complex – slight extension (20 degree) & slight ulnar deviation (10 degree)
2. MCP JT of fingers flexed (45 degree)
3. PIP JT is in flexion (30 degree)
4. DIP JT is in slightly flexed.