Anatomy Exam 2
Anatomical Snuffbox
(lateral-medial): ABD Pollicis Longus, Extensor Pollicis Brevis, scaphoid carpal, Extensor Pollicis Longus
The most mobile rays of the hand...
-1st, 4th, and 5th rays are more mobile than others -1st ray is the MOST mobile
Smith's Fracture
-A break to the end of the radius caused by a FOOSH with the wrist held in flexion -Volar/Palmar displacement -Usually less stable and requires surgical fixation
Complex regional pain syndrome or CRPS
-A possible complication after a distal radius (wrist) fracture -Exaggerated Pain Response, Redness, Edema, and Anhidrosis -Clinically this looks like a portion of the body, typically one limb, that is edematous and has changes in color and temperature, including being sweaty and/or shiny
Colles' Fracture
-A type of fracture of the distal forearm in which the broken end of the radius is bent backwards -Dorsal displacement -Usually treated via cast or splint
MEDIAL EPICONDYLITIS
-Less common -Pain with resisted wrist flexion, forearm pronation -"Golfer's elbow" -Common flexor tendon origin -Common muscles involved are the pronator teres and flexor carpi radialis
LATERAL EPICONDYLITIS
-More common than medial epicondylitis -Pain with resisted wrist extension, radial deviation -Tends to be Extensor Carpi Radialis Brevis (ECRB) as major contributor -Common extensor tendon origin -Often referred to as "tennis elbow"
De Quervain's Tenosynovitis is an injury caused by _____________ and is located in ____. It is _______ of the _________. A _______ can be utilized to __________ the area. The special test is ____________
-Overuse of the thumb -Extensor compartment #1- part of the anatomical snuff box -Inflammation of the synovial sheath -Thumb spica splint can be utilized to immobilize the area -Special test is Finklestein's Test
Functions of the TFCC
-To hold the distal radius and ulna together so there is no separation or distraction of the bones during weight bearing and strong gripping activities -To support distal radio-ulnar joint, radiocarpal joint -To reinforce the ulnar side of the wrist and form a portion of the radiocarpal joint -To provide some cushioning and shock absorption between the ulna and carpal bone
Open Tendon Injury
-a laceration through both skin and tendon -Linear or jagged -Clean or dirty/contaminated
A client who has an injury to Flexor zone ___ is at a high risk for adhesions
2
Radial Carpal Joint
2 Degrees of Freedom: Flexion/Extension + Radial/Ulnar Deviation
Under normal anatomical conditions, what percentage of weight bearing "load" is carried by the Ulna via the Triangulofibrocartilage complex (TFCC)?
20%
The Distal Transverse arch and Longitudinal arch share a common keystone....
2nd and 3rd MCP joints
Lumbricals
4 Muscles. Digits 2-5. Palmar side of Hand. Flex metacarpophalangeal joints. Extend the IP joints.
Dorsal/ Extensor Side of Wrist
6 Compartments under Extensor Retinaculum
Weight Bearing at Wrist:
80% via radius, 20% via ulna at TFC (Triagulofibrocartilagionous complex)
Jersey Finger
A closed tendon injury that involves rupture of the Flexor Digitorum Profundus (FDP) from the distal phalanx.
Which fracture type has the greatest risk for non-union and avascular necrosis?
A displaced fracture at the proximal pole of the Scaphoid.
Bennett or Rolando Fracture
A displaced, intra-articular fracture of the base of the 1st metacarpal into the CMC joint of the thumb.
What is the annular ligament?
A horizontal band that wraps around the radial head and holds it against the ulna while also allowing it to pivot during supination and pronation.
Intrinsic ligament
A ligament that connects 2 or more carpal bones and provides stability at the intercarpal joints at the wrist.
Difference between Mallet Finger and a DIP Flexion Contracture
A mallet finger deformity results in an inability to actively extend the DIP, while a DIP flexion contracture will cause a loss of both active AND passive extension.
Which type of elbow fracture commonly occurs?
A radial neck fracture is common since this is the narrowest part of the bone just below the radial head.
The CMC joint of the thumb is a ________ shaped joint with a ________ joint capsule that allows for __________
A saddle-shaped joint with a large loose joint capsule that allows a wide range of motions within the thumb including: flexion, extension, abduction, adduction, slight rotation, and opposition.
Pain felt at the medial wrist with weight bearing activities could indicate.....
