Clinical Approaches to
the Wrist and Hand
Dr. Matthew Szarko
anatomyconsultancy@gmail.com
Clinical Anatomy
Wrist Anatomy
• Ulna
– Styloid process
• Styloid process of ulna connected to triquetral and
pisiform bones by ulnar carpal ligament.
– Triangular fibrocartilage
Wrist Anatomy
• Radius
– Articulating surface for scaphoid and
lunate
• Radioulnar joint
– Head of ulna-ulnar notch on distal
radius
– Motion: Supination and pronation
Wrist Anatomy
• Colle’s Fracture
– Complete transverse fracture within distal 2 cm of radius.
– Distal fragment displaced dorsally.
– Results from forced dorsiflexion (fall from outstretched limb)
– Dinner fork deformity
Wrist Anatomy
• Carpals
– Proximal Row
• Moveable
• Scaphoid
• Lunate
• Triquetrum
• Pisiform
– Within flexor carpi
ulnaris tendon-
enhances mechanical
advantage.
Wrist Anatomy
• Carpals
– Distal Row
• Immobile
• Trapezium
• Trapezoid
• Capitate
• Hamate
Hand Anatomy
• Metacarpals
– I-V
– Head
– Neck
• Phalanges
– Proximal
– Intermediate
– Distal
Hand Anatomy
• Joints
– Carpometacarpal (CMC)
Joints
– Metacarpophalangeal
(MCP)Joints
– Interphalangeal
• Proximal Interphalangeal
Joint (PIP)
• Distal Interphalangeal Joint
(DIP)
• Digital articulations all
designed to function in
flexion.
Arches of the Hand
• Intrinsic hand muscles maintain
arches
Distal Transverse
• Proximal Transverse Head of 3rd metacarpal as
– Capitate as keystone keystone
– Relatively flexed Passes through all the
– Along immobile distal carpal row metacarpal heads
More mobile
Arches of the Hand
• Longitudinal
– Connects transverse arches.
– Central pillar- 2nd and 3rd metacarpals
– Thumb- 4th, 3rd-5th finger flexion
allows palm to flatten or cup.
• Try this! Cup hand and move index finger
Arches of the Hand
• Similar to foot
• Two longitudinal arches and 1
transverse arch.
• Hand more transverse (opposition)-
foot more longitudinal-foot flexion-
extension.
Muscles at the Wrist
• Motors of the wrist
– Flexor carpi radialis, Flexor carpi ulnaris,
Palmaris longus
– Extensor carpi radialis longus/brevis,
Extensor carpi ulnaris
– Control radial/ulnar deviation as well as
flexion/extension.
– Flexor carpi radialis
• Flex and abduct hand at wrist
Anterior Compartment
– Palmaris longus
• Flex hand at wrist
– Flexor carpi ulnaris
• Flex and adduct hand at
wrist
– Flexor pollicis longus
• Flex thumb IP joint
• Continued flexion MP and
CMC of thumb.
– Pronator quadratus
Muscles of the Digits
– Flexor digitorum
superficialis
• Flex intermediate phalanx
• Continued action flexes 1st
phalanx at hand
• Flexes hand at wrist, forearm
at elbow
– Flexor digitorum profundus
• Flex distal phalanx after
passing through tendon of
FDS
• Flex hand at wrist
Muscles of the digits
• Test FDS and FDP independently
– If DIPs can flex but PIPs cannot, there is a problem
with FDS.
Posterior Compartment
– Brachioradialis
• Assists elbow flexion
• Semipronator/semisupinator
of forearm (bring to neutral
position)
Muscles of the wrist
– Extensor carpi radialis longus
• Extends and abducts hand at
wrist
– Extensor carpi radialis brevis
• Extends and abducts hand at
wrist
• Prime hand dorsiflexor.
– Extensor carpi ulnaris
• Extends and adducts hand at
wrist
Muscles of the digits
– Extensor digitorum
• Extends MCP and CMC joints
– Extensor digiti minimi
• Extend proximal phalanx of 5th
digit at MCP
• Assist in hand extension at
wrist
• Extend middle and distal
phalanges of 5th digit when
proximal phalanx flexed.
– Extensor indicis
• Extends index finger
Wrist Movements
• Flexion:
– FDS/FDP, Flexor carpi radialis, Flexor carpi ulnaris, palmaris
longus, flexor pollicis longus.
• Extension:
– Extensor carpi radialis longus/brevis, extensor carpi ulnaris,
extensor digitorum, extensor digiti minimi, extensor indicis,
extensor pollicis longus.
Wrist Movements
• Ulnar Deviation (Adduction):
– Flexor carpi ulnaris, Extensor carpi ulnaris
• Radial Deviation (Abuction):
– Flexor carpi radialis, extensor carpi radialis longus/brevis,
abductor pollicis longus, extensor pollicis longus/brevis.
Anatomical Snuffbox
– Abductor pollicis longus
• Flex and abduct wrist
• Abducts and assists thumb CMC
flexion
– Extensor pollicis brevis
• Extends proximal phalanx of thumb
– Extensor pollicis longus
• Extends distal thumb phalanx
Thumb Movements
• Flexion
• Extension
• Abduction
• Adduction
• Opposition
Intrinsic Hand Muscles: A of A of A
• Deep Musculature:
– Lumbricals:
• Flex MCP joints
• Extend IP joints
– Palmar Interossei:
• Adduct digits towards middle
finger.
• PAD
– Dorsal Interossei:
• Abduct digits away from
middle finger.
• DAB
Intrinsic Hand Muscles: A of A of A
• Interossei and lumbricals in writing
– Lumbricals place digits into writing position (flex
MCP-Extend IP joints)
– Interossei adduct or abduct digits to make width of
letters.
