Upper Extremity 3.

Clavicle
- AKA: Collar bone; S-shaped bone

SHOULDER COMPLEX
Shoulder Complex
- 5 important bones
- 3 bony articulations
Functions:
- 3 other non-contractile structures
- Act as a strut
- 15 important muscles
- Allows greater mobility of the shoulder
- Transmits force to the sternum
Bones - Without this bone NO SHOULDER
ABDUCTION 0-180 DEGREES
1.Sternum Orientation:
Aka: Dagger bone Lateral (1/3): Concave anteriorly
Anatomical landmarks: Medial (2/3): Convex anteriorly
T2: Jugular notch
3rd rib or T4/T5: Sternal angle of Loius - Most commonly fractured bone (in the
T10: Xiphoid process (Dermatomal = T6) middle)
- MOI: FOOSH
Abnormalities: - 1st long bone to ossify (7 mos)
A. Pectus Carinatum - Last to be fully formed (21 years old)
-Aka: Pigeon chest
-Sternum is anteriorly and 4.Scapula
inferiorly displaced AKA: Shoulder blade
B. Pectus Excavatum Flat triangular shaped bone with 3 sides and 3
- Aka: Funnel Chest angles
- Sternum is posteriorly displaced
C. Barrel Chest Resting position:
-Seen in COPD – air trapping in Medial border of the scapula
their thorax - 5-6 cm or 2-3 finger widths from
-Sternum is anteriorly and the spinous process of the thoracic
superiorly displaced vertebrae
2.Ribs
Originates at the thoracic vertebrae (T1-T12) Anatomical landmarks:
T2: Superior Angle
Functions: T3: Scapular Spine
- Serves as a protection for internal organs T7: Inferior Angle
(e.g. heart and lungs)
- Serves as an attachment of muscles from - Acromion = highest point of the
the pectoral region scapula
- Has 12 pairs of ribs: - Orientation of Glenoid Fossa: (SAL)
 Superior
A. 1st – 7th rib  Anterior
- True ribs  Lateral
- Attaches directly to the sternum 5.Humerus
B. 8th – 10th rib - The mobile bone of the shoulder
- False ribs - Serves as an attachment for many muscles
- Attaches directly to 7th costal - Convex segment of the GH joint
cartilages
C. 11 – 12 rib
th th
Orientation:
- Floating ribs - MPS: Medial, Posterior, Superior
- No direct attachment
with the sternum Angles of shoulder:
Abnormalities: - Angle of inclination: 135 degrees
Costochondritis - Angle of torsion: 30 degrees
AKA: Tietze’s Syndrome Nerve injuries affecting the humerus
Inflammation of the costal cartilages Fx to the surgical neck: Axillary nerve (Traction or
Pain upon palpation at the costal cartilage Compression after dislocation)
Fx to the humeral shaft: Radial nerve
Fx to the lower medial end: Ulnar nerve
 Joints Rockwood Classification Grading
Type 1: Sprained AC, Intact CC
Type 2: Ruptured AC, sprained CC
1.Sternoclavicular joint Type 3: Ruptured AC and CC (AKA: Step
- The only connection of the UE to the axial skeleton deformity or separated shoulder)
- Primarily provide movements of the scapula Type 4: Ruptured AC and CC (clavicle
posteriorly displaced)
Kinematics: Type 5: Ruptured AC and CC (clavicle
Type of Joint: Saddle/ sellar joint superiorly displaced)
Degrees of freedom: 3 Type 6: Ruptured AC and CC (clavicle
inferiorly displaced)
Movements:
Elevation/Depression; Protraction/Retraction; Open pack position: Arms at the side
Transverse rotation (clavicle rotate posteriorly after Close pack position: 90 degrees of abduction
shoulder abduction > 90 degrees) Capsular pattern: @ extremes motion of ROM
Painful arc: 170-180 degrees of shoulder abduction
Formed from the articulation of the:
- Sternum Types of Acromion:
- Clavicle Type 1: Flat
- 1st rib Type 2: Curved (most common type in all population)
Type 3: Hooked (most commonly linked to
Ligaments: impingement)
A. Interclavicular ligament – limits depression Type 4: Upturned (Convex)
B. Anterior SC ligament – limits retraction
C. Posterior SC ligament – limits protraction 3.Glenohumeral joint
D. Costoclavicular ligament – Most important; - Formed by the glenoid fossa and humeral head
“STRONGEST”
- Anterior band limits retraction ; Posterior Kinematics:
band limits protraction - Type of Joint: Ball and socket
- Both bands limit Elevation - Degrees of freedom: 3
- Movements: Flexion/Extension;
Open packed position: Arms at the side Abduction/ Adduction; Internal/External
Close pack position: Full elevation Rotation
Capsular pattern: @ extremes ROM especially horizontal - Has little bony stability:
adduction and full elevation  Poor bone congruency
PJM: Protraction (ConCAVE moving surface); Elevation  Has areas of weakness:
(ConVEX moving surface) Foramen of Rouviere/ Ruvier – space
Posterior glide - inc retraction between middle and inferior GH
Superior glide - inc depression ligaments communicates with the
subcoracoid recess;
Foramen of Weitbrecht – small opening
