Chapter 7 The Wrist and Hand Manual of Structural Kinesiology R.T. Floyd, EdD, ATC, CSCS Many Archery, Relate wrist require sports require precise functioning of flexion, & hand & hand functional combined bowling, extension, anatomy golf, use abduction, of baseball, wrist to & joint adduction & hand tennis, actions joints of etc. wrist The Wrist & Hand 29 More 18 bones than are intrinsic 25 30 joints muscles 2007 McGraw-Hill Higher Education. All rights reserved. 7-1 2007 McGraw-Hill Higher Education. All rights reserved. 7-2 29 8 5 14 thumb bones, bones including 2 rows radius of 4 & bones ulna except metacarpal phalanges to the little thumb, bones, finger, (digits), join numbered 3 for the each wrist 1 phalange to bones form 5 from wrist Bones Thumb Other tendon Proximal, sesamoidsmay has middle, a sesamoidbone & which distal occur has in only in joints its 2flexor of fingers Eight Proximal to scaphoid(boat-shaped) carpal row bones lunate(moon-shaped) ulnarside navicularfrom radial Bones triquetrum(three-cornered) pisiform(pea-shaped) From Anthony CP, Kolthoff NJ: Textbook of anatomy and physiology, ed 9, St Louis, 1975, Mosby. 2007 McGraw-Hill Higher Education. All rights reserved. 7-3 2007 McGraw-Hill Higher Education. All rights reserved. 7-4 Eight Distal to trapezium carpal row, from bones trapezoid ulnarside (greater the radial multangular) (lesser Bones capitate(head-shaped) hamate(hooked) Scaphoidmost From Often Significant falling on often outstretched injured Usually treated dismissed properly long problem period as a if not sprain recognized hand& Bones immobilization or surgery of precise 2007 McGraw-Hill Higher Education. All rights reserved. 7-5 2007 McGraw-Hill Higher Education. All rights reserved. 7-6 1
Carpal concave bony creates arch bones is palmarside spanned form a three-sided by transverse arch frequently carpal tunnel ligaments the a carpal carpal & volar Bones source problems as syndrome carpal of tunnel known Medial epicondyle, Lateral medial & origin finger coranoidprocess for flexors condyloidridge, epicondyle many wrist -& Bones lateral ridge wrist &-origin supracondylar finger for extensors many & 2007 McGraw-Hill Higher Education. All rights reserved. 7-7 2007 McGraw-Hill Higher Education. All rights reserved. 7-8 Key distal bony landmarks for Key muscles motion base metacarpals, of involved 2nd, 3rd, pisiform, & in 5thwrist finger hamate bony muscles landmarks for & Bones base distal & distal of proximal, 1stmetacarpal, phalanxes middle, of thumb proximal & Wrist condyloid-type allows joint motion extension, adduction flexion, abduction, joint between occurs distal primarily radius proximal (scaphoid, triquetrum) carpal lunate, row && 2007 McGraw-Hill Higher Education. All rights reserved. 7-9 Wrist 70 65 15 25 to joint 90 85 25 40 degrees of flexion extension abduction adduction 2007 McGraw-Hill Higher Education. All rights reserved. 7-10 Each Metacarpophalangeal(MCP) Proximal Distal finger interphalangeal(dip) interphalangeal(pip) has 3 joints joints joints joints 2007 McGraw-Hill Higher Education. All rights reserved. 7-11 2007 McGraw-Hill Higher Education. All rights reserved. 7-12 2
Each Metacarpophalangeal(MCP) Condyloid 0 finger has 3 joints 85 to to 40100 degrees of extension of flexionjoints Each Proximal Ginglymus Full finger interphalangeal(pip) has 3 joints flexion extension to 90 to 120 degrees jointsof 2007 McGraw-Hill Higher Education. All rights reserved. 7-13 2007 McGraw-Hill Higher Education. All rights reserved. 7-14 Each Distal Ginglymus Flex finger interphalangeal(dip) 80 to has 903 degrees jointsfrom joints full extension Thumb Metacarpophalangeal(MCP) Full has 2 joints Ginglymus flexion extension into 40 to 90 joint degrees of 2007 McGraw-Hill Higher Education. All rights reserved. 7-15 2007 McGraw-Hill Higher Education. All rights reserved. 7-16 Thumb Interphalangeal(IP) Flex Ginglymus has 80 to 290 joints degrees joint Thumb Carpometacarpal(CMC) Unique 50 Flex to has 15 70 saddle-type to degrees 245 joints degrees of joint abduction & extend joint 0 of to thumb 20 degrees 2007 McGraw-Hill Higher Education. All rights reserved. 7-17 2007 McGraw-Hill Higher Education. All rights reserved. 7-18 3