Grip
– Coal hammer Grip
• Thumb is wholly occupied in
reinforcing clamping action of digits
(bunched fist).
– Power Grip
• Fingers flexed at all three joints
• No thumb reinforcement
• Usually performed with ulnar
deviation and extension of wrist.
– Hook Grip
Grip
• Fingers flexed so their pads lie directly
parallel and slightly away from palm.
• Requires relatively little muscle activity.
• Used when precision not needed but
power needed over a long period of
time.
• Ie. Carrying a suitcase by its handle.
• Only grasp pattern available when hand
intrinsics not working.
– Paralysis of hand intrinsics- hand relies on
hook grasp for all functional task
completion.
Grip
– Dynamic Tripod
• Thumb, index finger, and middle finger for precision
handling of an object.
• 4th and 5th digits used for support and static control.
Brachial Plexus (5-3-6-3-5)
• 5 Roots
– From anterior
(ventral) rami of
spinal nerves
– Scalene
muscles
• 3 Trunks
– Superior (C5-
C6)
– Middle (C7)
– Inferior (C8-T1)
Brachial Plexus
• 6 Divisions
– Each trunk
splits into
anterior and
posterior
• 3 Cords
– Posterior (C5-
T1)
– Lateral (C5-C7)
– Medial (C8-T1)
– Named in
reference to
axillary artery
Brachial Plexus Branches
• Axillary nerve (C5-C6)
• Musculocutaneous
nerve (C5-C7)
• Median nerve (C5-T1)
• Ulnar nerve (C8-T1)
• Radial nerve (C5-T1)
Brachial Plexus Injury
• Superior injuries
(C5-C6)
– Result from
excessive increase in
angle between neck
and shoulder
• Inferior injuries (C7-
T1)
– Occurs when upper
limb pulled suddenly
superior
Clinical Assessment
Wrist and Hand
• Common Pathologies:
• Ape hand deformity
– Wasting of the thenar eminence as a result of median nerve
palsy.
– Thumb falls back in line with the fingers as a result of extensor
muscle pulling.
– Patient unable to flex or oppose the thumb.
• Hand of Benediction
– Wasting of hypothenar muscles, interossei, and two medial
lumbricals due to ulnar nerve palsy.
• Drop-Wrist deformity
– Radial nerve palsy and extensors not functioning.
Wrist and Hand
• Common Pathologies:
• Dupuytren contracture
– Progressive genetic disease-conracture of the palmar fascia
– Fixed flexion deformity of MCP and PIP joints
– Usually seen in ring or little finger-skin often adherent to fascia.
• Swan Neck Deformity
– Flexion of MCP and DIP, extension of PIP
– Result of contracture of intrinsic muscles
– Often seen in rheumatoid arthritis or following trauma
• Trigger Finger
– Thickening of flexor tendon sheath causing sticking of tendon when
patient attempts to flex finger.
– As condition worsens, the finger won’t let go and fixe flexion
deformity occurs.
– Usually occurs in 3rd-4th finger.
– Associated with rheumatoid arthritis- worse in the morning
Wrist and Hand
• Functional Tests:
– Forearm supinated, resting on table
• Wrist flexion
– 0kg nonfunctional, 0-1kg functionally poor, 1-2kg functionally fair, 2.5kg+
functional
– Forearm pronated, resting on table
• Wrist extension lifting 0.5-1kg
– 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps functionally fair, 5-
6 reps functional
– Forearm between supination and pronation resting on table
• Radial deviation lifting 0.5-1kg
• Thumb flexion with resistance from rubber band around thumb
– 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps functionally fair,
5+ reps functional
Wrist and Hand
• Functional Tests:
– Forearm resting on table, rubber band around
thumb and index finger
• Thumb extension from rubber band around thumb
• Thumb abduction against resistance of rubber band
– 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps
functionally fair, 5+ reps functional
– Forearm resting on table
• Thumb adduction, lateral pinch of piece of paper
• Thumb opposition, pulp to pulp pinch of piece of paper
– Hold 0s nonfunctional, Hold 1-2s functionally poor, Hold 3-4s
functionally fair, Hold 5+s functional
Wrist and Hand
• Functional Tests:
– Finger flexion, patient grasps mug or glass using cylindrical grasps
and lifts off table
– 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps functionally fair, 5+ reps
functional
– Patient attempts to put on rubber glove keeping fingers straight
– 21+s nonfunctional, 10-20s functionally poor, 4-8s functionally fiar, 2-4s functional
– Patient attempt to pull fingers appart (abduction) resistance of
rubber bands and
– Hold 0s nonfunctional, Hold 1-2s functionally poor, Hold 3-4s functionally fair, Hold
5+s functional
– Patient holds piece of paper between fingers whilst examiner pulls
on paper
– Hold 0s nonfunctional, Hold 1-2s functionally poor, Hold 3-4s functionally fair, Hold
5+s functional
Wrist and Hand
• Special Tests:
– Durkan’s (to replease Tinels)
– Phalen’s (original method)
Clinical Case Studies
• 38 year old male got his right ring finger caught in a player’s shirt while playing
touch football
• Felt pop in his finger and developed pain
• Now in your clinic 4 hours later
• What are the possibilities?
Jersey Finger
• Rupture of FDP tendon
• Inability to flex tip of
finger
• Splint in position
• Repair within 7 days
• 26 year old sergeant playing basketball and “jammed” his left middle finger
• Pain and swelling of middle finger PIP joint (global)
• Pain with resisted flexion and extension
• What are the possibilities
Do you want X-rays?
Treatment
• Splint in extension for 6 to 8 weeks.
• Pain relief
• Watch for complications
What is the Diagnosis?
• Tear of the central slip
of the extensor tendon
Complications if Missed
• Loss of function
• Persistent pain
• Boutonniere deformity
