Sie sind auf Seite 1von 163

Topic:

The wrist
complex
Submitted by : Gaganpreet kaur
(14204104)
Submitted to: Dr.Supreet Bindra
The wrist (carpus) consists of two
compound joints:
The radiocarpal joint
The midcarpal joints
Referred to collectively as the wrist
complex
Radiocarpal joint structure:
The radiocarpal joint
is formed by
radius and radioulnar
disc as part of the
triangular
fibrocartilage complex
(TFCC) proximally
and by the
scaphoid,lunate and
triquetrum distally.
The distal radius has a
single ,continuous ,biconcane
curvature that is long and shallow
from side to side
And shorter and sharper
anteroposteriorly.
The proximal joint
surface is composed
of
The lateral radial
facet-scaphoid
The medial radial
facet lunate
The triangular
fibrocartilage
complex -triquetrum
The compound
proximal
radiocarpal joint
surface is oblique
and angled
slightly volarly
and ulnarly .
The average
inclination of
distal radius is
23.
The distal radius is
also tilted 11
degree volarly with
the posterior radius
slightly longer than
volar radius.
The triangular fibrocartilage
complex :
Consists of :
The radioulnar
disc
And the various
attachments that
provide the
primary support
for the distal
radioulnar joint.
The articular disc is a
fibrocartilaginous
continuation of the
articular cartilage of the
distal radius.
The disc is connected
medially via two dense
fibrous connective
tissue laminae
The upper laminae
include the dorsal and
volar radioulnar
ligaments which attach
to ulnar head and
styloid
The lower lamina has
connections to the
sheath of the
extensor carpi
ulnaris tendon and to
triquetrum ,hamate
and the base of fifth
metacarpal through
fibers from the ulnar
collateral ligament
The so called
meniscus homolog .
The scaphoid ,lunate and triquetrum
compose the proximal carpal row .
Proximal carpal row articulates with
the distal radius.
Ulnar variance
Ulnar negative variance is described
as a short ulna in comparison with
the radius at the distal end.
Ulnar positive variance the distal
ulna is ling in relation to distal radius.
Avascular necrosis of the lunate
,kienbocks disease
Radiocarpal capsule and
ligaments:
Joint is enclosed by a strong but
somewhat loose capsule and is
reinforced by capsular and
intracapsular ligaments.
Most ligaments that cross the
radiocarpal joint also contribute to
stability at the midcarpal joint .
Midcarpal joint structure:
The midcarpal joint is the articulation
between the scaphoid ,lunate and
triquetrum proximally
The distal carpal row composed of
the trapezium,trapezoid,capitate and
hamate.
The capitate and hamate are most
strongly bound together with,at the
most a small amount of play
between them.
It is also foundation for the
transverse and longitudinal arches of
the hand.
Ligaments of wrist complex:
The ligaments of the wrist complex are
designated either
Extrinsic or intrinsic
The extrinsic ligaments are those that
connect the carpals to the radius or ulna
proximally or to metacarpals distally.
The intrinsic ligaments are those that
interconnect the carpals themselves and
are also known as interosseous or
intercarpal ligaments.
Volar carpal ligaments:
Volar extrinsic ligaments into two groups:
The radiocarpal
The ulnocarpal ligaments
The composite ligament known as the volar
radiocarpal ligament.
Three bands:
The radioscaphocapitate (radiocapitate)
Short and long radiolunate
(radiolunotriquetral)
Radioscapholunate ligaments
The radial collateral ligament may be
considered an extension of the volar
radiocarpal ligament and capsule.
The ulnocarpal ligament complex is
composed of the triangular
fibrocartilage complex .
The ulnolunate ligament
The ulnar collateral ligament.
Two volar intrinsic ligaments:
The scapholunate interosseous
ligament, which is being key factor in
maintaining scaphoid stability.
The second key intrinsic is the
lunotriquetral interosseous ligament .
This ligament is credited with
maintaining stability between the
lunate and triquetrum.
Injury to this leads to lunate
instability.
Dorsal carpal ligaments :
Dorsal radiocarpal ligament major
wrist ligament
The ligament whole converges on the
triquetrum from the distal radius
with possible attachments along thw
way to the lunate and the
lunotriqutral interosseous ligament.
A second dorsal
ligament is the
dorsal intercarpal
ligament which
course horizontally
from the triquetrum
to the lunate
,scaphoid and
trapezium.
The two together
from horizontal V
that contributes to
radiocarpal stability .
Function of wrist complex
The proximal row is an intercalated
segment, a relatively unattched
middle segment of three segments
linkage
It function as an intercalated
segment between the distal radius
and the relatively immobile segment.
Flexion and extension:
Range of flexion and extension:
65 to 85-flexion
60 to 85 extension
During flexion scaphoid seems to
show the greatest motion whereas
lunate moves least.
Conceptual framework for flexion
and extension:
Wrist flexion
Active extension is initiated at the distal
carpal row and at the firmly attached
metacarpals by the wrist extensor muscles
attached .
The distal carpals glide relatively fixed
proximal bones.
