Wrist & Hand

Wrist / Hand – classical anatomy Opponens Pollicis – A PA: ridge of trapezium & Flexor Retinaculum DA: anterior surface of 1st metacarpal Act: Acts on CMC joint to cup palm & oppose fingers IN: Recurrent Branch of Median Nerve Abductor Pollicis Brevis - B PA: tubercle of trapezium & Flexor Retinaculum DA: Lat. side of base of prox. phalynx of thumb Act. ABducts thumb In. recurrent branch of median nerve Flexor Pollicis Brevis - C PA: Flexor Retinaculum, deeply – ulnar side of 1st MC DA: Base of proximal phalanx of thumb Act: Flexes proximal phalanx of thumb IN: Recurrent Med Nerve Flexor Pollicis Longus - D PA: Anterior surface of middle 1/3 of radius DA: distal phalanx of thumb Act. Flexes distal phalanx of thumb IN: median nerve (palmar interosseous) D C B A Interosseous muscles Palmar (x3) - PAD = Palmar ADduct Dorsal (x4) - DAB = Dorsal ABduct All innervated by the Ulnar nerve Wrist / Hand – Clinical anatomy Wrist and hand joints are commonly involved in inflammatory conditions (e.g . rheumatoid, seronegative spondarthropathy). Generalised osteoarthritis predominantly involves DIPJs and PIPJs, the first CMCJ and the scapho-trapezoid joint (other carpal joints are spared). Crystal-associated arthropathy --> Isolated involvement of radiocarpal and midcarpal joints is common Pain Pain from any of the small joints in the wrist and hand is usually well localised BUT three common conditions may cause radiation of pain on the radial side of the hand First CMCJ arthropathy (70) (usually osteoarthritis).This is the one joint that may cause wide radiation (distally up the thumb, proximally up the distal forearm), though pain is maximal over the joint itself. De Quervain's tenosynovitis (71). Pain is maximal around the radial styloid but often radiates into the thumb and proximally up the forearm. Carpal tunnel syndrome (72). The key symptom suggesting peripheral nerve entrapment is nocturnal or early morning exacerbation of symptoms (symptoms may be confined to this time). In carpal tunnel syndrome, median nerve compression may cause (1) paraesthesia and dysaesthesia distally to the thumb, index and middle fingers, often with clumsiness, and (2) painful aching proximally up the forearm, occasionally to the 70 71 elbow. Radiated pain - Pain and sensory disturbance may radiate into the hand from above, particularly the elbow (arthritis, epicondylitis), shoulder (arthropathy, rotator cuff), and cervical spine (root entrapment of C6, 7, 8). In these situations symptoms are often less well defined and accompanied by more proximal symptoms. Fractures Scaphoid # is the most common hand #. Usually as the result of fall on palm with and abducted. Pain on lateral side of wrist on dorsiflexion and abduction of the hand. Due to poor blood supply union can take several months. AVN of the proximal fragment can occur if displaced à degenerative wrist disease st # 1 metacarpal = Bennett fracture – usually due to fighting # 5th metacarpal occurs due to punching with clenched fist = Boxer’s fracture Nerve injury Median nerve injury / laceration Hand of benediction – loss of flexion of the 2nd & 3rd prox distal IP joints Can also affect thenar mm so affect thumb function Patterns of hand arthritis OA – PIP (bouchards), DIP (heberdens), thumb base RA – MCP, PIP, rheumatoid nodules, ulnar deviation, swan neck, boutonniere Psoriatic – DIP (or any others) + nail changes NB – methatrexate can induce multiple hand nodules 72 Wrist / Hand – Examination Inspection at rest Extensor aspect Skin changes - erythema, psoriasis, vitiligo, mixed hyper/hypopigmentation ('salt and pepper' appearance of scleroderma), skin tightness with loss of flexures (sclerodactyly: typical of scleroderma and overlap connective tissue syndromes); and current or past evidence of trauma. Nail changes - clubbing, thimble pitting, splinter haemorrhages, subungual hyperkeratosis, dystrophy and abnormalities of nailfold capillaries. Swelling Deformity - subluxation , squaring, deviation, nodes, swan neck, boutonniere, Z-thumb Wasting -, marked 'guttering' Attitude - pain and discomfort. With synovitis of any hand/wrist joints the patient is most comfortable in mild flexion. Palmar surface Observe pronation movement Skin changes - Palmar erythema (RA), Dupuytren's contracture, Small vessel infarcts Swelling - Swelling on the volar aspect most commonly represents flexor tenosynovitis, often most obvious proximal to the wrist crease, between the distal palmar crease and finger base, and occasionally between the skin creases of the fingers Wasting - Irrespective of age, both thenar and hypothenar eminences should be convex. Localised outer thenar wasting usually reflects median nerve compression: it often also accompanies first CMCJ arthritis. Lateral surface Ablity to Fully Extend Fingers – if flexed but can be extended & returns to flexed on release = extensor tendon rupture. If partial active, but full passive, extension = rupture of the extensor tendon slips, permitting the extensor tendon to drop to the ulnar side of the MCPJ. Volar Subluxation of the Carpus – produces a 'dinner fork' deformity the most characteristic hand deformity of rheumatoid Swelling over dorsum of wrist – can be synovitis (radiocarpal, midcarpal) or extensor tenosynovitis. Tenosynovial swelling moves proximally with the tendons (finger flexion), its distal boundary becoming more definite as the tenosynovium 'tucks' in (the 'tuck' or 'shelf sign). Joint swelling remains unaltered by extensor tendon movement. Volar Subluxation at the MCPJs - may be more obvious from the lateral view Inspection During Usage Power grip – ability to curl fingers into palm. Fine precision pinch – thumb to fingers in turn Palpation Increased Warmth - marked coolness may be noted with Raynaud's. Increased warmth, particularly over the wrist and the MCPJs, is easily felt if present. Radiocarpal Joint – tenderness. Swelling & crepitus on movement Inferior Radioulnar Joint – check styloid size, swelling, crepitus MCPJs – check for swelling, tenderness Metacarpal squeeze IPJs – tendeness, swelling, crepitus DON’T FORGET THUMB Additional tests De Quervain's tenosynovitis Localised area of tenderness may be detected in a line along the lateral border of the distal radius (+/- increased temperature and linear soft-tissue swelling) Finkelstein's test - ask the patient to grasp the thumb in the palm while the examiner cautiously performs passively lateral flexion to the ulnar side. This manoeuvre can be uncomfortable in normal individuals but in de Quervain's tenosynovitis it causes marked pain Carpal tunnel syndrome The patient's symptoms may be reproduced (1) by percussion over the anterior wrist distal to the proximal skin crease (Tinel's sign), or (2) by asking the patient to sustain forced flexion of the wrist for at least 1 min (Phalen's test) The median supplies the lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis ('LOAF'). For thenar weakness test abductor pollicis brevis – restisted active abduction (vertical from palm) Ulnar nerve lesion Compression can occur at the elbow (affects dorsal & palmar hand surfaces and fingers) or through Guyon’s canyon (affects little and ring finger only). Weakness of dorsal interosseous (abduction) occurs early, with palmar (adduction) involved later Radial nerve lesion This causes weak wrist dorsiflexion if mild, wrist drop if severe, with wasting of the forearm muscles. Sensory loss on the dorsum of the hand is minimal. Hip – Classical anatomy The joint is reinforced by the iliofemoral ligament, inferiorly by the pubofemoral ligament, and posteriorly by the ischiofemoral ligament The ligamentum teres is an intracapsular ligament that runs from the transverse ligament to the fovea: it has no joint stabilising function but carries blood vessels which supply a small area of the head around the fovea Clinically relevant bursae around the hip include: Trochanteric bursa between the greater trochanter and gluteus maximus. Iliopectineal bursa between the anterior capsule and iliopsoas (communicating with the joint in about 15%). Ischiogluteal bursa over the ischial tuberosity, overlying the sciatic nerve. Internal hip muscles 1. Psoas major – L1-3 = hip flexion 2. Iliacus – L2-4 = hip flexion Superficial anterior thigh 3. Vastus lateralis – L2-4 = knee extension 4. Rectus femoris – L2-4 = knee extension & hip flexion 5. Vastus medialis – L2-4 = Knee extension 6. Sartorius – L2-3 = Flexes, abducts & lateral rotates hip, flexes knee 2 Deep anterior thigh 8 9 6 4 7 10 5 3 7. Vastus intermedialis – L2-4 = knee extension 8. Pectineus – L2-3 = Adducts, flexes & medially rotates hip 9. Adductor longus – L2-4 = adductor 10. Gracilis – L2-3 = Adducts & medially thigh, flexes knee 12 Lateral thigh 11 13 11. Tensor fascia latae – L4-5 = flexes, abducts & medially rotates hip Superficial posterior thigh 12. Gluteus medius – L5-S1 = abductor & medial rotator 13. Gluteus maximus – L5-S2 = extensor & lateral rotator 14. Semimembranosus – L5-S2 = Flexes knee, extends & medially rotates hip 15. Semitendiosus – L5-S2 = Flexes knee, extends & medially rotates hip 16. Biceps femoris short 17. Biceps femoris long – L5-S2 = Flexes knee, extends & medially rotates hip 14 16 15 17 Nerves 1. Inferior gluteal 2. Pudendal 3. Posterior cutaneous nerve of thigh 4. Sciatic 5. Tibial 6. Common fibular (peroneal) 7. Superior gluteal Arteries 1. Common Femoral 2. Profunda femoris (deep artery) 3. superior lateral genicular 4. Anterior tibial 5. Fibular 6. Posterior tibial 7. Inferior medical genicular 8. Popliteal 9. Medial circumflex femoral 10. Obturator Hip – clinical anatomy Hip pain is often ill-defined, worsened by loading and movement (e.g. rising from sitting, standing, walking, putting on socks), and felt primarily in the anterior groin (a). Trochanteric bursitis = (b). Sacroiliac pain. Deep in the buttock, with variable radiation down