Wrist Movements Flexion & extension Abduction & adduction Fingers Flex & extend MCP joints also abduct & adduct Movements Middle phalange is reference point to differentiate abduction & adduction Thumb, index & middle fingers abduct when they move laterally toward radial side of hand Ring & little fingers adduction when they move medially toward ulnar side of hand Medial movement of thumb, index & middle fingers toward ulnar side of hand is adduction Lateral movement of ring & little finger toward radial side of hand is abduction 2007 McGraw-Hill Higher Education. All rights reserved. 7-19 2007 McGraw-Hill Higher Education. All rights reserved. 7-20 Flexion Movements movement of palm of hand and/or phalanges toward anterior or volar aspect of forearm Extension Movements movement of back of hand and/or phalanges toward posterior or dorsal aspect of forearm 2007 McGraw-Hill Higher Education. All rights reserved. 7-21 2007 McGraw-Hill Higher Education. All rights reserved. 7-22 Abduction (radial flexion) Movements movement of thumb side of hand toward lateral aspect or radial side of forearm Also, movement of fingers away from middle finger Movements Adduction (ulnar flexion) movement of little finger side of hand toward medial aspect or ulnar side of forearm Also, movement of fingers toward middle finger 2007 McGraw-Hill Higher Education. All rights reserved. 7-23 2007 McGraw-Hill Higher Education. All rights reserved. 7-24 4
Movements Opposition movement of thumb across palmar aspect to oppose any or all of the phalanges Reposition movement of thumb as it returns to anatomical position from opposition with hand and/or fingers Extrinsic 6 according 3 muscles muscles to move function of wrist wrist & but location & hand not fingers grouped flexor palmaris wrist flexors carpi radialis ulnaris & thumb 3 extensor wrist extensors carpi radialis ulnarisbrevis 2007 McGraw-Hill Higher Education. All rights reserved. 7-25 2007 McGraw-Hill Higher Education. All rights reserved. 7-26 9 Also Generally Flexors muscles involved primary weaker in wrist in movers their joint wrist actions of actions phalanges digitorumsuperficialis digitorumprofundus Flexor pollicis (thumb flexor) Extensors extensor) digitorum indicis digitiminimi Extensor Abductor of pollicis thumb brevis(thumb & wrist extensor) 2007 McGraw-Hill Higher Education. All rights reserved. 7-27 2007 McGraw-Hill Higher Education. All rights reserved. 7-28 All Median anteromedial on wrist anterior epicondyle flexors aspect aspect generally of of wrist humerus proximal have & hand with their forearm insertions origins and on flexor through carpi nerve carpal ulnaris & tunnel all & flexor palmaris tendons except pass Carpal Swelling pressure function & sensation tunnel of & in median inflammation carpal function syndrome tunnel nerve its can resulting leading distribution cause to in increased reduced decreased motor particularly common with repetitive use of the hand and wrist in manual labor and clerical work such as typing and keyboarding Often, slight modifications in work habits and hand & wrist positions during these activities can be preventative Flexibility exercises for the wrist & finger flexors may be helpful 2007 McGraw-Hill Higher Education. All rights reserved. 7-29 2007 McGraw-Hill Higher Education. All rights reserved. 7-30 5