The ligaments spanning the capitate and
scaphoid draw the capitate and scaphoid
together into closed packed position.
Continued extensor
force noe moves the
combined unit of distal
carpal row and the
scaphoid on relatively
fixed lunate and
triquetrum.
At approximately 45
degree of extension of
the wrist complex the
scapholunate
interosseous ligament
brings the scaphoid and
lunate into closed
packed position.
Completion occurs as the proximal
articular surface of the carpals move
as a relatively solid unit on the radius
and triangular fibrocartilage
complex.
Radial and ulnar deviation:
Range of deviations:
15 to 21 of radial deviation
20 to 45 of ulnar deviation
The proximal row displays a unique
reciprocal motion .
In full radial deviation both the
radiocarpal and midcarpal joints are
in closed pack position.
Wrist instability
Injury to one or more of the
ligaments attached to the scaphoid
and lunate may diminish or remove
the synergistic stabilization of the
lunate and scaphoid.
When this occurs the scaphoid
behaves as an unconstrained
segment following its natural
tendency to collapse into flexion on
the volarly inclined surface of the
The base of the flexed scaphoid slides
dorsally on the radius and subluxes.
Released from scaphoid stabilization the
lunate and triquetrum together act as
an unconstrained segment following
their natural tendency to extend.
The muscular forces that bypass the
proximal carpals apply force to distal
carpals cause them to flex on the
extended lunate and triquetrum.
The flexed distal carpals glide dorsally
on the lunate and triquetrum
accentuating the extension of them.
This zigzag pattern of the three
segments is known as intercalated
segmental instability.
When the lunate assumes an
extended posture the presentation is
referred to as dorsal intercalated
segmental instability(DISI).
Scapholunate advanced collapse:

With sufficient ligamentous laxity the


capitate may sublux dorsally off the
extended lunate or commonly
migrate into gap between the flexed
scaphoid and extended lunate.
The progressive degentrative
problem from an untreated dorsal
intercalated segmental instability is
known as scapholunate advenced
collapse.
When the
ligamentous union of
the lunate and
triquertum is
disrupted through
injury .
The lunate and
triquetrum together
normally tend to
move toward
extension and offset
the tendency of
scaphoid to flex.
When lunate is no longer linked with
the triquetrum ,the lunate and
scaphoid together fall into flexion
and the triquetrum and distal carpal
row extend.
This ulnar perilunate instability is
known as volar intercalated
segmental instability (VISI)..
Muscles of the wrist
complex:
The primary role of the muscles of
the wrist complex is to provide a
stable base for the hand while
permitting positional adjustments
that allow for an optimal length
tension relationship in longer finger
muscles.
Volar wrist musculature:
Six muscles have tendons crossing the volar
aspect of the wrist and therefore are capable
of creating a wrist flexion movement.
These are:
Palmaris longus
The flexor carpi radialis
The flexor carpi ulnaris
The flexor digitorium superficialis
The flexor digitorium profundus
Flexor pollicis longus
The first three of these
muscles are primary
wrist muscles.
The last three are
flexors of the digits with
secondary action of
wrist
At wrist level all of the
volar wrist muscles pass
beneath the flexor
retinaculum along with
median nerve except
the palmaris longus and
the flexor carpi ulnaris
muscles.
Muscle Origin Insertion Action Innervation
palmaris medial distal half of flexes hand median nerve
longus epicondyle of flexor (at wrist) and (C7 and C8)
humerus retinaculum tightens
and palmaris palmar
aponeurosis aponeurosis
flexor common base of the flexes the median nerve
carpi flexor tendon second and wrist,
radialis from the third abducts the
medial metacarpals hand
epicondyle of
the humerus
flexor carpi common pisiform, hook flexes wrist, ulnar nerve
ulnaris flexor tendon of hamate, and adducts hand
& (ulnar base of 5th
head) from metacarpal
medial border
of olecranon
& upper 2/3 of
the posterior
border of the
ulna
flexor posterior base of the flexes the median nerve
digitorum border of distal phalanx metacarpop via anterior
profundus the ulna, of digits 2-5 halangeal, interosseous
proximal proximal branch (radial
two-thirds interphalan one-half);
of medial geal and ulnar nerve
border of distal (ulnar one-
ulna, interphalan half)
interosseou geal joints
s membrane
flexor humeroulnar shafts of the flexes the median nerve
digitorum head: middle metacarpoph
superficiali common phalanges of alangeal and
s flexor tendon; digits 2-5 proximal
radial head: interphalange
middle 1/3 of al joints
radius
flexor anterior base of the flexes the median nerve
pollicis surface of distal phalanx metacarpoph via anterior
longus radius and of the thumb alangeal and interosseous
interosseous interphalange branch
membrane al joints of
the thumb
Dorsal wrist musculature:
The dorsum of the wrist complex is crossed by the
tendons of nine muscles:
The extensor carpi radialis longus
The extensor carpi radialis brevis
The extensor carpi ulnaris
The extensor digitorium communis
The extensor indicis proprius
The extensor digiti minimi
The extensor pollicis longus
The extensor pollicis brevis
The abductor pollicis longus
Muscle Origin Insertion Action Innervati
on
extensor lower one-third dorsum of the extends the wrist; radial
carpi of the lateral second abducts the hand nerve
radialis supracondylar metacarpal
longus ridge of the bone (base)
humerus
extensor common dorsum of the extends the wrist; deep radial
carpi extensor third abducts the hand nerve
radialis tendon (lateral metacarpal
brevis epicondyle of bone (base)
humerus)
extensor common medial side of extends the wrist; deep radial
carpi extensor the base of adducts the hand nerve
ulnaris tendon & the the 5th
middle one-half metacarpal
of the posterior
border of the
ulna
extensor common joins the extends the deep radial
digiti extensor extensor metacarpophalange nerve
minimi tendon (lateral digitorum al, proximal
epicondyle of tendon to the interphalangeal and
extensor interosseou base of the extends the deep radial
pollicis s membrane proximal thumb at nerve
brevis and the phalanx of the
posterior the thumb metacarpop
surface of halangeal
the distal joint
radius
extensor interosseous base of the extends the deep radial
pollicis longus membrane distal phalanx thumb at the nerve
and middle of the thumb interphalange
part of the al joint
posterolateral
surface of the
ulna
The Hand complex

The hand consists of five digits :four fingers


and a thumb.