the posterior thigh. It is often exacerbated by standing on one leg Bursitis. Trochanteric bursitis causes localised pain and tenderness over the trochanter, with occasional radiation down the lateral thigh (b). It is particularly painful when lying on the affected side (e.g. in bed). Pain from ischiogluteal bursitis is felt mainly posteriorly and is particularly worsened by sitting. Enthesopathy. Adductor enthesopathy ('groin strain') usually follows a sporting injury and causes pain in the medial groin, worsened by standing on the affected leg. Abductor enthesopathy produces similar pain to trochanteric bursitis, but is usually worsened by walking. Meralgia paraesthetica. Entrapment neuropathy of the lateral cutaneous nerve of the thigh (beneath the inguinal ligament) causes burning pain and numbness over the anterolateral thigh. It may accompany massive or rapidonset obesity, pregnancy, and wearing of tight corsets or jeans. Root pain. Prolapsed intervertebral discs or lesions involving Ll/L2 nerve roots (both rare) may produce groin pain (225). Its sharp quality and exacerbation by straining/coughing (± accompanying back pain) help suggest its nature. Symphysitis. This may produce supra-pubic pain and tenderness, worse during the stance phase of walking. Notes: If there is a pelvic tilt, check for scoliosis Exaggerated lumbar lordosis is compensation for fixed flexion of the hip Flexed & externally rotated is the loose pack position for the hip Trendelenburg gait occurs when pelvic abductors are weak When stood on bad leg, pelvis sags to sound side & shoulder on bad side dips to keep balance Hip - Examination Inspection of the Patient Observe the patient standing Pelvic tilt - shown by loss of level between the anterior superior iliac spines. This may be due to adduction or abduction deformity from hip disease, a short leg, or primary scoliosis. Rotational deformity - see if the feet face forwards to the same degree. Exaggerated lumbar lordosis - this may indicate a fixed flexion deformity of one or both hips. Scoliosis - this often accompanies pelvic tilt. Muscle wasting - secondary to hip, primary muscle or neurological disease. POPLITEAL FOSSA – check for swelling. Not possible once laid on couch Trendelenburg test - shows up gross weakness of the hip abductors (gluteus medius, minimus). Ask the patient to lift one foot off the ground. If the abductors are weak, the pelvis will drop down on the contralateral side: the patient may lose balance, stumble, and be unable to keep the foot raised. The common causes of a positive Trendelenburg test are hip disease (unilateral or bilateral), an L5 root lesion (unilateral), and conditions characterised by generalised weakness (usually bilateral). Observe the patient walking Antalgic gait - usually indicating a painful hip. The patient shortens stance phase on the affected hip, leaning over the affected side to avoid painful contraction of the hip abductors. Trendelenburg gait - indicating weakness of the abductors on the affected side. During the stance phase on the affected side, the contralateral pelvis dips down and the body leans to the unaffected side. If bilateral, this produces 'waddling gait'. Observe the Patient Lying on a Couch Skin changes (especially scars, inguinal rash). Swelling. Usually not visible as joint is deep. Deformity - particularly fixed flexion, external rotation or abduction deformity. If fixed flexion is not readily apparent utilise Thomas' test (234). Flex the other hip to 90° to eliminate the lumbar lordosis (confirmed by placing a hand under the patient's lumbar spine) and watch for flexion of the affected hip. Leg length inequality- apparent by looking at the heels. If there is apparent discrepancy use a soft tape measure to estimate on each side: Attitude - a painful hip with synovitis is most comfortable if held in mild flexion, abduction, and external rotation. Observe if this is the position the patient keeps wanting to adopt. Palpation Tenderness (± swelling) over the following areas: anterior joint line may reflect hip synovitis or iliopectineal bursitis. adductor origins may reflect adductor enthesopathy: resisted active adduction may reproduce the pain. greater trochanter for tenderness due to trochanteric bursitis or abductor enthesopathy (Active abduction of the affected leg) ischial tuberosity suggests ischiogluteal bursitis Movements Flexion (about 120°). This is tested with the knee flexed to relax the hamstrings Abduction (about 45°) and adduction (about 30°). Internal and external rotation (about 45° each). With hip & knee flexed to 90°. Internal rotation in flexion is the earliest and most constant movement to be affected by hip disease. Extension (about 15°). Thomas' test detects loss of extension (i.e. fixed flexion). Otherwise lay the patient prone and attempt to immobilise the pelvis by downward pressure with one hand (over the sacrum) while extending the hip with the other hand.