chapter the hand 7 - elsevier health sciences medical books
TRANSCRIPT
173173
The hand c0007 c0007 7 CHAPTER
ANATOMY 173Bony landmarks to be palpated 173Ligaments 174Muscles 174
Extensors 174Flexors 175Abductors, adductors and opposers 175
MEASUREMENT 176Range of movement – CMC joint of the thumb 176
Abduction 176Flexion/extension 177
Range of movement – MCP joint of the thumb 178
Flexion 178Range of movement – IP joint of the thumb 179
Flexion 179Range of movement – MCP joint of the finger 180
Flexion 180Abduction 181
Range of movement – PIP joint of the finger 182
Flexion/extension 182Range of movement – DIP joint of the finger 183
Flexion/extension 183Observational/reflective checklist 185
● ANATOMY
1. The carpometacarpal (CMC) joint of the thumb is a synovial saddle joint.
2. It is an articulation between the trapezium and the base of the first 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 and
opposition occur at this joint.
BONY LANDMARKS TO BE PALPATED The Carpus – Scaphord, Lunate, Triquetral, Pisiform, Trapezium, Trapezoid, Capitate, Hamate. The Metacarpals and Phalanges.
s0010 s0010
p0010 p0010 o0010 o0010
o0020 o0020
o0030 o0030
o0040 o0040
o0050 o0050
s0020 s0020
p9000p9000
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THE HAND174174
LIGAMENTS s0030 s0030
Table 7.1
Ligaments of the hand
Ligament Origin Insertion Limitation to movement
Radial carpometacarpal ligament
Lateral surface of the trapezium
Lateral surface of the first metacarpal
Anterior oblique ligament
Anterior surface of the trapezium
Medial side of the first metacarpal
Taut posterior oblique ligament
Posterior oblique ligament
Posterior surface of the trapezium
Medial side of the first metacarpal
Taut anterior oblique ligament
t0010 t0010
Table 7.2
The extensors of the thumb
Muscle Origin Insertion Nerve supply
Action(s )
Extensor pollicis longus
Middle third of posterior surface of ulna and interosseous membrane
Dorsal surface of the distal phalanx of thumb
Posterior interosseous branch of the radial nerve C7, 8
Extension and radial deviation of the wrist. Extension of all the thumb joints
Extensor pollicis brevis
Middle part of the posterior surface of the radius and interosseous membrane
Dorsal surface of the base of the proximal phalanx
Posterior interosseous branch of the radial nerve C7, 8
Extension and radial deviation of the wrist.Extension of the carpometacarpal and metacarpophalangeal (MCP) joints of the thumb
t0020 t0020
MUSCLES Extensors
s0040 s0040
s0050 s0050
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175Anatomy
Flexors s0060 s0060
Table 7.3
The flexors of the thumb
Muscle Origin Insertion Nerve supply
Action(s)
Flexor pollicis longus
Upper anterior surface of radius and interosseous membrane
Palmar surface of distal phalanx of the thumb
Anterior interosseous branch of median nerve C8, T1
Flexion of the wrist joint. Flexion of the interphalangeal and metacarpophalangeal joints of the thumb.Vital in all gripping activities
Flexor pollicis brevis
Flexor retinaculum, tubercle of the trapezium, capitate and trapezoid
Radial side of the base of the proximal phalanx of the thumb
Median nerve T1
Flexion of the carpometacarpal and metacarpophalangeal joints of the thumb. It also produces medial rotation of the thumb
t0030 t0030
Abductors, adductors and opposers s0070 s0070
Table 7.4
The abductors, adductors
Muscle Origin Insertion Nerve supply
Action(s)
Abductor pollicis longus
Upper, posterior surface of ulna, middle third of the posterior surface of the radius and the interosseous membrane
Radial side of the base of the first metacarpal
Posterior interosseous branch of the radial nerve C7, 8
Working with abductor pollicis brevis it abducts the thumb. Working with the extensors it extends the thumb at the CMC joint.Working by itself it moves the thumb into a mid-extended and abducted position
Abductor pollicis brevis
Flexor retinaculum, and tubercles of scaphoid and trapezium
Radial side of proximal phalanx of the thumb
Median nerve T1
Abduction of the thumb at the CMC and MCP joints
(table continues)
t0040 t0040
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THE HAND176
Fig 7.1 Goniometric measurement of the carpometacarpal joint of the thumb – abduction.