Each digit has
a carpometacarpal joint and
a metacarpophalangeal(MP)joint.
The fingers each have two
interphalangeal(IP)joint,
the proximal interphalangeal (PIP)and distal
interphalangeal(DIP),and
the thumb has only one.
Carpometacarpal joints of the
fingers:
The carpometacarpal joints of the
fingers are composed of the
articulations between
the distal carpel row and
the bases of the second through fifth
metacarpal joints.
The second metacarpal articulates
primarily with the trapezoid and
secondarily with the trapezium and
capitate.
The third metacarpal articulates
primarily with the capitate,and the
fourth metacarpal articulates with
the hamate.
The fifth metacarpal articulates with
the hamate.
The deep transverse metacarpal
ligament spans the heads of the
second through fourth metacarpals
volarly.
this ligament tethers together the
metacarpal heads and effectively
prevents the attached metacarpals
from any more than minimal
abduction at the carpometacarpal
joints.
Carpal Tunnel syndrome
When the median nerve becomes
compressed within the carpal tunnel,
aneuropathy known as carpel tunnel
syndrome(CTS)
the proximal edge of the transverse carpal
ligament is the most common site for wrist
flexion induced median nerve compression.
the tunnel is narrowest, however, at the
level of the hook of the hamate ,where
median nerve compression is unlikely to be
affected by changes in wrist position.
Carpometacarpal joint range of
motion
The second through fourth carpometacarpal
joints are plane synovial joints with one degree
of freedom: flexion/extension.
The second and third carpometacarpal joints are
essentilally immobile and may be considered to
have zero degrees of freedom.
The forth carpometacarpal joint has perceptible
flexion/extension.
The fifth carpometacarpal joint is a saddle joint
with two degrees of freedom,including
flexion/extension,some abductionand a limited
amount of opposition.
Palmar Arches
The function of the finger carpometacarpal
joints and their segments overall is to
contribute 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 other palmar arches can easily be
visualized as occuring transversely across
the plan and longitudinally down the palm.
The adjustable positions of the
first,fourth,and fifth metacarpal
heads around the relatively fixed
second and third metacarpals form a
mobile distal transverse arch at the
level of the metacarpal heads that
arguments the fixed proximal
transverse arch of the distal carpal
row.
The longitudinal arch transverses the
length of the digits from proximal to
distal.
The deep transverse metacarpal
The palmar arches allow the palm and the
digits to confirm optimally to the shape of
the object being held
This maximizes the amount of surface
contact,enhancing stability as well as
increasing sensory feedback.
The fifth carpometacarpal joint is crossed
and acted on by the opponens digiti
minimi(ODM)muscle.
This oblique is attached proximally to the
ulnar side of he fifth metacarpal.
It is optimally positioned,therefore,to flex
and rotate the fifth metacarpal about its
long axis.
Metacarpophalangeal joints of the
finger:
Each of the four
metacarpophalangeal joints of the
fingers is composed of the convex
metacarpal head proximally and the
concave base of the first phalanx
distally.
It is condyloid with two degrees of
freedom:
Flexion/extension
Abduction/adduction
Volar plates:
The volar plate or palmar plate at each of
the metacarpophalangeal joints is a unique
structure that increases joint congruence.
It provide stability by limiting
hyperextension and therefore provides
indirect support to the longitudinal arch.
It is composed of fibrocartilage and is firmly
attached to the base of the proximal
phalanx distally but not to the metacarpal
proximally.
The plates blends with and lies deep
to the metacarpophalangeal joint
capsule and the deep transverse
metacarpal ligament volarly.
In joint flexion ,the flexible
attachments of plate allow the plate
to slide proximally on the metacarpal
head without impeding motion.