A tear of the TFCC
Tinel sign performed at the hook of the hamate
A test that could be used to help confirm compression of the ulnar nerve at Guyon's Canal.
Which flexor pulley is released if a client has a painful Trigger Finger?
A1
The most important pulleys to have fully functioning and intact because they prevent bowstringing of the tendons away from the finger itself.
A2 and A4 pulleys
Hypothenar Muscles
ABDuctor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi
Adhesions in Flexor zone 2 limit ____ and _______
AROM, PROM
Which muscles are within the hypothenar eminence?
Abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi, and palmaris brevis
Longitudinal Arch
Along line of 2nd & 3rd Rays. 2nd & 3rd metacarpals phalangeal joints are keystones.
NURSEMAID'S ELBOW - RADIAL HEAD DISLOCATION
An injury that can happen primarily in childhood is a radial head dislocation (nurse maid's elbow). This is due to a traction or distraction force that pulls the forearm away from the humerus and pulls the radial head out of the annular ligament, dislocating it.
Describe the arthrokinematics at the humeroradial joint during a combined motion of elbow flexion and supination of the forearm.
Arthrokinematics include a combined spin and a roll-and-slide in similar directions.
The Proximal Transverse Arch is at what level? _____ is the keystone
At level of CMC. Capitate is keystone.
Distal Transverse Arch
At level of MCP. 2nd & 3rd metacarpals phalangeal joints are keystones
The blood supply to the scaphoid bone enters via the distal end of the bone, (distal pole). Due to this, the closer to the proximal end the fracture occurs, the more likely there will be.....
Avascular necrosis (bone death)
A forearm that passively supinates as the elbow is passively extended to its end range strongly suggests that the ___________ muscle is excessively tight/stiff?
Biceps Brachii (an elbow flexor and forearm supinator muscle)
MUSCLES ACTING AT THE ELBOW - FLEXION
Biceps Brachii, Brachialis, Brachioradialis
TFCC and Interosseous Membrane have this in common....
Both of these structures help distribute weight bearing forces between the radius and ulna.
What is the position of the PIP and DIP for each of the deformities covered so far?
Boutonniere- PIP in flexion, DIP in extension Mallet Finger- Loss of active DIP extension Swan Neck- PIP in hyperextension, DIP in flexion Jersey Finger- Loss of active DIP flexion
Make a preliminary list of the structures that could limit either elbow flexion or elbow extension if they were to become shortened or tight.
Brachialis, Biceps Brachii, Brachioradialis, and Triceps Limit Elbow Extension- The anterior joint capsule
Base, Proximal, Middle, and Distal Phalangeal Joints
CMC- carpometacarpal joint, at the base of the metacarpal MCP- metacarpophalangeal joint, proximal portion PIP- proximal interphalangeal joint, midportion DIP- distal interphalangeal joint, distal end of each digit 2-5
What is the keystone of the proximal transverse, or proximal carpal arch?
Capitate
Capitate
Carpal at base of 3rd metacarpal. Where to line up goniometer axis to measure radial/ulnar deviation.
Pisiform
Carpal embedded in tendon of Flexor Carpi Ulnaris
This deformity is caused by an injury to the central slip insertion and can be detected by Elson's Test before the changes to joint position become significant.
Closed Boutonniere Deformity
What would you see clinically if the patient had shortening of the lumbrical muscles?
Considering the lumbrical muscles flex the fingers at the MCP joints and extend them at the IP joints, they are essential in movements such as gripping and pinching. If these muscles were shortened, the patient would be unable to grip or pinch objects.
The Radial Nerve crosses ________________, but innervates ________________
Crosses anterior to the lateral epicondyle of the elbow, but innervates the posterior upper arm and forearm.
An excessive amount of valgus angle at the elbow is called __________, whereas a decreased amount of valgus causing the arm to be straighter or an angulation in the opposite direction is ___________.
Cubitus Valgus, Cubitus Varus
The interosseous membrane does NOT resist a ___________ force.
Distraction (The interosseous membrane does NOT resist a distraction force through the forearm like would happen if you were holding heavy suitcases or hanging from your hands on a pull-up bar.)
The extensor tendon zone that is at the MCP joint.
Extensor Tendon Zone 5
A Mallet Finger deformity occurs related to a terminal tendon rupture in which Zone?
Extensor Zone 1
Zone of Mallet Finger deformity
Extensor Zone 1
Zone of Boutonniere deformity
Extensor Zone 3
True or False: It is possible to extend the DIP in isolation and not in tandem with the PIP
False
The zones of injury are anatomical structures. T or F?
