The Wrist and Hand

Bones of the Wrist and hand

Joint Capsular Pattern Close Packed Loose Packed
Position Position

Pain at extremes
Distal Radioulnar 5º supination 10ºsupination
of rotation

Flexion &
Radiocarpal Neutral with slight
extension equally Extension
(Wrist) ulnar deviation
limited
Midway between
1st
Abduction, abduction,
Carpometacarpal Full opposition
extension adduction, flexion
(CMC)
and extension
Midway between
Equal limitation in
2-5th CMC Full flexion flexion and
all directions
extension

MCP and IP Flexion, extension Full flexion Slight flexion

Wrist Movements

Wrist Flexion
Flexor carpi radialis Wrist Extension
Flexor carpi ulnaris Extensor carpi radialis longus
Palmaris longus Extensor carpi radialis brevis
Flexor digitorum Extensor carpi ulnaris
superficialis
Wrist Movements
Radial Deviation
Extensor carpi radialis
longus
Ulnar deviation
Extensor carpi
Extensor carpi radialis ulnaris
brevis
Flexor carpi
Extensor pollicis ulnaris
longus

Extensor pollicis brevis

Flexor carpi radialis

Abductor pollicis
longus
Finger Movements
Extension of 2nd to 5th Flexion of 2nd to 5th Abduction of 2nd to 5th Adduction of 2nd to 5th
fingers fingers fingers fingers
Extensor digitorum Flexor digitorum Dorsal interossei 2nd – Palmar interossei
Lumbricals superficialis 4th) (2,4,5)

Dorsal Interossei (2-4 Flexor digitorum Abductor digiti minimi Extensor Indicis (2nd )
assists) profundus (5th finger)

Palmar interossei Flexor digiti minimi (5th

(2,4,5 assists) finger)

Extensor indicis (for 2nd Lumbricals

digit)
Dorsal Interossei (2-4
assists)

Palmar interossei
(2,4,5 assists)
Thumb Movements
Thumb Flexion Thumb Extension Thumb Abduction Thumb Adduction
Flexor pollicis Extensor pollicis Abductor pollicis Adductor pollicis
longus longus longus
Palmar Interossei
Flexor pollicis brevis Extensor pollicis Abductor pollicis (1st)
brevis brevis
Adductor pollicis
(assists) Abductor pollicis
longus
Palmar intersossie
(1st assists)

Thumb Opposition
Opponens pollicis
Carpal Bones

Most commonly
fractured

Most commonly
dislocated and second
most commonly
fractured
Muscles of the forearm and hand
Intrinsic muscles of the hand
Anatomical Snuff Box
Lateral Border
Good spot for testing Abductor Pollicis Longus
radial nerve sensation
Extensor Pollicis Brevis
only

Medial Border
-Extensor Pollicis Longus

Floor
Radial styloid
Scaphoid
Trapezium
Base of First metacarpal

Contents
Cephalic vein
Radial artery
Superficial radial nerve
Swan Neck and Boutonniere Deformity
There is flexion of the MCP and DIP joints and
hyperextension of the PIP joint. This is due to a
contracture of the intrinsic muscles. Commonly
seen in patients with Rheumatoid arthritis or
after trauma.

Hyperextension of the MCP and DIP joints and

flexion of the PIP. It is due to a rupture of the
central tendinous slip of the extensor hood.
Commonly seen in patients with Rheumatoid
arthritis or after trauma.
Ulnar drift

Ulnar deviation of the digits because of weakening of the capsuloligamentous

structures of the MCP joints and the accompanying “bowstring effect” of the
extensor communis tendon.
Extensor plus deformity

This deformity is caused by shortening or adhesions of the extensor communis tendon

proximal to the MCP joint. It results in the inability of the patient to simultaneously
flex the MCP and PIP joints.
Claw Fingers

MCP joints are hyperextended and the DIP and PIP joints are flexed. This is due to loss
of intrinsic muscle activity and overactivity of the extrinsic muscles extensor muscles
on the proximal phalanx. This is usually due to a combined median and ulnar nerve
injury.
Trigger Finger
Also known as digital stenosing
tenosynovitis
Due to a thickening of the flexor
tendon sheath which causes sticking
of the tendon when the patient
attempts to flex the finger.

On extending the finger there is a

snapping sound as the tendon glides
in the sheath.

As condition progresses the person

can flex the finger with some
difficulty but they are unable to
extend the fingers actively.
Ape Hand Deformity

Wasting of the thenar eminence of the hand. Occurs as a result of a median nerve
palsy. The person is unable to flex or oppose the thumb.
Bishop’s Hand or Benediction Deformity

Wasting of the hypothenar muscles of the hand, the interossei muscles and the medial two
lumbricals. It usually occurs because of ulnar nerve palsy. The fourth and fifth fingers are
maintained in flexion.
Zigzag Deformity of the Thumb

The thumb is flexed at the CMC joint and hyperextended at the MCP joint. It is
associated with rheumatoid arthritis and may also be familial.
Dupuytren’s Contracture

There is a fixed flexion deformity of the MCP and PIP joints. It is due to a
contracture of the palmar fascia. Usually occurs in the 50 - 70 age group and is
more common in females than males. Most commonly seen in the ring and little
finger.
Mallet Finger

The DIP remains in a flexed position. This is due to a rupture of the extensor
tendon where it inserts into the distal phalanx.
Polydactyly

Congenital abnormality characterized by the presence of more than the normal

number of fingers.
Syndactyly

Congenital deformity – fusion of the digits

Functional Position or Resting Position of
the Hand

20 to 35 degrees wrist extension and 10 – 15 degrees of ulnar deviation. This

position allows for full flexion of the fingers and therefore the greatest power grip.
It also facilitates thumb and finger interaction.
The Carpal Tunnel

http://www.mdguidelines.com/images/Illustrations/carpal_t.jpg
 What is Carpal Tunnel Syndrome (CTS)
 Compression of the median nerve at the
wrist. This occurs within the carpal
tunnel.

 This causes tingling and numbness in

the thumb, middle, index and half of the
ring finger.

 Muscle weakness if compression is not

relieved.

 There may also be wrist pain.

 Hand function can be affected

DeQuervain's stenosing tenosynovitis
 Involves tendons of two specific muscles on the
thumb side of the hand - the abductor pollicis
longus (APL) and the extensor pollicis brevis
(EPB).

 The compartment (a sheath) around the tendons

swell and enlarge, making thumb and wrist
movement painful.
 Making a fist, grasping or holding objects painful

 Because of the pain and swelling, motion such as

pinching may be difficult.

 Irritation of the nerve lying on top of the tendon

sheath may cause numbness on the back of the
thumb and index finger.
Structures to palpate
The carpal bones
Radial styloid
Ulnar styloid
Metacarpals
Phalanges
Flexor carpi ulnaris and radialis
Palmaris longus