The deep transverse metacarpal
ligament runs transversely across the
heads of the four
metacarpophalangeal joints of the
fingers.
Collateral ligaments:
The radial and ulnar collateral
ligaments of the
metacarpophalangeal joint are
composed of two parts:
The collateral ligament proper
The accessory collateral ligament
Range of motion:
The total range of motion varies
with each finger.
Flexion and extension increases
radially to ulnarlywith the index
finger having approximately 90
degree of metacarpophalangeal
joint flexion and the little
approximately 110 degree.
The index and little fingers have
more frontal plane mobility than
do the middle and ring fingers.
Interphalangeal joints of the
finger:
Each of the proximal interphalangeal
and distal interphalangeal joints of
the fingers is composed of the head
of a phalanx and the base of the
phalanx distal to it.
Each interphalangeal joint is a true
synovial hinge joint with one degree
of freedom :
Flexion /extension
Volar plates reinforce each of the
jinterphalangeal joint
capsule,enhance stability and limit
hyperextension.the plates at the
interphalangeal joints are structurally
and functionally identical to those at
the metacarpophalangeal joint
except that plates are not connected
by a deep transverse ligament.
Collateral ligaments of the
interphalangeal joints provide
stability.
Injuries to the collateral ligaments of
the proximal interphalangeal are
common,particularly in sports and
workplace injury
The lateral collateral of the index finger to
be strongest of the proximal
interphalangeal collateral ligament whereas
the fifth proximal interphalangeal joint had
weakest collateral ligaments.
The total range of flexion /extension
available to the index finger is greater at
the proximal interphalangeal joint (100 to
110) than it is at the distal interphalangeal
joint(80).
The ranges of pip and dip flexion at each
finger increases ulnarly with the fifth
proximal interphalangeal and distal
interphalangeal joint achieving 135 and 90 .
Anti deformity positioning
After trauma to the hand,a custom
fabricted splint is commonly provided
to immobilize the injured structures.
The purpose of this device is to
provide support and protection to the
injured region during the healing
process,while attempting to minimize
the potential problems at the joints
created by immobilization.
Because the collateral ligaments of the
metacarpophalangeal joints are slack
with extension ,immobilization in
metacarpophalangeal extension in a
splint would place the ligaments at risk
for adative shortening.
It will lead to limit in joint flexion and
distruption of longitudnal arch leading
to impairments in grasp and functional
use.
Extrinsic finger flexors:
Functionally the extrinsic muscles are
also divided into flexors and
extensors.
There are two extrinsic muscles that
contribute to finger flexion:
Flexor digitorium superficialis
The flexor digitorium profundus
The flexor digitorium superficialis
muscles primarily flexes the PIP joint
,but it also contributes to MCP joint
flexion.
The flexor digitorium profundus muscle
can flex the MCP,PIP and the DIP joints
and is considered to be the more active
of the two muscles.
Both the flexor digitorium superficialis
and flexor digitorum profundus musces
are dependent on wrist position for an
optimal length-tension relationship
Mechanisms of finger
flexion:
Optimal function of the flexor
digitorium superficialis and flexor
digitorium profundus muscles
depends not only on stabilization by
the wrist musculature but also on
intact flexor gliding mechanisms.
The gliding mechanisms consist of
the
Flexor retinacula
Bursae and digital tendon sheaths
The fibrous retinacular structures tether the
long flexor tendons to the hand;
The bursae and tendon sheaths facilitate
friction free excursion of the tendon on the
fibrous retinacula.
The retinacula prevent bowstringing of the
tendons that would result in loss of excursion
and work efficiency in the contracting muscles
that pass under them.
As the tendons of flexor digitorium superficialis
and flexor digitorium profundus muscle cross
the wrist to enter the hand ,they first pass
beneath the proximal flexor retinaculum and
trough the carpal tunnel under the transverse
carpal ligament.
The flexor digitorium superficialis and
flexor digitorium profundus tendons
of each finger pass through a fibro-
osseous tunnel that is comprised of :
five transversely oriented annular
pulleys or vaginal ligaments
And three cruciate pulleys.
The first two annular pulleys lie
closely together with one at the head
of metacarpal and second larger one
along volar midshaft of the proximal
phalanx.
The third annular pullry lies at the distal
most part of the proximal phalanx
Fourth lies centrally on the middle
phalanx
A fifth pulley may lie at the base of the
distal phalanx.
The three cruciate pulleys also tether the
long flexor tendons:
One is located between the A2 and A3
pulleys and is designated as C1.
The next C2 pulley lies between A3 and
A4 pulley
The last cruciate pulley C3 lies
between the A4 and A5 pulley.
The A4,A5,C3 structures contain only
flexor digitorium profundus tendon
because the flexor digitorium
superficialis muscles insert on the
middle phalanx proximal to these
stustures.
The thumbs has distinct pulley
system including two annular and
one oblique pulley.

Vascular supply to the gliding


mechanism is criticalto maintaining
synovial fluid and tendon nutrition
Direct vascularization of each tendon
occurs through vessels that reach the
tendon via the vincula tendinum.