False, they are used as a reference for surgical procedures and rehabilitation protocols
SWAN NECK DEFORMITY
Finger deformity caused by volar plate rupture or an untreated mallet finger A digit in PIP hyperextension and DIP in flexion Lateral bands slip dorsally
flexor pollicis longus action
Flexion of thumb at IP joint
The capsular pattern at the humeroradial and humeroulnar joint is loss of _______ greater than ________.
Flexion, Extension
Motions of Digits 2-5
Flexion, extension, abduction, adduction
Motions of Thumb
Flexion, extension, abduction, adduction, and opposition. (Opposition of the thumb involves a combination of abduction, flexion, and internal rotation at the CMC as well as flexion at the MCP joint).
Wrist
Flexion/Extension + Radial/Ulnar Deviation
What Flexor zone of injury was called no man's land?
Flexor Tendon Zone 2
Which zone of injury carries the highest risk for adhesions after a tendon laceration and repair?
Flexor Tendon Zone 2 ("No Man's Land")
An injury to Flexor Zone 1 affects the
Flexor digitorum profundus alone.
In the thumb, damage to the __________ occurs in flexor zone 1 and 2
Flexor pollicis Longus
What types of motion would put tension through a flexor tendon? An extensor tendon?
Flexor: Gripping, lifting objects Extensor: Straightening fingers, opening hand, wrist extension
Motion between 2 rows of carpals:
Glidiing
Which position of the hand puts the lumbricals in a position of maximal stretch?
Intrinsic minus position
How are the thumb joints different from those of the other fingers?
It has a CMC, sometimes called the TMC, because it is the trapezium articulating with the first metacarpal. Then there is the MCP, and only one interphalangeal joint or IP.
Where does the Ulnar nerve travel?
It travels down the forearm to the wrist where it passes through Guyon's canal through the pisiform bone and the hook of the hamate to enter the hand and innervate the hypothenar muscles and deep musculature there.
The structures that can shift in position from neutral to either volar or dorsal and cause either Boutonniere or Swan Neck deformities.
Lateral bands of the dorsal apparatus
Lunate
Least Stable of All Carpals
Which muscles insert into the dorsal apparatus?
Lumbricals, extensor indicis muscle, dorsal interossei, and palmar interossei
Which position would put the joints of the fingers into closed-pack positions?
MCP (metacarpophalangeal joints) in flexion, and the IPs in extension
Compare Jersey Finger and Mallet Finger.
Mallet finger is the disruption of extension at the DIP joint secondary to an extensor tendon injury or bony avulsion of its insertion site on the distal phalanx. -The patient will present with an inability to fully extend the distal phalanx. Jersey finger is the disruption of DIP joint flexion secondary to a flexor tendon injury or bony avulsion of its insertion site on the distal phalanx. -The patient will present with inability to fully flex the distal phalanx.
Extensor Carpi Radialis Longus & Extensor Carpi Radialis Brevis perform what actions?
Medial to Brachioradialis. Perform wrist extension & radial deviation
Flexor digitorum superficialis splits into two slips and reconnects onto the ________ phalanx of digits ______
Middle, 2-5
The distal radioulnar joint moves in _________ with the __________ to create _________ motion as the _________ rotates over a _________
Moves in conjunction with the superior radioulnar joint to create pronation-supination motion as the radius rotates over a fixed ulna
Which muscles are within the thenar eminence?
Opponens pollicis, flexor pollicis brevis, abductor pollicis brevis
Extensor muscles of wrist
Origin: Lateral Epicondyl of Humerus
Flexor muscles of wrist
Origin: Medial Epicondyle of Humerus
DeQuervain's Tenosynovitis is an _______ injury. IT is caused by _______. The special test used is_______. It is located in _____ and involves the muscles ________
Overuse of Thumb. Inflammation of synovial sheath. Dorsal side of wrist. Special test: Finklestein's Test. Extensor compartment #1: ABD Pollicis Longus and Extensor Pollicis Brevis
The A3 Annular Pulley is at which joint?