f0010 f0010
Table 7.4 (Continued)
Muscle Origin Insertion Nerve supply
Action(s)
Opponens pollicis
Flexor retinaculum and tubercle of the trapezium
Lateral half of the anterior surface of the first metacarpal
Median nerve T1
Opposition of the thumb – abduction, medial rotation, and flexion and adduction of the CMC joint. This allows precise hand actions to take place
Palmaris brevis
Palmar aponeurosis and flexor retinaculum
The skin of the medial border of the hand
Ulnar nerve T1
This muscle wrinkles the skin on the ulnar side of the hand and assists the thumb in producing a good grip
● MEASUREMENT
RANGE OF MOVEMENT – CARPOMETACARPAL (CMC) JOINT OF THE THUMB Abduction
s0080 s0080
s0090 s0090
s0100 s0100
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in the
s0110 s0110 p0110 p0110
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Measurement 177
mid-position, their wrist is in the anatomical position and the thumb maintains contact with the metacarpal of the index finger. Goniometer axis: The axis of the goniometer is placed at the junction of the bases of the first and second metacarpal. (A small goniometer is required.) Stationary arm: This is parallel to the longitudinal axis of the second metacarpal. Moveable arm: This is parallel to the longitudinal axis of the first metacarpal. 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/extension
s0120 s0120 p0120 p0120
s0130 s0130 p0130 p0130
s0140 s0140 p0140 p0140
s0150 s0150 p0150 p0150 s0160 s0160
Fig 7.2 Goniometric measurement of the carpometacarpal joint of the thumb – flexion and extension.
f0020 f0020
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in supination and their wrist is in neutral. Goniometer axis: The axis of the goniometer is placed over the CMC 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 the thumb metacarpal. End position: Flexion – the thumb if flexed across palm (15°). Extension – the thumb is extended away from the palm (20°).
s0170 s0170 p0160 p0160
s0180 s0180 p0170 p0170
s0190 s0190 p0180 p0180 s0200 s0200 p0190 p0190
s0210 s0210 p0200 p0200
p0210 p0210
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THE HAND178
RANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP) JOINT OF THE THUMB Flexion
s0230 s0230
s0240 s0240
Fig 7.3 Goniometric measurement of finger metacarpophalangeal (MCP) flexion.
f0030 f0030
Clinical tip During the movement the interphalangeal (IP) joint is allowed to flex.
b0010 b0010
p0280 p0280
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in the mid-position and their wrist is slightly extended. The MCP joint being measured is in 0° of extension. Stabilization: The clinician stabilizes the metacarpal. Goniometer axis: The axis of the goniometer is placed over the dorsal aspect of the joint being measured. (A small goniometer is required.) Stationary arm: This is parallel to the longitudinal axis of the shaft of the metacarpal. Moveable arm: This is parallel to the longitudinal axis of the proximal phalanx. End position: The MCP joint is flexed to the limit of motion.
s0250 s0250 p0220 p0220
s0260 s0260 p0230 p0230
s0270 s0270 p0240 p0240
s0280 s0280 p0250 p0250
s0290 s0290 p0260 p0260
s0300 s0300 p0270 p0270
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Measurement 179
Fig 7.4 Goniometric measurement of thumb interphalangeal (IP) flexion.
f0040 f0040
RANGE OF MOVEMENT – INTERPHALANGEAL (IP) JOINT OF THE THUMB Flexion
s0320 s0320
s0330 s0330
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in the mid-position and their wrist is slightly extended. The IP joint being measured is in 0° of extension. Stabilization: The clinician stabilizes the metacarpal. Goniometer axis: The axis of the goniometer is placed over the dorsal aspect of the joint being measured. Stationary arm: This is parallel to the longitudinal axis of the shaft of the proximal phalanx. Moveable arm: This is parallel to the longitudinal axis of the distal phalanx. End position: The thumb is flexed to the limit of motion.
s0340 s0340 p0290 p0290
s0350 s0350
p0300 p0300 s0360 s0360 p0310 p0310
s0370 s0370 p0320 p0320
s0380 s0380 p0330 p0330
s0390 s0390 p0340 p0340
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THE HAND180
RANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP) JOINT OF THE FINGER Flexion
s0410 s0410
s0420 s0420
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in pro-nation and their wrist is extended. The MCP joint being measured is in 0° of extension. Stabilization: The clinician stabilizes the metacarpal. Goniometer axis: The axis of the goniometer is placed over the dorsal aspect of the joint being measured. Stationary arm: This is parallel to the longitudinal axis of the shaft of the metacarpal. Moveable arm: This is parallel to the longitudinal axis of the proximal phalanx. End position: The MCP joint is flexed to the limit of motion.
s0430 s0430 p0350 p0350
s0440 s0440
p0360 p0360 s0450 s0450 p0370 p0370
s0460 s0460 p0380 p0380
s0470 s0470 p0390 p0390
s0480 s0480 p0400 p0400
Fig 7.5 Goniometric measurement of finger metacarpophalangeal (MCP) flexion.