These are folds of the synovial
membrane that carry blood vessels
to the body of the tendon.
Function:
The function of annular pulleys is to
keep the flexor tendons close to the
bone,allowing only a minimum
amount of bowstring and migration
volarly from the joint axes.
It enhances both tendon excursion
efficiency and work efficiency of long
flexors.
Trigger finger :
It is disability that can be created
when repetitive trauma to a flexor
tendon results inn the formation of
nodules on the tendon results in the
formation of nodules on the tendon
and thickening of an annular pulley.
During active finger flexion the
nodules gets caught beneath the
pulley requiring passive extension to
unlock the stuck flexed position.
Flexor gliding mechanism at MCP
joint:
The flexor gliding mechanism at the MCP
joint is particularly complex because of its
multilayered structure.
From deep to superficial at each of MCP
joints of the fingers,there are :
The fibrocartilaginous volar plate which is
in contact with the metacarpal head.
The fibrous longitudnal fibers of the MCP
joint capsule which blends with volar
aspect of the plate.
The fibers of the deep transverse
metacarpal ligament which has
grooves on its volar surface for the
long flexor tendons of the fingers and
forms the floor of the afibro-osseous
tunnel.
The flexor digitorium profundus
tendon which lies in the groove of
the transverse metacarpal ligament
The flexor digitorium superficialis
tendon,which lies just superficial to
the flexor digitorium profundus
The digital tendon sheaththat
envelops both flexors tendons
theA! Annular pulley that forms the
roof of the fibro-osseous tunnel and
lies most superficially in thos set of
interconnected layers.
Extrinsic finger extensors:
The extrinsic finger extensors are :
the extensor digitorum communis,
the extensor indicis proprius,and
the extensor digiti minimi mucles.
Each of these muscles passes from the forearm
to the hand beneath the extensor
retinaculum,which maintains proximity of the
tendons to the joints and improves excursion
efficiency of the extensor retinaculum and
is enveloped by an isolated bursa or tendon
sheath that generally ends as soon as the
tendons emerge distal to the extensor
retinaculum.
At approximately the level of the
metacarpophalangeal joint,the
extensor digitorum communis tendon
of each finger merges with a broad
aponeurosis known as
interchangeably as the extensor
expansion, the dorsal hood, or the
extensor hood.
Extensor mechanism:
The foundation of the extensor
mechanism is formed by the tendons
of the extensor digitorum communis
muscle, the extensor hood, the
central tendon, and the lateral bands
that merge into the terminal tendon.
The first two components that add to
the extensor mechanism are the
passive components of the triangular
ligament and the sagittal bands.
The lateral bands are interconnected dorsally
by a triangular band of superficial fibers known
as the triangular, or dorsal retinacular,
ligament. the triangular ligament helps
stabilize the bands on the dorsum of the finger.
the dorsal interossei(DI),volar
interossei(VI),and lumbrical muscles are the
active components of the extensor mechanism.
The dorsal interossei and volar interossei
,muscles are proximally from the sides of the
metacarpal joints.
Distally, some muscles fibers go deep to insert
directly into the proximal phalanx, whereas
others join with and become part of the hood
that wraps around the proximal phalanx.
The interossei muscles may also contribute fibres
to the central tendon and both lateral bands.
The lumbrical muscles attach proximally to the
flexor digitorum profundus tendons and distally to
the lateral band.
The lumbrical and interossei muscles are together
often referred to as the intrinsic muscles of the
fingers. With the addition of the oblique retinacular
ligaments (ORLs),the structure of the extensor
mechanism for each finger is complete.
Final passive elements that contribute to the
extensor mechanism are the oblique retinacular
ligaments. The oblique retinacular ligaments arise
from both sides of the proximal phalanx and from
the sides of the annular and cruciate pulleys
volarly.
Extensor mechanism influence on
Metacarpophalangeal joint function:
The extensor digitorium communis tendon
passes dorsal to the metacarpophalangeal joint
axis.
An active contraction of the muscles creates
tension on the sagittal bands of the extensor
mechanism, pulls the bands proximally over the
metacarpophalangeal joint, and extends the
proximal phalanx.
An isolated contraction of the extensor
digitorum communis muscle will result in
metacarpophalangeal joint hyperextension with
interphalangeal flexion.
The accompanying interphalangeal flexion is
produced by passive tension in the flexor
digitorum superficialis and flexor digitorum
profundus muscles when the
metacarpophalangeal joint is extended. This
position of fingers is known as clawing.
The zigzag pattern that occurs when a
compressive force is exerted across several
linked segments, one of which is an unstable
intercalated segment.
When the intrinsic muscles are weak or paralyzed
,the extensor digitorum communis muscle is
unopposed, and the fingers claw not only with
active metacarpophalangeal joint extension but
also at rest.
The clawing at rest demonstrates that
the passive tension in the intact
extensor digitorum communis muscle
exceeds the passive tension in the
remaining metacarpophalangeal joint
flexors. The clawed position is also
known as an intrinsic minus position
because it is attributed to the absence
of the finger intrinsic muscles.
