[Type text] The Hand

Boutonniere deformity (tendon rupture)

Anatomy
Close packed structure with intricate tendon attachments and a high density neurological supply Blood supply: Brachial aa-> radial & ulnar aa-> ant/ post interosseous aa, then to palmar and dorsal carpal branches and palmar/ dorsal carpal arches Venous drainage: Deep and superficial venous arches -> ulnar/ radial/ interosseous veins. Bones: st th 1 (lateral) to 5 (medial) metacarpals, 5 proximal phalanges, 4 middle phalanges (thumb doesnt have one), 5 distal phalanges. Joints: carpals -metacarpals (CMC), 5 Intermetacarpal, 3 metacarpals -phalanges (MCP), 5 st Interphalangeal (1 IP) of thumb and 4 Proximal Interphalangeal joints (PIP) of digits 2-5 4 Distal Interphalangeal joints (DIP) of digits 2-5 Functions Evolution: Opposition Strut system: mobility on the periphery and stability medially Main function of the wrist is to sub-serve hand function Orientate the hand in space main function of the upper limb The distal radio-ulna joint permits extensive forearm rotation while the radio-carpal joint integrity is maintained so that the hand may function in various rotational positions.
allows a remarkable amount of torque to be delivered to the otherwise stabilised radio-carpal complex without interfering with flexion/extension or radio/ulna deviation

Radio-Carpal joint

biaxial ellipsoid joint Active mvmnts: Flex, ext, abd, add, circumduction Passive: ant&post shift, txx, compression, spring of the carpal arch Ligaments: 5 major ligaments: (a) Palmar radio-carpal ligament (b) Palmar ulna-carpal ligament (c) Dorsal radio-carpal ligament (d) Radial collateral ligament (e) Ulnar collateral ligament (f) Radiate capitates lig: axis of movement

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Intercarpal articulation

Carpometacarpal joints (CMC) Blood supply-dorsal/ palmar carpal arches, deep palmar arch, metacarpal arteries Nerve supply- ant. interosseous of Median, post. interosseous radial, dorsal/ deep branches of ulnar st st 1 (thumb) Saddle synovial joint between 1 Met and trapezium, separate to other CMC joints Ligaments Capsule reinforced by palmar and dorsal ligs and ulnar and radial collateral lig (ulnar Movements stronger): medial stability and lateral mobility Orientation of 45 Flex/ext, adb/add, circumduction, limited axial rotation and opposition/ reposition Carpals/Mets 2- Plane joints, common joint capsule and synovial cavity. Continuous with intermetacarpal 5 joints. Ligaments Loose capsule, palmar and dorsal ligs (movement also limited by interosseous ligs between metacarpal bases and superficial and deep transverse ligs between heads) nd rd th th Movements Virtually none for 2 / 3 mets, 4 more mobile, 5 most mobile on opposition Intermetacarpal Plane joints common capsule with CMC joints (not thumb) /Mets 2-5 bases Ligaments Loose capsule, palmar and dorsal ligs , interosseous ligs between metacarpal bases and superficial and deep transverse ligs between heads nd rd th th Movements Virtually none of 2 / 3 mets, 4 more mobile, 5 most mobile on opposition: Metacarpophalangeal joints (MCP) Condyloid synovial Blood supply- deep digital arteries arising from superficial palmar arches Nerve supply- digital nerves of Ulnar and Median nerves Thumb:valgus injury, buttonhole injury Ligaments Palmar lig (volar plate, thick and densely fibrous with groove for flexor sheath) with check ligaments to prevent hyperextension, collateral ligaments (taut in flexion, limiting abd/ add: delicated task can be carried out) Deep and superficial transverse ligs beween met heads st Movements flex/ ext, abd/add, limited axial rotation. (1 MCP (thumb) more limited in movement Proximal Interphalangeal joints (PIP) Hinge Blood supply (as for MCP) Nerve supply (as for MCP) ligaments Collateral ligs reinforce the capsule, palmar plate with strong, taut check ligs, dorsal extensor apparatus movements Flexion, extension (limited by palmar ligament) Distal Interphalangeal joints (DIP) Hinge Blood and nerve supply as for DIP Ligaments Collateral ligs reinforce the capsule, palmar plate with check ligs (laxity varies), dorsal extensor apparatus Movements Flexion (limited compared to PIP) Extension

Muscles
Long muscles of forearm M (C6, C7) Flexor Carpi Radialis M (C6, C7) Palmaris longus Flexor Carpi Ulnaris Flexor Digitorum
U (C8,T1)

Medial epicondyle Medial epicondyle Medial epicondyle Sup-post. border of ulna Medial epicondyle,