f0050 f0050
Clinical tip During the movement the proximal interphalangeal (PIP) joint is allowed to flex and the distal interphalangeal (DIP) joint remains in extension.
b0020 b0020
p0410 p0410
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Measurement 181
Fig 7.6 Goniometric measurement of finger metacarpophalangeal (MCP) abduction.
f0060 f0060
RANGE OF MOVEMENT – METACARPOPHALANGEAL (MCP) JOINT OF THE FINGER Abduction
s9000 s9000
s0490 s0490
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in pro-nation and their wrist is in neutral. Stabilization: The clinician stabilizes the metacarpals. Goniometer axis: The axis of the goniometer is placed over the dorsal surface of the MCP joint being measured. Stationary arm: This is parallel to the long axis of the shaft of the metacarpal. Moveable arm: This is parallel to the long axis of the proximal phalanx. End position: The finger is moved away from the mid-line. Alternate method: The patient spreads his/her hand out on a page. The clinician draws round the hand. After the patient removes their hand, the clinician records the linear measurement between the mid-point of each finger.
s0500 s0500 p0420 p0420
s0510 s0510
p0430 p0430 s0520 s0520 p0440 p0440
s0530 s0530 p0450 p0450
s0540 s0540 p0460 p0460
s0550 s0550 p0470 p0470
s0560 s0560
p0480 p0480
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THE HAND182
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in pro-nation and their wrist and fingers are in extension (0° of extension at the MCP and IP joints). Stabilization: The clinician stabilizes the phalanx, proximal to the joint being measured. Goniometer axis: The axis of the goniometer is placed over the dorsal surface of the PIP joint being measured. Stationary arm: This is parallel to the longitudinal axis of the proximal phalanx. Moveable arm: This is parallel to the longitudinal axis of the middle phalanx. End position: The PIP joint is flexed to the limit of motion.
s0600 s0600 p0490 p0490
s0610 s0610 p0500 p0500
s0620 s0620 p0510 p0510
s0630 s0630 p0520 p0520
s0640 s0640 p0530 p0530
s0650 s0650 p0540 p0540
Fig 7.7 Goniometric measurement of proximal interphalangeal (PIP) flexion and extension.
f0070 f0070
RANGE OF MOVEMENT – PROXIMAL INTERPHALANGEAL (PIP) JOINT OF THE FINGER Flexion/extension
s0580 s0580
s0590 s0590
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Measurement 183
Fig 7.8 Goniometric measurement of distal interphalangeal (DIP) flexion and extension.
f0080 f0080
RANGE OF MOVEMENT – DISTAL INTERPHALANGEAL (DIP) JOINT OF THE FINGER Flexion/extension
s0670 s0670
s0680 s0680
Starting position: The patient is positioned in sitting, their arm supported on a table. Their elbow is flexed, their forearm is in supi-nation and their wrist and fingers are in extension (0° of extension at the MCP and IP joints). Stabilization: The clinician stabilizes the phalanx, proximal to the joint being measured. Goniometer axis: The axis of the goniometer is placed over the dorsal surface of the DIP joint being measured. Stationary arm: This is parallel to the longitudinal axis of the middle phalanx. Moveable arm: This is parallel to the longitudinal axis of the distal phalanx. End position: The DIP joint is flexed to the limit of motion.
s0690 s0690 p0550 p0550
s0700 s0700 p0560 p0560
s0710 s0710 p0570 p0570
s0720 s0720 p0580 p0580
s0730 s0730 p0590 p0590
s0740 s0740 p0600 p0600
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THE HAND184
Notes p0610 p0610
Treatment record p0620 p0620
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Measurement 185
Observational/reflective checklist
Observational/reflective checklist
Observation Y/N Comments
Introduction and preparation for the skill
Was the treatment area properly prepared for the patient, e.g. pillow, blanket, safe environment, etc.?
Did the therapist introduce him/herself?
Was the patient comfortable? Was the patient adequately exposed/draped?
Was an explanation of the procedure given?
Was the explanation clear and succinct?
Was consent obtained? Performing the skill
Was the plinth set at the correct height?
Was the therapist’s posture compromised?
Did the therapist identify the joint and other relevant bony landmarks?
Was the goniometer correctly aligned?
Was the reading of the joint range of movement accurate?
Did the therapist compare both sides of the body?
Safe and effective performance of the technique
Was the procedure carried out with due care and attention?
How would you rate the proficiency in the overall performance of the skill?
Excellent Very good
Good
Satisfactory
Borderline
Fail
s0750 s0750
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