Extensor Mechanism influence on
interphalangeal joint function:
The proximal interphalangeal and
distal interphalangeal joints are
joined by active and passive forces in
such a way that the distal
interphalangeal extension and
proximal interphalangeal extension
are interdependent.
When the proximal interphalangeal
joint is actively extended, the distal
interphalangeal joint will also extend.
Each proximal interphalangeal joint is crossed
dorsally by the central tendon and lateral bands of
the extensor mechanism.
The extensor digitorum communis,interossei,and
lumbrical muscles all have attachments to the hood,
central tendon,or lateral bands at or proximal to the
proximal interphalangeal joint.
An extensor digitorum communis muscle contraction
alone will not produce effective interphalangeal
extension.
An active contraction of a dorsal
interossei,volarinterossei, or lumbrical , muscle alone
is capable of extending the proximal interphalangeal
and distal interphalangeal joints completely because
of their more direct attachments to the central
tendon and lateral bands.
Two sources of tension in the extensor
expansion appear to be necessary to
fully extend the interphalangeal joints.
Source 1 is normally an active
contraction of one or more of the
intrinsic finger muscles.
Source 2 may be either an active
contraction of the extensor digitorum
communis muscle or passive stretch of
the extensor digitorum communis
muscle created by metacarpophlangeal
Intrinsic Finger Musculature:
Dorsal and volar interossei Muscles:
The dorsal interossei and volar interossei
muscles, arise from between the metacarpals
and are an important part of the extensor
mechanism. There are four dorsal interossei
muscles and three to four volar interossei
muscles.
The interossei muscle fibers join the extensor
expansions in two locations. Some fibers attach
proximally to the proximal phalanx and to the
extensor hood; some fibers attach more distally
to the lateral bands and central tendon.
The first dorsal interossei muscle has the
most consistent attachment of its group,
inserting entirely into the bony base of the
proximal phalanx and the extensor hood.
The dorsal interossei muscles of the middle
and ring fingers each have both proximal
and distal attachments. The little finger
does not have a dorsal interossei muscle.
The abductor digiti minimi(ADM) muscle
is,in effect, a dorsal interossei muscle and
typically has only a proximal attachment.
The three volar interossei muscles of the
fingers consistently appear to have distal
attachments only .
The first dorsal interossei muscle has only a
proximal attachment; the second ,third, and fourth
dorsal interossei muscles have both proximal and
distal attachments; the fifth dorsal interossei
muscle has only a proximal attachment; and the
three volar interossei muscles of the fingers have
only distal attachments.
All of the dorsal interossei and volar interossei
muscles pass dorsal to the transverse metacarpal
ligament but just volar to the axis for
metacarpophalangeal joint flexion/extension. All
the interossei muscles,therefore,are potentially
flexors of the metacarpophalangeal joint. The
ability of the interossei muscles to flex the
metacarpophalangeal joint,however,will vary
somewhat with matacarpophalangeal joint
position.
Wartenbergs sign:
In the ulnar nerve deficient hand ,the little
finger also assume a mcp joint abducted
position with loss of the intrinsic muscles.
Abduction of the little finger may be result
of the unbalanced pull of the extensor digit
minmi muscle among those individuals
having a direct connection of the extensor
digiti minimi muscle to the abductor
tubercle of the proximal phalanx.
Lumbrical muscles:
The only muscles in the body that attach at
both ends to tendons of other muscles .
Each muscles arses from a tendon of the
flexor digitorium profundus muscle in the
palmsses vol transverse metacarpal
ligament and attaches to the lateral band of
the extensor mechanism on the radial side.
It cross the MCP joint volarly and the
interphalangeal joint dorsally.
When the lumbrical muscles contracts
it pulls not only on its distal
attachment but also on its proximal
attachment.
Because proximal attachment of the
lumbrical muscle is on somewhat
movable tendon shortening of the
lumbrical muscle not only increases
tension in the lateral bands to extend
the interphalangeal joints but also
pulls the flexor digitorium profundus
tendon distally.
Structure of the Thumb:
Carpometacarpal joint of the Thumb:
The carpometacarpal joint of the thumb
is the articulation between the trapezium
and the base of the first metacarpal.
Unlike the carpometacarpal joints of the
fingers, the first carpometacarpal joint is
a saddle joint with two degrees of
freedom:
flexion/extension and
abduction/adduction.
The net effect at this joint is a
circumduction motion commonly
termed opposition. Opposition
permits the tip of the thumb to
oppose the tips of the fingers.
First Carpometacarpal Joint
Structure:
The first carpometacarpal joint surfaces
consist not only saddle-shaped surfaces but
also of a spherical portion located near the
anterior radial tubercle of the trapezium.
The saddle-shaped portion of the trapezium
is concave in the sagittal plane and convex
in the frontal plane.
The spherical portion is convex in all
directions. The base of the first metacarpal
has a reciprocal shape to that of the
trapezium.