Wrist Flexor on located posterolateralaspect extensors on humeral posterior generally epicondyle aspect of have proximal of with wrist their insertions & forearm origins proximal & & extensor to wrist tendons immediately hand tissue to during dorsal prevent known flexion aspects the & tendons extension flexor are by transverse held & from extensor in place bowstringing bands retinaculum palmar of Wrist Generally posterolaterallyto hand Flexor abductors cross wrist insert joint on anterolaterally& carpi carpi radialis radial side of Abductor Extensor pollicis radialis brevis brevis 2007 McGraw-Hill Higher Education. All rights reserved. 7-31 2007 McGraw-Hill Higher Education. All rights reserved. 7-32 Wrist cross posteromediallyto hand Flexor adductors Extensor wrist carpi joint carpi ulnaris anteromedially& insert on ulnarside of ulnaris Intrinsic insertions Radial opponenspollicis abductor hand side on bones muscles -four of muscles hand have origins of thumb & flexor adductor pollicis pollicis brevis brevis Ulnarside opponensdigitiminimi abductor flexor digitiminimibrevis -three muscles of little finger 2007 McGraw-Hill Higher Education. All rights reserved. 7-33 2007 McGraw-Hill Higher Education. All rights reserved. 7-34 Intrinsic Remainder 3 4 lumbricals palmarinterossei dorsal hand of muscles hand -11 different muscles Anteromediallyat forearm hand Primarily and wrist anterior flexion elbow at & Flexorcarpiulnaris radialis Palmaris 2007 McGraw-Hill Higher Education. All rights reserved. 7-35 2007 McGraw-Hill Higher Education. All rights reserved. 7-36 6
Anteromediallyat elbow anterior Primarily phalangealflexion & at forearm wrist hand & and superficialis Flexor profundus digitorum pollicis Posterolaterallyat forearm hand Primarily and wrist posterior extension elbow at & Extensor brevis carpi radialis ulnaris 2007 McGraw-Hill Higher Education. All rights reserved. 7-37 2007 McGraw-Hill Higher Education. All rights reserved. 7-38 Posterolaterallyat forearm Primarily extension and wrist posterior & elbow phalangeal at hand & Extensorindicis Extensordigitiminimi digitorum Extensorpollicis Abductor brevis All the brachial wrist radial, & plexus hand median, muscles & ulnarnerves are innervated of the from Nerves 2007 McGraw-Hill Higher Education. All rights reserved. 7-39 2007 McGraw-Hill Higher Education. All rights reserved. 7-40 Radial Posterior nerve interosseousnerve from radialis C6, brevis C7, from & C8 digitorum digitiminimi carpi ulnaris radial nerve Nerves Abductor Extensor indicis pollicis brevis Median Anterior Palmaris nerve digitorumsuperficialis carpi radialis -arising from C6, C7, C8, & T1 Flexor interossseousnerve digitorumprofundusfor pollicis from index median & long nerve finger Nerves Intrinsic abductor 2ndlumbrical (superficial muscles pollicis head), brevis, opponenspollicis, flexor pollicis and brevis 1st& 2007 McGraw-Hill Higher Education. All rights reserved. 7-41 2007 McGraw-Hill Higher Education. All rights reserved. 7-42 7
Ulnarnerve from Flexor for 4th& C8 carpi digitorumprofundus & 5thfingers T1-branching ulnaris Nerves Ulnarnerve T1 Remaining flexor adductor dorsal pollicis intrinsic -branching pollicis, brevis(deep muscles palmarinterossei, from head), C8 & lumbrical, abductor interossei, opponensdigitiminimi, 3rd& 4th Nerves Sensation one-half finger digitiminimibrevis of to ring ulnarside finger & of entire & hand, flexor little ulnar 2007 McGraw-Hill Higher Education. All rights reserved. 7-43 2007 McGraw-Hill Higher Education. All rights reserved. 7-44 Flexion of wrist Abduction of wrist Weak flexion of elbow Weak pronation of forearm Flexor Carpi Radialis Muscle Flexion of wrist Weak flexion of elbow Palmaris Longus Muscle 2007 McGraw-Hill Higher Education. All rights reserved. 7-45 2007 McGraw-Hill Higher Education. All rights reserved. 7-46 Flexion of wrist Adduction of wrist, together with extensor carpi ulnaris muscle Weak flexion of elbow Flexor Carpi Ulnaris Muscle Extensor Carpi Ulnaris Muscle Extension of wrist Adduction of wrist together with flexor carpi ulnaris muscle Weak extension of elbow 2007 McGraw-Hill Higher Education. All rights reserved. 7-47 2007 McGraw-Hill Higher Education. All rights reserved. 7-48 8
