CHAPTER The Hand 7 - Elsevier

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CHAPTERANATOMY 173Bony landmarks to bepalpated 173Ligaments 174Muscles 174Extensors 174Flexors 175Abductors, adductorsand opposers 175MEASUREMENT 176Range of movement – CMCjoint of the thumb 176Abduction 176Flexion/extension 177Range of movement – MCPjoint of the thumb 178s0010Flexion 178Range of movement – IPjoint of the thumb 179Flexion 179Range of movement – MCPjoint of the finger 180Flexion 180Abduction 181Range of movement – PIPjoint of the finger 182Flexion/extension 182Range of movement – DIPjoint of the finger 183Flexion/extension 183Observational/reflective checklist 185 ANATOMY1. The carpometacarpal (CMC) joint of the thumb is a synovialsaddle joint.2. It is an articulation between the trapezium and the base of thefirst metacarpal.3. The two surfaces are reciprocally concavoconvex.4. A loose but strong fibrous capsule encloses the joint.5. Movements of flexion, extension, abduction, adduction andopposition occur at this joint.p0010o0010o0020o0030o0040o0050s00207The handc0007BONY LANDMARKS TO BE PALPATEDp9000The Carpus – Scaphord, Lunate, Triquetral, Pisiform, Trapezium,Trapezoid, Capitate, Hamate. The Metacarpals and Phalanges.173CH007.indd 17311/12/2008 7:32:24 PM

174THE HANDLIGAMENTSs0030Table 7.1t0010Ligaments of the handLigamentOriginInsertionLimitation tomovementRadialcarpometacarpalligamentLateral surface ofthe trapeziumLateral surfaceof the firstmetacarpalAnterior obliqueligamentAnterior surfaceof the trapeziumMedial side of thefirst metacarpalTaut posterioroblique ligamentPosterior obliqueligamentPosterior surfaceof the trapeziumMedial side of thefirst metacarpalTaut anterioroblique ligamentMUSCLESExtensorss0040s0050Table 7.2t0020The extensors of the nsorpollicislongusMiddle thirdof posteriorsurface ofulna andinterosseousmembraneDorsal surfaceof the distalphalanx ofthumbPosteriorinterosseousbranch ofthe radialnerve C7, 8Extension and radialdeviation of the wrist.Extension of all thethumb jointsExtensorpollicisbrevisMiddle part ofthe posteriorsurface of theradius andinterosseousmembraneDorsal surfaceof the base ofthe proximalphalanxPosteriorinterosseousbranch ofthe radialnerve C7, 8Extension and radialdeviation of the wrist.Extension of thecarpometacarpal andmetacarpophalangeal(MCP) joints of thethumbCH007.indd 17411/12/2008 7:32:25 PM

AnatomyFlexors175s0060Table 7.3The flexors of the )FlexorpollicislongusUpper anteriorsurface ofradius andinterosseousmembranePalmar surfaceof distalphalanx of thethumbAnteriorinterosseousbranch ofmediannerve C8, T1Flexion of the wristjoint. Flexion of theinterphalangeal andmetacarpophalangealjoints of the thumb.Vital in all culum,tubercle ofthe trapezium,capitate andtrapezoidRadial side ofthe base ofthe proximalphalanx of thethumbMediannerve T1Flexion of thecarpometacarpal andmetacarpophalangealjoints of the thumb. Italso produces medialrotation of the thumbAbductors, adductors and opposerss0070Table 7.4The abductors, on(s)AbductorpollicislongusUpper,posteriorsurface ofulna, middlethird of theposteriorsurface of theradius and theinterosseousmembraneRadial sideof the baseof the firstmetacarpalPosteriorinterosseousbranch ofthe radialnerve C7, 8Working withabductor pollicisbrevis it abducts thethumb. Workingwith the extensors itextends the thumbat the CMC joint.Working by itself itmoves the thumb intoa mid-extended andabducted d tuberclesof scaphoidand trapeziumRadial sideof proximalphalanx ofthe thumbMediannerve T1Abduction of thethumb at the CMCand MCP joints(table continues)CH007.indd 17511/12/2008 7:32:25 PM