Flexion/extension of the joint occurs
around a somewhat oblique A-P axis,
whereas abduction/adduction occurs
around a oblique coronal axis.
The first carpometacarpal joint ROM
as
an average of 53 degree of
flexion/extension,
42degree of abduction/adduction, and
17 degree of rotation.
The capsule of the carpometacarpal
joint is relatively lax but is reinforced
by radial,ulnar,volar,and dorsal
ligaments.
There is also an Intermetacarpal
ligament that helps tether the bases
of the first and second metacarpals,
preventing extremes of radial and
dorsal displacement of the base of
the first metacarpal joint.
The dorsoradial and anterior oblique
ligaments are reported to be key
stabilizers of the carpometacarpal joint.
Some investigators hold that the axial
rotation seen in the metacarpal during
opposition is a function of incongruence
and joint laxity.
Osteoarthritic (OA) changes with aging
are common at the first carpometacarpal
joint and may be attributable to the
cartilage thinning in high-load areas
imposed on this joint by pinch and grasp
across incongruent surfaces.
First Carpometacarpal joint
Function:
It is the unique range and direction of
motion at the first carpometacarpal joint
that produces opposition of the thumb.
Opposition is ,
sequentially,abduction,flexion,and
adduction of the first metacarpal, with
simultaneous rotation.
These movements change the
orientation of the metacarpal, bringing
the thumb out of the palm and
positioning the thumb for contact with
fingers.
When the first carpometacarpal joint
is fused in extension and adduction.
Opposition cannot occur.
The importance of opposition is such
that fusion of the first
carpometacarpal joint may be
followed over time by an adaptation
of the trapezioscaphoid joint that
develops a more saddle-shaped
configuration to restore some of the
lost opposition.
Metacarpophalangeal and
Interphalangeal joints of the Thumb:

The metacarpophalangeal joint of the


thumb is the articulation between the
head of the first metacarpal and the
base of its proximal phalanx.
It is considered to be a condyloid joint
with two degrees of freedom:
flexion/extension and
abduction/adduction.
The first metacarpophalangeal joint
is reinforced extracapsularly on its
volar surface by two sesamoid
bones.
These are maintained in position by
fibers from the collateral ligaments
and by an intersesamoid ligament.
They support this by noting that the
sesamoid bones of the first
metacarpophalangeal joint do not
appear until around 12 years of age.
The interphalangeal joint of the
thumb is the articulation between
the head of the proximal phalanx and
the base of the distal phalanx.
It is structurally and functionally
identical to the interphalangeal joints
of the fingers.
Thumb Musculature:
Extrinsic Thumb Muscles:
There are four extrinsic thumb
muscles :
the flexor pollicis longus (FPL),
extensor pollicis brevis (EPB),
extensor pollicis longus (EPL),
and abductor pollicis longus (APL)
muscles.
The flexor pollicis longus muscle is
located volarly.
The flexor pollicis longus muscle
inserts on the distal phalanx and is
the correlate of the flexor digitorum
pro-fundus muscles of the fingers.
The flexor pollicis longus tendon at
the wrist is invested by the radial
bursa, which is continuous with its
digital tendon sheath
The flexor pollicis longus muscle is
unique in that it functions
independently of other muscles and
is the only muscle responsible for
flexion of the thumb interphalangeal
.
The flexor pollicis longus tendon sits
between the sesamoid bones and appears
to derive some protection from those
bones.
Three of the thumb extrinsic muscles are
located dorsoradially.
The extensor pollicis brevis and abductor
pollicis longus muscles run a common
course from the dorsal forearm, traversing
through the first dorsal compartment and
crossing the wrist on its radial aspect.
The abductor pollicis longus muscle
inserts on the base of the metacarpal
joint, whereas the extensor pollicis
brevis muscle inserts on the base of
the proximal phalanx.
The abductor pollicis longus and
extensor pollicis brevis muscles also
radially deviate the wrist slightly.
.
The extensor pollicis longus muscle
originates in the forearm by the
abductor pollicis longus and extensor
pollicis brevis muscle but crosses the
wrist closer to the dorsal midline
before using the dorsal radial
tubercle as an anatomical pulley to
turn toward the thumb
Intrinsic Thumb Muscles:
There are four thenar muscles that
originate primarily from the carpal bones
and the flexor retinaculum.
The opponens pollicis(OP) is the only
intrinsic thumb muscle to have its distal
attachment on the first metacarpal. Its
action line is nearly perpendicular to the
long axis of the metacarpal joint and is
applied to the lateral side of the bone.
.
The abductor pollicis brevis,
flexor pollicis brevis.
Adductor pollicis, and first volar
interossei muscles all insert on the
proximal phalanx
The flexor pollicis brevis muscle has
two heads of insertion. Its larger
lateral heads attaches distally with
the abductor pollicis brevis muscle
and also applies some abductor
force.
the first dorsal interossei muscle is a
bipennate muscle arising from both the first
and second metacarpals and from the
intercarpal ligament that joins the
metacarpal bases.