2. Acromioclavicular Joint between superior and middle GH
- For refinement and control ligaments communicating with the
Kinematics: subtendinous bursa
- Type of Joint: plane synovial joint  Middle GH ligament is mc
- Degrees of freedom: 3 absent
- Movements: Upward/ Downward rotation;  No inferior protection
Elevation/ Depression; Protraction/ Stabilizers:
Retraction Static: Glenoid labrum – deepens the
- Prone to TRAUMA concavity of the glenoid fossa
 MOI: Direct blow to the Dynamic: Rotator cuff muscles; Biceps
shoulder Tendon; Muscles for scapular
Ligaments: motion
A. Anterior AC ligament: limits retraction
B. Posterior AC ligament: limits protraction Ligaments:
C. Coracoclavicular ligament: “Strongest” A.Coracohumeral ligament: Primary
- Pulls up weight of the UE stabilizing ligament when arm is dangling
- Injured during SHOULDER - Limits 0-60 degrees of Abduction
SEPARATION (step deformity) + ER and anterior translation
Has 2 fibers: - Limits inferior translation of the
1. Trapezoid ligament (M/L) humerus
2. Conoid ligament (Sup/Inf)
 B.Superior GH ligament: - Permitting elevation of the body in
- Limits 0-45 degrees of Abduction activities such as walking with crutches or
+ ER and anterior translation performing seated push-ups during
- Limits inferior translation transfers
C.Middle GH ligament Movements:
- Strongest ligament in GH joint  Elevation/ Depression
- MC absent (more prone to  Protraction/ Retraction
anterior instability  Upward/ Downward Rotation
- Limits 45-90 degrees of  Anterior and Posterior Tilting
Abduction ER and anterior
translation Scapulohumeral Rhythm
D.Inferior GH ligament Requirements for FULL ELEVATION (RISE)
- Most important ligament in GH - R – Rotation of the clavicle (posterior @ 90
joint degrees of abduction)
- Composed of complex parts
- I – Inferior translation of the humerus
which include:
Anterior band - S – Scapular stabilization or co-contraction of
Axillary pouch scapular motion
Posterior band - E – ER of the humeral head
- Serves as a hammock or sling
- Provides anterior stabilization, during Functions:
abduction of the arm (during throwing or  Increase ROM of arm
pitching) 90% cases anterior dislocation  Maintain articulation
- Limits > 90 degrees of abduction + ER and  Maintains length-tension
anterior translation relationship
3 phases:
Open pack position: 55 abduction, 30 horizontal adduction Phase 1:
Close pack position: 90 abduction, full ER - AKA: Setting phase
Capsular Pattern: OLD: ErAbIR; New: ErAbF=IR - Available ROM: 0-30 degrees
Painful arc: 60 – 120 degrees of shoulder abduction - Purely GH movement ONLY; NO
motion of scapula
PJM: - Clavicle 0-5 elevation without
Flexion: Posterior glide rotation
Abduction: Inferior glide
External Rotation: Anterior glide Phase 2:
External Rotation (Adhesive capsulitis): Posterior - Available ROM is 30-90 degrees
glide - 2:1 (GH:ST) ratio occur
- Clavicle 0-15 elevation without
4.Scapulothoracic joint rotation
- Combination of AC and SC joint; NOT TRUE JOINT
- Aka: False joint, pseudo joint, functional joint Phase 3:
- Lacks anatomical characteristics of a synovial joint - Available ROM is 90 - 180
- Lacks ligamentous support degrees
- 2:1 (GH:ST) ratio occur
Functions: - Clavicle 15 elevation with 30-50
- Essential for the mobility of the UE degrees of rotation
- GH is only capable of 0-110 degrees of
abduction Coracoacromial Arch
- GH + STJ = 0-180 degrees of abduction - AKA: Suprahumeral arch, Subacromial space
- Increasing the ROM of the shoulder to - Roof of glenohumeral joint
provide greater reach. Functions:
- Maintaining favorable length-tension > Protects the soft tissue structures from
relationship for the deltoid muscle to the superior blows directed downward
function above 90 degrees of GH elevation > Prevents superior dislocations of the GH
to allow better shoulder joint stability joint
throughout a greater motion - Passageway of important structures
- Providing glenohumeral stability through (usually impinge during impingement
maintained glenoid and humeral head syndrome)
alignment for work in the overhead a.Supraspinatus tendon
position b.Biceps tendon (long head)
- Providing for injury prevention through c.Subacromial bursa
shock absorption of forces applied to the
outstretched arm
Transverse Humeral Ligament O: Ribs 1-8 by digitations and aponeurosis of intercostals
- Consists of a narrow sheet of connective tissue that runs I: Medial border of the scapula
between the lesser and greater tubercles of the humerus N: Long Thoracic Nerve
- Hold the long head of biceps brachii in place A: Protraction and Upward Rotation