Extensor Carpi Radialis Brevis Muscle Extensor Carpi Radialis Longus Muscle Extension of wrist Abduction of wrist Weak flexion of elbow Extension of wrist Abduction of wrist Weak flexion of elbow Weak pronation to neutral from a fully supinated position 2007 McGraw-Hill Higher Education. All rights reserved. 7-49 2007 McGraw-Hill Higher Education. All rights reserved. 7-50 Flexor Digitorum Superficialis Muscle Flexion of fingers at metacarpophalangeal & proximal interphalangeal joints Flexion of wrist Weak flexion of elbow Flexor Digitorum Profundus Muscle Flexion of 4 fingers at metacarpophalangeal, proximal interphalangeal, & distal interphalangeal joints Flexion of wrist 2007 McGraw-Hill Higher Education. All rights reserved. 7-51 2007 McGraw-Hill Higher Education. All rights reserved. 7-52 Flexor Pollicis Longus Muscle Flexion of thumb carpometacarpal, metacarpophalangeal, & interphalangeal joints Flexion of wrist Abduction of wrist Extensor Digitorum Muscle Extension of 2 nd, 3 rd, 4 th, & 5 th phalanges at metacarpophalangeal joints Extension of wrist Weak extension of elbow 2007 McGraw-Hill Higher Education. All rights reserved. 7-53 2007 McGraw-Hill Higher Education. All rights reserved. 7-54 9
Extensor Indicis Muscle Extension of index finger at metacarpophalangeal joint Weak wrist extension Weak supination of forearm from a pronated position Extensor Digiti Minimi Muscle Extension of little finger at metacarpophalangeal joint Weak wrist extension Weak elbow extension 2007 McGraw-Hill Higher Education. All rights reserved. 7-55 2007 McGraw-Hill Higher Education. All rights reserved. 7-56 Extensor Pollicis Longus Muscle Extension of thumb at carpometacarpal, metacarpophalangeal, & interphalangeal joint Extension of wrist Abduction of wrist Weak supination of forearm from a pronated position Extensor Pollicis Brevis Muscle Extension of thumb at carpometacarpal & metacarpophalangeal joints Weak wrist extension Wrist abduction 2007 McGraw-Hill Higher Education. All rights reserved. 7-57 2007 McGraw-Hill Higher Education. All rights reserved. 7-58 Abductor Pollicis Longus Muscle Intrinsic of the Hand Abduction of thumb at carpometacarpal joint Abduction of wrist Extension of thumb at carpometacarpal joint Weak supination of forearm from a pronated position Weak flexion of wrist 2007 McGraw-Hill Higher Education. All rights reserved. 7-59 Modified from Van De Graaff KM: Human anatomy, ed 4, New York, 1995, McGraw-Hill. 2007 McGraw-Hill Higher Education. All rights reserved. 7-60 10
Intrinsic of the Hand Thenar eminence - muscular pad on palmar surface of 1 st metacarpal abductor pollicis brevis opponens pollicis flexor pollicis brevis adductor pollicis Intrinsic of the Hand Hypothenar eminence - muscular pad that forms ulnar border on palmar surface abductor digiti minimi flexor digiti minimi brevis opponens digiti minimi Intermediate muscles three palmar interossei four dorsal interossei four lumbrical muscles 2007 McGraw-Hill Higher Education. All rights reserved. 7-61 2007 McGraw-Hill Higher Education. All rights reserved. 7-62 Intrinsic of the Hand Four muscles act on CMC of thumb opponens pollicis - opposition in thumb metacarpal abductor pollicis brevis & flexor pollicis brevis abduct thumb metacarpal flexor pollicis brevis flexes thumb metacarpal adductor pollicis adducts thumb metacarpal flexor pollicis brevis & adductor pollicis flex proximal phalanx of thumb Intrinsic of the Hand Three palmar interossei adduct the 2 nd, 4 th, & 5 th phalanges Four dorsal interossei flex & abduct index, middle, & ring proximal phalanxes assist with extension of middle & distal phalanxes of index, middle, & ring fingers Third dorsal interossei adducts middle finger 2007 McGraw-Hill Higher Education. All rights reserved. 7-63 2007 McGraw-Hill Higher Education. All rights reserved. 7-64 Intrinsic of the Hand Four lumbricales flex index, middle, ring, & little proximal phalanxes extend middle & distal phalanxes of index, middle, ring, & little fingers. Three muscles act on little finger opponens digiti minimi causes opposition of little finger metacarpal abductor digiti minimi abducts 5 th metacarpal flexor digiti minimi brevis flexes 5 th metacarpal 2007 McGraw-Hill Higher Education. All rights reserved. 7-65 Flexorcarpi Palmaris radialis Wrist Flexion ulnaris Flexor superficialis profundus digitorum pollicis 2007 McGraw-Hill Higher Education. All rights reserved. 7-66 11