176THE HANDTable 7.4 s)OpponenspollicisFlexorretinaculumand tubercleof thetrapeziumLateralhalf of theanteriorsurface ofthe firstmetacarpalMediannerve T1Opposition of thethumb – abduction,medial rotation, andflexion and adductionof the CMC joint. Thisallows precise handactions to take placePalmarisbrevisPalmaraponeurosisand flexorretinaculumThe skin ofthe medialborder ofthe handUlnar nerveT1This muscle wrinklesthe skin on the ulnarside of the hand andassists the thumb inproducing a good grip MEASUREMENTs0100s0080RANGE OF MOVEMENT – CARPOMETACARPAL (CMC)JOINT OF THE THUMBAbductions0090f0010Fig 7.1 Goniometric measurement of the carpometacarpaljoint of the thumb – abduction.s0110p0110Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in theCH007.indd 17611/12/2008 7:32:25 PM

Measurementmid-position, their wrist is in the anatomical position and the thumbmaintains contact with the metacarpal of the index finger.Goniometer axis: The axis of the goniometer is placed at thejunction of the bases of the first and second metacarpal. (A smallgoniometer is required.)Stationary arm: This is parallel to the longitudinal axis of thesecond metacarpal.Moveable arm: This is parallel to the longitudinal axis of the firstmetacarpal. In the start position this will indicate 15–20 . Record as 0 .End position: The thumb is abducted to the limit of motion (70 Flexion/extensionf0020Fig 7.2 Goniometric measurement of the carpometacarpaljoint of the thumb – flexion and extension.s0170p0160Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is insupination and their wrist is in neutral.Goniometer axis: The axis of the goniometer is placed over theCMC joint of the thumb. (A small goniometer is required.)Stationary arm: This is parallel to the longitudinal axis of the radius.Moveable arm: This is parallel to the longitudinal axis of thethumb metacarpal.End position: Flexion – the thumb if flexed across palm (15 n – the thumb is extended away from the palm (20 ).p0210CH007.indd 17711/12/2008 7:32:26 PM

178s0230s0240THE HANDRANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP)JOINT OF THE THUMBFlexionFig 7.3 Goniometric measurement of fingermetacarpophalangeal (MCP) flexion.f0030Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in themid-position and their wrist is slightly extended. The MCP jointbeing measured is in 0 of extension.Stabilization: The clinician stabilizes the metacarpal.Goniometer axis: The axis of the goniometer is placed over thedorsal aspect of the joint being measured. (A small goniometer isrequired.)Stationary arm: This is parallel to the longitudinal axis of theshaft of the metacarpal.Moveable arm: This is parallel to the longitudinal axis of theproximal phalanx.End position: The MCP joint is flexed to the limit of 90p0260s0300p0270b0010Clinical tipp0280During the movement the interphalangeal (IP) joint is allowedto flex.CH007.indd 17811/12/2008 7:32:27 PM

Measurements0320s0330179RANGE OF MOVEMENT – INTERPHALANGEAL (IP) JOINTOF THE 70p0320s0380p0330s0390p0340CH007.indd 179Fig 7.4 Goniometric measurement of thumbinterphalangeal (IP) flexion.Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in themid-position and their wrist is slightly extended. The IP joint beingmeasured is in 0 of extension.Stabilization: The clinician stabilizes the metacarpal.Goniometer axis: The axis of the goniometer is placed over thedorsal aspect of the joint being measured.Stationary arm: This is parallel to the longitudinal axis of theshaft of the proximal phalanx.Moveable arm: This is parallel to the longitudinal axis of thedistal phalanx.End position: The thumb is flexed to the limit of motion.11/12/2008 7:32:28 PM

180s0410s0420THE HANDRANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP)JOINT OF THE FINGERFlexionFig 7.5 Goniometric measurement of fingermetacarpophalangeal (MCP) flexion.f0050Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in pronation and their wrist is extended. The MCP joint being measured isin 0 of extension.Stabilization: The clinician stabilizes the metacarpal.Goniometer axis: The axis of the goniometer is placed over thedorsal aspect of the joint being measured.Stationary arm: This is parallel to the longitudinal axis of theshaft of the metacarpal.Moveable arm: This is parallel to the longitudinal axis of theproximal phalanx.End position: The MCP joint is flexed to the limit of 70p0390s0480p0400b0020Clinical tipp0410During the movement the proximal interphalangeal (PIP) joint isallowed to flex and the distal interphalangeal (DIP) joint remainsin extension.CH007.indd 18011/12/2008 7:32:28 PM