Bicipital Groove - “Scapular Stabilizer”

- AKA: Intertubercular groove; Sulcus intertubercularis - AKA: Saw muscle; Boxer’s muscle
- Where the tendon of the biceps pass through - One of the most important muscles of the shoulder
- Structure that separates greater and lesser tubercle girdle; primary protractor
- Strongest portion of Serratus anterior: Lower 5
digitations
Muscles - Most commonly injured after procedure: Radical
Mastectomy
Pectoralis Major - Type of winging: Medial winging of scapula (Open
book paralysis)
- Most difficult ADL: Combing hair

Trapezius

O: Clavicle; manubrium and 1-7 costal cartilage

I: Lateral lip of bicipital groove
N: Medial and lateral pectoral nerve
A: FADIR
2 Fibers: Sternocostal (V-stretch 140-145 degrees) and
O: Occiput, ligamentum nuchae, C7-T12 spinous process
Clavicular (90-90 flexion)
I: Upper traps (clavicle); middle traps (acromion); Lower
traps (scapular spine)
Pectoralis Minor
N: Spinal accessory nerve
A: Upper trapezium (shrug); Middle trapezium (retract);
Lower trapezius (depression); Collective Function: Upward
rotation of the scapula

- “Scapular Stabilizer”
- AKA: Shawl muscle; Monk’s hood; Musculus
Cucullaris
- Superficial muscle at the back
- Most commonly injured in Radical Neck
O: 3-5 ribs Dissection Surgery
I: Coracoid process - Type of winging: Lateral Winging of the Scapula or
N: Medial Pectoral Nerve Sliding Door Paralysis
A: Elevates rib cage (when scapula is fixed); Anterior tilting of
scapula; Depresses the shoulder joint Latissimus Dorsi
Accessory for inspiration; First stretch muscle in forward
head posture

Serratus Anterior

O: Iliac crest, Spinous process T6- T12, L1-L5, inferior angle of

the scapula
I: Floor of the bicipital groove
N: Thoracodorsal nerve
A: ExAdIR
 - AKA: Swimmer’s muscle - Can initiate abduction given that the
- Broadest and widest muscle of the body supraspinatus is weak and the other
- Impotant CRUTCH-WALKING muscle: along with rotator cuff muscles are intact to
Triceps and Lower Traps counter the accessory motions
(Lats Dorsi>Triceps>Lower Trapezius) - Can fully abduct without
supraspinatus but weak
Levator Scapulae - Responsible for the characteristic
roundness of the shoulder
- Can perform all motions of the
shoulder except: Shoulder Adduction

Rotator Cuff Muscles

- Composed of: (SITS)
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
O: C1-C4 Transverse process
I: Vertebral border (superior border)
Functions:
N: Dorsal Scapular Nerve
- Compression of the humeral head
A: Elevation and Downward Rotation
(primary function of SITS muscles) into
the glenoid fossa providing a critical
Rhomboids
stabilizing mechanism known as
“concavity compression”
- Rotation of the humerus relative to
the scapula
- Acts with the deltoid muscle and the
long head of biceps to maintain
stability of glenohumeral joint.