The thenar muscles are active in most
grasping activities, regardless of the precise
position of the thumb as its participates.
The opponens pollicies muscle works
together most frequently with the abductor
pollicies brevis and the flexor pollicies
brevis muscles,although the intensity of the
relation varies.
The thumb is gently brought into
contact with any of the fingers, activity
of the opponens pollicies muscle
predominates in the thumb, and
abductor pollicies brevis activity
exceeds that of the flexor pollicies
brevis muscle.
Prehension:
Prehension activities of the hand involve
the grasping or taking hold of an object
between any two surfaces in the hand;
the thumb participates in most but not
all prehension tasks.
Prehension can be categorized as either
power grip or
precision handling .
each of these two categories has
subgroups that further define the grasp.
Power grip:
The fingers in power grip usually
function in concert to clamp on and
hold an object into palm.
The fingers assume a position of
sustained flexion that varies in
degree with the size, shape and
weight of the object.
The palm is likely to contour to the
object as th plamar arches from
around it.
These are :
Cylindrical grip
Spherical grip
Hook grip
Lateral prehension
Cylindrical grip:
This involves use of the flexors to position
the fingers around and maintain grasp on
an object.
The function in the fingers is performed
largely by the flexor digitorium profundus
especially in the dynamic closing action of
the fingers
In static phase, the FDS muscle assists
when intensity of the grip requires greater
force
Thumb position in cylindrical grip is
the most variable of the digits.
The thumb usually comes around the
object then flexes and adducts to
close the vise.
The flexor pollicis longus and thenar
muscles are all active.
Cylindrical grip is typically performed
with the wrist in neutral
flexion/extension and slight ulnar
deviation.
Spherical grip:
It is similar to cylindrical grip.
The extrinsic finger and thumb flexors
and thenar muscles follow similar
patterns of activity and variability.
The main distinction can be made by
the greater spread of the fingers to
encompass the object.
This evokes more interossous activity
The MCP joint abduct.
Opening the hand during object
approach and object release is
primarily an extensor function,
calling in activity of
The lumbricals
Extensor digitorium communis
And the thumb extrinsic muscles.
Hook grip:
It is specialized form of prehension.
It is function primarily of fingers.
It may include the palm but never
includes the thumb.
The major muscular activity is
provided by the flexor digitorium
profundus and flexor digitorum
superficialis muscles.
The thumb is held in moderate to full
extension by thumb extrinsic muscles.
Lateral prehension:
It is unique form of grasp.
Contact occurs between two adjacent
fingers.
The MCP and IP joints are usually
maaintaned extension as MCP joint
simultaneously adduct and abduct.
It is only form prehension in which
the extensor musculature
predominates in the maintenance of
the posture.
The extensor digitorium communis
and the lumbricals muscles are
active to extend the MCP and IP
joints
MCP joint abduction and adduction
are performed by the interossei
muscles.
Precision handling:
It is finer motor control and are more
dependent on intact sensation.
The thumb serves as one jaw of what has
been termed a two jaw chuck
The thumb is generally abducted and
rotated from the palm.
The second and opposing jaw is formed by
the distal tip ,the pad or the side of a finger.
When two fingers oppose the thumb it is
called a three-jaw chuck.
The three varieties of precision
handling :
Pad-to-pad prehension
Tip -to tip prehension
Pad-to-side prehension
Pad to-pad prehension:
It involves oppostion of the pad or pulp of
the thumb to the pad or pulp of the finger.
The pad of the distal phalanx of each digit
has the greatest concentration of tactile
corpuscles found in the body.
The MCP and proximal IP joints of the
finger are partially flexed with degree of
flexion being dependent on the size of the
object being held.
The thumb in pad to pad prehension
is held in carpometacarpal
flexion,abduction and rotation
The wrist is more typically held in
neutral radial/ulnar dviation and
slight extension.
Tip to-tip prehension:
In this IP joints of the finger and
thumb must have the range and
avilable muscles force to create
nearly full joint flexion.
The MCP joint of the opposing finger
must also be ulnarly deviated to
present the tip of the finger to the
thumb.
In first finger the ulnar deviation
occurs as MCP joint adduction.
In remaining fingers MCP abduction
produces ulnar deviation.
Activity of the FDP ,flexor pollicis
longus and interossei muscles is a
necessity.
Pad to-side prehension:
It is also known as key grip or lateral pinch
because key is held between the pad of
the thumb and side of the index finger.
The activity level of the flexor pollicis
brevis muscles increases and that of the
opponens pollicis muscle decreases in
comparison with tip-to tip prehension.
Slight lexion of the distal phalanx of the
thumb is required
The wrist will again assume neutral
flexion/extension and drop into slight
ulnar deviation to put the key in the
line with the forearm so that
pronation or supination can be used
to turn the key.
Functional position of the wrist and
hand:
The functional position is:
The wrist complex in slight extension
(20 degree) slight ulnar deviation(10
degree).
Fingers moderately flexed at MCP
joints(45 degree) and proximal IP
joints (30 degree) and slightly flexed
at distal IP joints