Measurements9000s0490181RANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP)JOINT OF THE s0530p0450s0540p0460s0550p0470s0560p0480CH007.indd 181Fig 7.6 Goniometric measurement of fingermetacarpophalangeal (MCP) abduction.Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in pronation and their wrist is in neutral.Stabilization: The clinician stabilizes the metacarpals.Goniometer axis: The axis of the goniometer is placed over thedorsal surface of the MCP joint being measured.Stationary arm: This is parallel to the long axis of the shaft of themetacarpal.Moveable arm: This is parallel to the long axis of the proximalphalanx.End position: The finger is moved away from the mid-line.Alternate method: The patient spreads his/her hand out on apage. The clinician draws round the hand. After the patient removestheir hand, the clinician records the linear measurement between themid-point of each finger.11/12/2008 7:32:29 PM

182s0580s0590THE HANDRANGE OF MOVEMENT – PROXIMAL INTERPHALANGEAL (PIP)JOINT OF THE 620p0510s0630p0520s0640p0530s0650p0540CH007.indd 182Fig 7.7 Goniometric measurement of proximalinterphalangeal (PIP) flexion and extension.Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in pronation and their wrist and fingers are in extension (0 of extension atthe MCP and IP joints).Stabilization: The clinician stabilizes the phalanx, proximal to thejoint being measured.Goniometer axis: The axis of the goniometer is placed over thedorsal surface of the PIP joint being measured.Stationary arm: This is parallel to the longitudinal axis of theproximal phalanx.Moveable arm: This is parallel to the longitudinal axis of themiddle phalanx.End position: The PIP joint is flexed to the limit of motion.11/12/2008 7:32:29 PM

Measurements0670s0680183RANGE OF MOVEMENT – DISTAL INTERPHALANGEAL (DIP)JOINT OF THE 710p0570s0720p0580s0730p0590s0740p0600CH007.indd 183Fig 7.8 Goniometric measurement of distalinterphalangeal (DIP) flexion and extension.Starting position: The patient is positioned in sitting, their armsupported on a table. Their elbow is flexed, their forearm is in supination and their wrist and fingers are in extension (0 of extension atthe MCP and IP joints).Stabilization: The clinician stabilizes the phalanx, proximal to thejoint being measured.Goniometer axis: The axis of the goniometer is placed over thedorsal surface of the DIP joint being measured.Stationary arm: This is parallel to the longitudinal axis of themiddle phalanx.Moveable arm: This is parallel to the longitudinal axis of thedistal phalanx.End position: The DIP joint is flexed to the limit of motion.11/12/2008 7:32:30 PM

184THE HANDp0610Notesp0620Treatment recordCH007.indd 18411/12/2008 7:32:30 PM

Measurements0750185Observational/reflective checklistObservational/reflective checklistObservationIntroductionand preparationfor the skillY/NCommentsWas the treatment areaproperly prepared for thepatient, e.g. pillow, blanket,safe environment, etc.?Did the therapist introducehim/herself?Was the patient comfortable?Was the patient adequatelyexposed/draped?Was an explanation of theprocedure given?Was the explanation clear andsuccinct?Was consent obtained?Performing theskillWas the plinth set at thecorrect height?Was the therapist’s posturecompromised?Did the therapist identifythe joint and other relevantbony landmarks?Was the goniometer correctlyaligned?Was the reading of thejoint range of movementaccurate?Did the therapist compareboth sides of the body?Safe andeffectiveperformanceof the techniqueWas the procedure carriedout with due care andattention?How wouldyou rate theproficiencyin the overallperformanceof the skill?ExcellentVery goodGoodSatisfactoryBorderlineFailCH007.indd 18511/12/2008 7:32:30 PM

CH007.indd 18611/12/2008 7:32:31 PM

173 c0007 The hand 7 CHAPTER ANATOMY 173 Bony landmarks to be palpated 173 Ligaments 174 Muscles 174 Extensors 174 Flexors 175 Abductors, adductors and opposers 175 MEASUREMENT 176 Range of movement - CMC

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