PIP
BOUTONNIERE DEFORMITY
PIP in flexion, DIP in hyperextension Lateral bands move in a volar/palmar direction Elson's Test
Carpal Tunnel
Palmar/Volar side, between carpals and flexor retinaculum/transverse carpal ligament. 9 tendons & median nerve pass through it: 4-Flexor Digitorum Superficialis + 4-Flexor Digitorum Profundus + Flexor Polllicis Longus
DRUJ + SRUJ
Pronation/Supination-Radius rotates over fixed Ulna
Radial Styloid
Proximal to base of thumb. Site of pain for DeQuervain's Tenosynovitis. Insertion point for brachioradialis.
Which ligament supports the superior radioulnar joint to prevent radial head dislocation (nursemaid's elbow)?
Quadrate ligament
If a client is complaining of numbness and tingling in the lateral and dorsal area of the thumb, which nerve is most likely being compressed at the wrist?
Radial Nerve
Tests for Carpal Tunnel
Reverse Phalen Test, Phalen's Test, a Carpal Tunnel Compression Test, and a Tinel Sign
What makes up the Radial Carpal Joint
Scaphoid, Lunate, Distal Radius
If the combination of abduction and external rotation put a great deal of force through the medial collateral ligaments at the elbow, which position would put a similar force through the lateral collateral ligaments?
Shoulder abduction with internal rotation
Carpals Mnemonic
Straight Line To Pinky, Here Comes The Thumb Proximal (Radius to Ulnar): Scaphoid, Lunate, Triquitrum, Pisiform Distal (Ulnar to Radius) Hamate, Capitate, Trapezoid, Trapezium
MUSCLES ACTING AT THE ELBOW- SUPINATION AND PRONATION
Supinators- Biceps Brachii, Supinator Pronators- Pronator Teres, Pronator Quadratus
The most stable rays of the hand...
The 2nd and 3rd rays
Which of the carpal bones has a large projection "hook" on the palmar side that forms a portion of Guyon's canal, through which runs the ______________ Nerve.
The Hamate bone, Ulnar
The Adductor Pollicis is innervated by....
The Ulnar Nerve
Camper's Chiasm
The anatomical landmark that signifies the split of the FDS tendon that allows the FDP tendon to pass through it and insert on the distal phalanx.
Longitudinal Arch
The arch of the hand that follows the path of the 2nd and 3rd rays with the corresponding 2nd and 3rd MCP joints as its keystone.
What is the keystone of the distal transverse, or distal carpal arch?
The central 2nd and 3rd MCP joints
What occurs during flexion of the elbow?
The coronoid process of the ulna approaches the coronoid fossa of the humerus as the articular surfaces of the proximal radius and ulna move in an anterior direction.
Which thumb muscle in the palm is innervated by the Ulnar Nerve?
The deep branch of the ulnar nerve innervates the Adductor Pollicis and the medial head of the Flexor Pollicis Brevis.
The trapezium bone articulates with...
The first metacarpal of the thumb
The Interosseous Membrane is a _________ that connects the _____ to the ______, functions as a ______ for many muscles, holds the _________, and helps _________ forces from the ________ onto the ________ with weight bearing.
The flat band of tissue that connects the radius and ulna, functions as an attachment point for many muscles, holds the 2 bones to each other, and helps transfer forces from the radius onto the ulna with weight bearing.
During which phase of healing is a repaired tendon at its weakest and at highest risk for re-rupture if the post-surgical protocol or MD orders are not followed?
The inflammatory phase
If a client falls onto an outstretched arm and there is a varus force at the elbow, which ligament is most likely to be damaged or ruptured?
The lateral collateral ligament.
Which head of the Triceps can do both elbow and shoulder extension and why?
The long head of the triceps can do both elbow and shoulder extension. It serves 2 functions because it crosses both the glenohumeral joint and the elbow.
Dupuytren's Contracture
The pathology of the hand that involves tightening of the palmar fascia/aponeurosis into tight bands that limit extension of the affected digits.
Annular VS Cruciate Pulleys of the hand
The pulleys that have fibers oriented horizontally across the digit are the Annular pulleys (A1-A5), and those shaped like an X are the cruciate pulleys (C0-C3).
What can be palpated within the first dorsal compartment?
The radial styloid, the scaphoid tubercle, and Lister's tubercle can be used as superficial landmarks for the first dorsal compartment.
What occurs during pronation and supination at the superior radioulnar joint?
The round head of the radius pivots within the radial notch of the ulna.
If your client has an intra-articular fracture of the radial notch of the ulna, which joint will be most likely to later exhibit some osteoarthritis or degenerative changes?
The superior radioulnar joint
When are the tendons most at risk for re-rupture?