2 + 3 Mets Flex. Retinaculum, palmar aponeurosis Pisiform, Hamate, base th of 5 Met Middle Phalanx of digits

nd

rd

Flexion, abduction, radial deviation @ wrist Weak hand flexion Flexion, adduction, ulnar deviation @ wrist Flexion @ PIP, MCP,

M (C6, C7)

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Superficialis coronoid process (ulna) oblique line of radius Ulna Radius, interosseous memb. Lat. Supracondylar ridge of humerus Lateral epicondyle Lateral epicondyle Lateral epicondyle Lateral epicondyle Radius, ulna , interosseous membrane Radius, interosseous membrane Ulna, interosseous membrane Ulna 2-5 Wrist joints

Flexor Digitorum profundus Flexor pollicis longus Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Abductor Pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis

M (C6, C7) U (C8,T1) M (C6, C7)

R (C6, C7) R (C6, C7) R (C6, C7) R (C6, C7, C8) R (C6, C7, C8) R (C6, C7, C8)

Base distal phalanges digits 2-5 Base distal phalanx of thumb nd Base 2 Met Base 3 Met Distal + middle phalanges digits 2-5 th Tendon of ED of 5 digit th Base 5 Met 1 Met
st st rd

R (C6, C7, C8) R (C6, C7, C8) R (C6, C7, C8)

Base 1 prox phalanx Base 1

st

distal phalanx
nd

Tendon of ED of 2 digit 1 Met

st st

Flexion @ IP, MCP and wrist joints Flexion @ IP, MCP of thumb Extends, abducts hand @ wrist Extends, abducts hand @ wrist Extends DIP, PIP, MCP, digits 2-5 and wrist th Extends 5 digit @ MCP and extends wrist Extends, abducts hand @ wrist Extends/ abducts thumb @ CMC joint & abducts wrist Extends thumb @ MCP, CMC joint & wrist Extends thumb @ IP, MCP, CMC joint & wrist nd Extends 2 digit @ DIP, PIP, MCP joints and wrist Rotates thumb + other thenar eminence mm to oppose thumb Abducts thumb,assists opponens Flexes MCP of thumb, assists opponens Enables extension @ IP joints while MCP joints flexed Adducts thumb Rotates 5 met + other hypothenar eminences mm to oppose little finger Abducts little finger Flexes little finger at MCP joint Corrugate skin of palm Adduct fingers towards digit 3 (middle), flexion @ MCP joint Abduct fingers away from digit 3, flexion @ MCP joint
th

Intrinsic hand muscles M (C6, C7) Opponens Pollicis Abductor pollicis brevis Flexor pollicis brevis Lumbricals (4)
M (C6, C7) M (C6, C7) Lateral 2 = M
(C6, C7)

trapezium, flexor retinaculum Scaphoid, trapezium, flexor retinaculum st 1 Met, trapezium, flexor retinaculum Tendons of FDP

Medial 2 = U

Base of 1 prox phalanx st Base of 1 prox phalanx Extensor hood of ED (lateral aspects) Base of 1 prox phalanx th 5 Met
th st

Adductor pollicis Opponens digiti minimi Abductor Digiti minimi Flexor digiti minimi brevis Palmaris brevis Palmar interossei Dorsal interossei

(C8) U (C8,T1)

U (C8,T1)

2 + 3 Mets, capitate, trapezoid Flexor retinaculum, hook of hamate Pisiform, tendon of FCU Flexor retinaculum, hook of hamate Flexor retinaculum, palmar aponeurosis Met 1,2,4,5

nd

rd

U (C8,T1) U (C8,T1) U (C8,T1) U

(C8,T1)

Base of 5 prox phalanx th Base of 5 prox phalanx Skin of palm Prox. Phalanges of 1,2,4,5 Prox. Phalanges of 2,3,4

U (C8,T1)

Adjacent sides of Mets 1-5

[Type text] Vindicater Vascular Inflammatory Neurological Degenerative Infection Congenital Autoimmune Trauma Endocrine Rheumatologic
Dupuytrens contracture Volkmanns Contracture, Raynaulds, tenosynovitis s due to nerve entrapment proximally e.g CTS, thoracic outlet syndrome, cervical radiculopathy, TIA/ CVA syringomyelia, peripheral neuropathy, reflex sympathetic dystrophy st OA (esp 1 CMC, MCP), extensor pollicis longus rupture May track via synovial sheath to forearm, paronychia (nailbed infection)/ fungal Thalidomide, trigger thumb (25%) FOOSH, direct impact/ crushing => tendon avulsion, # Disorders producing CTS, RA, arthritis mutilans, psoriasis