Wrist Flexion Wrist Extension radialis radialis brevis ulnaris Flexor carpi radialis Flexor carpi ulnaris Palmaris Flexor digitorum Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis Extensor pollicis brevis superficialis Flexor digitorum profundus Flexor pollicis 2007 McGraw-Hill Higher Education. All rights reserved. 7-67 2007 McGraw-Hill Higher Education. All rights reserved. Wrist Extension 7-68 Wrist Extension radialis radialis brevis ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis Extensor pollicis brevis 2007 McGraw-Hill Higher Education. All rights reserved. radialis radialis brevis ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis 7-69 Extensor pollicis brevis 2007 McGraw-Hill Higher Education. All rights reserved. Wrist Abduction Wrist Abduction Flexor carpi radialis radialis radialis brevis Abductor pollicis Flexor carpi radialis radialis radialis brevis Abductor pollicis Extensor pollicis Extensor pollicis brevis 2007 McGraw-Hill Higher Education. All rights reserved. 7-70 Extensor pollicis Extensor pollicis brevis 7-71 2007 McGraw-Hill Higher Education. All rights reserved. 7-72 12
Flexor Extensor ulnariscarpi carpi Wrist Adduction superficialis digitorum profundus Phalangeal Flexion Flexor pollicis 2007 McGraw-Hill Higher Education. All rights reserved. 7-73 2007 McGraw-Hill Higher Education. All rights reserved. 7-74 digitorum minimi indicis digiti Phalangeal Extension Extensor brevis pollicis digitorum minimi indicis digiti Phalangeal Extension Extensor brevispollicis 2007 McGraw-Hill Higher Education. All rights reserved. 7-75 2007 McGraw-Hill Higher Education. All rights reserved. 7-76 Web Sites Radiologic Anatomy Browser http://radlinux1.usuf1.usuhs.mil/rad/iong/index.html This site has numerous radiological views of the musculoskeletal system. University of Arkansas Medical School Gross Anatomy for Medical Students http://anatomy.uams.edu/anatomyhtml/grossresources.html Dissections, anatomy tables, atlas images, links, etc. Loyola University Medical Center: Structure of the Human Body www.meddean.luc.edu/lumen/meded/grossanatomy/ga.html An excellent site with many slides, dissections, tutorials, etc., for the study of human anatomy Wheeless Textbook of Orthopaedics www.wheelessonline.com/ This site has an extensive index of links to the fractures, joints, muscles, nerves, trauma, medications, medical topics, lab tests, and links to orthopedic journals and other orthopedic and medical news. 2007 McGraw-Hill Higher Education. All rights reserved. 7-77 Web Sites Arthroscopy.Com www.arthroscopy.com/sports.htm Patient information on various musculoskeletal problems of the upper and lower extremity Premiere Medical Search Engine http://www.medsite.com/default.asp?bhcp=1 This site allows the reader to enter any medical condition and it will search the net to find relevant articles. Virtual Hospital www.vh.org Numerous slides, patient information, etc. Medical Multimedia Group www.healthpages.org/ahp/library/hlthtop/ctd/ A Patient's Guide to Cumulative Trauma Disorder(CTD) 2007 McGraw-Hill Higher Education. All rights reserved. 7-78 13
Web Sites Medical Multimedia Group www.healthpages.org/ahp/library/hlthtop/cts/ctsndx.htm A Patient's Guide to Carpal Tunnel Syndrome Physioroom.com www.physioroom.com/injuries/arm/index.shtml Articles on hand and wrist injuries Dartmouth Medical School www.dartmouth.edu/~anatomy/wrist-hand/muscles/ of the wrist and hand American Academy of Orthopaedic Surgeons http://orthoinfo.aaos.org/category.cfm?topcategory=arm Patient Education Library on the Hand MayoClinic.com www.mayoclinic.com/invoke.cfm?id=ar00030 Hand exercises for people with arthritis Web Sites American Society for Surgery of the Hand http://www.assh.org/content/navigationmenu/patientspublic/ HandConditions/ExtensorTendonInjuries/Extensor_Tendon_In j.htm Extensor Tendon Injuries 2007 McGraw-Hill Higher Education. All rights reserved. 7-79 2007 McGraw-Hill Higher Education. All rights reserved. 7-80 14