Tissue that heals with scar formation will never return to the full tensile strength it once had, and will have increased risk for re-injury to that area. The first inflammatory phase is where the tendons are at their highest risk.
TFCC
Triagulofibrocartilaginous disc, Extensor Carpi Ulnaris tendon, Ulnar collateral ligament. Function: hold distal radius & ulna together especially during weight-bearing & gripping; Portion of radialcarpal joint; shock-absorption between radius & carpals
MUSCLES ACTING AT THE ELBOW - EXTENSION
Triceps Brachii- Long head, Lateral head, Medial head
The median N. passes through the carpal tunnel. T or F?
True
True or False: Tissue that heals with scarring (stress riser) will not return to 100% of its prior strength/function
True
Guyon's Canal
Ulnar nerve travels through, between pisiform & hook of hamate.
Valgus/Varus Stress Test
Valgus stress test- where we push the elbow in towards the body while holding the forearm steady to test the medial or ulnar collateral ligament. Varus stress test- trying to push the elbow out away from the body while holding the forearm steady to test the lateral or radial collateral ligament. There should not be any give to either of these structures and therefore if there is any laxity felt, this would be a positive test.
The lateral collateral ligament/radial collateral ligament resists a _______ force at the elbow.
Varus
What would you see clinically if the patient had shortening of the extrinsic extensor tendons?
When these tendons are cut/injured/shortened, it can be impossible to bend the fingers or thumb.
Ulnar Styloid Process
Where to line up goniometer axis to measure wrist flexion & extension.
Flexor Carpi Radialis performs what actions?
Wrist Flexion & Radial Deviation
Flexor Carpi Ulnaris performs what actions?
Wrist Flexion & Ulnar Deviation
Define phalanx
a bone of the finger or toe
Closed Tendon Injury
a closed avulsion from the bone or rupture of the tendon structure itself without disruption to the skin
SKIER'S THUMB (GAMEKEEPER'S THUMB)
a rupture of the ulnar collateral ligament, or medial collateral ligament, due to hyper extension of MCP at the metacarpophalangeal joint of the thumb, or an avulsion fracture where the ligament pulls the piece of bone with it as it breaks free.
Function of the volar plate
a thick ligament that connects two bones in the finger, and functions to prevent hyperextension
The flexor digitorum profundus flexes the ___________
finger at the DIP joint
The flexor digitorum superficialis flexes the ________
finger at the PIP joint
If a client is lacking passive range of motion at the DIP without any preceding injury, they are most likely experiencing a....
flexion contracture
The function of the Lumbricals
flexion of the MCP joint and extension of the PIP and DIP joints of digits 2-5
The flexor digitorum profundus passes through a hole in the flexor __________ called _________
flexor digitorum superficialis, Camper's Chiasm
Thenar Eminence Muscles
flexor pollicis brevis, abductor pollicis brevis, opponens pollicis
The Wrist Flexors and the Pronator Teres share a common origin at the....
medial epicondyle of the humerus
Excessive valgus forces at the elbow can damage or cause a rupture in the _____________ ligament, and this is seen in little league pitchers. What surgery can repair it?
medial or ulnar collateral ligament (injury occurs due to gradual overuse or overstretch of the UCL until it gives way and tears or ruptures completely... Tommy Johns surgery for repair.)
Patients who have external fixators or percutaneous pins must be extra cautious about infection control since the pins have a direct line from the outside world to the bone, and therefore increased risk of.......
osteomyelitis
Digit 5 is the
pinky or little finger
What would you see clinically if the patient had shortening of the extrinsic flexor tendons? Unable to do what?
shortening of these tendons would make it difficult to extend/open the hand, or straighten the fingers.
What can be palpated within the anatomical snuff box?
the area between the extensor pollicis longus and extensor pollicis brevis and where you can palpate the scaphoid bone.
Digit 1 is the
thumb
The distal ulna does NOT articulate with the carpals, but with the ______________?
triangulofibrocartilaginous disc
Damage to the Ulnar Nerve can cause....
weakness to the flexor carpi ulnaris, the muscles of the small finger of the hand, the deep muscles of the hand, and numbness, burning, or tingling in the 4th and 5th digits.
A Colles' Fracture that healed with malalignment and caused an increase in the amount of palmar tilt of the radius would limit.....
wrist extension
A client who experiences a FOOSH and a complete rupture of their Scapholunate Ligament (Intrinsic wrist ligament), is most likely to experience......
wrist instability and eventual degenerative changes.