Common Problems
Fibrous contracture of palmar fascia causing flexion contractures of fingers (esp digits 4 & 5) @ MCP and IP joints in causasian males between 40-60 yoa, also congenital, epileptics, diabetics, alcoholism, liver, hypothyroid disease and also familial component. s Painless thickening of palmar skin + underlying fascia +/- dimples or nodules. Begins nr. Distal palmar creases, mainly digits 4 & 5. 40% = bilateral. is rare. ROM into extension of affected digits is TTT Surgical excision of fibrous part of palmar aponeurosis. May recur. Ischaemic contracture of long flexor muscles of fingers and pronators, (damage to belly in forearm) E.g. following tight plastercast/ injury to brachial artery Cold, dark ischaemic arm, pulse, on finger extension Intermittent ischaemic attacks of hands esp when stressed/ cold (usually bilateral)causing cyanosis/ blanching, parasthesia/ . More common in females and also connective tissue diseases e.g. SLE Due to disturbance in sympathetic vasomotor activity. TTT with Ca2+ channel blockers e.g. nifedipine Inflammation of tendon sheathes Due to overuse/ RSI, XS stress on tendon/ RA, infection Usually affects ECU, AbdPL, EPB s- movement and on passive+ active movement of affected muscle. th If affecting 5 digit may track into palm and carpal tunnel If affecting thumb, via sheath of FPL to radial bursa If AbdPL or EPB, then called DeQuervains. Overuse, knitting/ wringing clothes = common triggers (common in women) s = aching discomfort over styloid process of radius RAD to hand/ forearm and agg. by wrist flexion, adduction, A/R abduction and extension of thumb, pinching is reproduced by Finkelsteins test. (flex & ulnar deviate wrist with thumb tucked into fist) TTT- rest/ cortisone/ surgery Rupture / avulsion of insertion of extensor digitorum tendon to middle phalanx producing PIP flexion and DIP extension. Caused by direct blow/ crush, forced flexion of PIP, minor trauma if tendon already weakened by e.g. RA s initially swelling, , ROM.later good active ROM in flexion @ all joints, but active extension @ PIP. When PIP passively extended, active flexion of DIP lost due to tension in intrinsics.

Volkmanns contracture

Raynauds

Tenosynovitis

Boutonniere deformity

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Swan neck deformity Mallet finger TTT- splint PIP in hyperextension leaving DIP free for 6-8wks, Exx active flexion of DIP Common in RA Contraction and spasm of intrinsic muscles causes hyperextension @ PIP and and MCP joint subluxes palmwards and becomes flexed. Rupture / avulsion of distal extensor tendon Caused by direct blow, violent flexion of distal phalanx, lacerations s- distal phalanx in flexion with active extension at DIP TTT- splint for 6 wks st Rupture/chronic laxity of collateral ligs of 1 MCP (thumb) Usually caused by traumatic hyperabduction of thumb Rupture of EPL tendon as it pulls round listers tubercle of radius Predisposed by Colles #, general wear & tear/ overuse s- extension at IP of thumb TTT- after healing, tendon graft Nodule on tendon/ thickening of sheath which prevents smooth gliding of tendon. 25% congenital, also s- snap/ locking on flexion (sometimes extension) of thumb @ MCP TTT- steroid injection, surgery Nodule on tendon/ thickening of sheath which prevents smooth gliding of tendon. More common in RA, diabetes, middle aged females s- initially difficulty flexing smoothly, then locking in flexion, (no active extension), clicking/ snapping on passive extension, pain TTT- steroid injection, surgery Usually bilateral, symmetrical inflammation of joints (esp. females 30-40yoa) Esp wrist (may present as CTS), MCP joints and PIP joints s swelling, pain and ROM in affected joints (multiple), worse am, difficulty with buttons/ writing. Also with systemic signs. Late signs are ulnar deviation @ MCP and complications like boutonieres deformity, swan neck deformity TTT- Education, support groups, Exx, Dietary advice, DMARDSs NSAIDs Severe, acutely inflamed joints (usually PIP) Psoriatic plaques on extensor surfaces and systemic signs (may have pitting/ thickening of fingernails Non inflammatory wear of articular surfaces and formation of new bone. Common in CMC and MCP joints of thumb, and DIP of digits 2-5 in Pts over 45yoa s insidious onset pain and stiffness with ROM, heberdens nodes(DIP), slight stiffness after rest (morning) which wears off with use. (late stage lateral deviation @ DIP joints Scaphoid (dual blood supply), colles # Carpal bones tend to dislocate dorsali. Lunate tends to dislocate distally and it can lead to CTS Congenital deformity of the ulna Only appears apparent at the age of 10- the wrist is deviated anteriorly leaving the ulnar head protecting posteriorly May require surgical intervention in severe cases

Skiers thumb Ext. pollicis longus rupture

Trigger thumb

Trigger finger

RA

Psoriatic arthropathy OA

# Subluxation Median nerve/ulnar nerve Madelungs deformity