1.Supraspinatus

O: Spinous process of C7-T5

I: Vertebral border or the scapula
N: Dorsal scapular nerve
A: Scapular adduction and downward rotation of the scapula
(RETRACTION)

Deltoids

O: Supraspinous fossa
I: Greater tubercle
N: Suprascapular Nerve
A: Abduction

- Prone to injury; passes through the coracoacromial

arch which puts pressure in overhead activities.
- Initiator of abduction in normal individuals
- Capable of performing total motion of abduction
O: Lateral 3rd of the clavicle (ANTERIOR); Acromion (MIDDLE); without the assistance of deltoids
Spine of the scapula (POSTERIOR) - To isolate: Flexion and IR (Empty can position)
I: Deltoid tuberosity - To palpate: ExAdIR
N: Axillary Nerve - To apply UTZ: Abduct below 90 degrees + IR
A: Flexion, horizontal adduction and IR (ANTERIOR); pure
abduction (MIDDLE); Extension, Horizontal abduction, ER
(POSTERIOR)
- Comprise of 40% of the mass of the
scapulohumeral muscles
 2.Infraspinatus Teres Major

O: Infraspinous fossa O: Lateral border of the scapula

I: Greater tuberosity I: Medial lip of the bicipital groove
N: Suprascapular Nerve N: Lower subscapular nerve
A: ER shoulder specially when arms are at the side A: IR

3.Teres minor Biceps Brachii

O: Lateral border of the scapula

I: Greater tubercle O: Supraglenoid tubercle (LONG HEAD); coracoids process
N: Axillary nerve (SHORT HEAD)
A: ER (abduct at 90 degrees) I: radial tuberosity
N: Musculocutaneous nerve
4.Subscapularis A: Flexion of SH and elbow; Forearm supination

Triceps brachii

O: Subscapular fossa
I: Lesser Tuberosity
N: Upper and lower subscapular nerve
A: IR O: Infraglenoid tubercle (LONG HEAD); Spiral groove (MIDDLE
AND LATERAL)
Anterior shoulder dislocation: subscapularis will be I: Olecranon process
strengthened so the humeral head will go back to its original N: Radial nerve
position A: Elbow extension and weak shoulder extensor
 Brachial Plexus Triangular space
- Nerve root arises from the ventral rami of C5-T1
Borders:
Superior: Teres minor
Inferior: Teres major
Lateral: long head of triceps brachii

Triangular Interval/Triceps hiatus

Borders:
Superior: Teres major
Lateral: Humerus
Medial: long head of triceps brachii

Special Structures of the Shoulder

Quadrangular space

Borders:
Superior: Teres minor
Inferior: Teres major
Medial: long head of triceps brachii
Lateral: surgical neck of the humerus
Contents:
 Axillary Nerve
 Posterior Circumflex Humeral
artery
 ELBOW
ElbowAND
and FOREARM
Forearm
3.Proximal Radio-ulnar joint - AKA: Superior radioulnar joint
- Formed by convex radial head and the concave
radial notch of the ulna and annular
- Positioning of the hand in the appropriate position ligament
- Stability depends on the bone congruity - Diarthrodial, uniaxial joint
- Type of Joint: Modified or loose hinged joint capable of
flexion/extension Open packed position: 70 flexion, 35 supination
- Compound synovial joint Close packed position: 5 forearm supination
- Enclosed in a single capsule; damage of one structure will Capsular pattern: Pronation = supination
affect the other

Composed of 3 bones: Articulations:

Ligaments
Distal humerus Humero-ulnar
Proximal radius Humero-radial 1. Interosseus membrane
Proximal ulna Proximal radio-ulnar joint - AKA: Middle radioulnar ligament
- Serves to help distribute forces
throughout the forearm
Carrying angle
- Prevents displacement if the
AKA: Cubitus valgus
radius on ulna during pushing
Measurement:
activities
- Long axis of the humerus
- Long axis of the FA
2. Oblique cord
Capitulum and Trochlea (more inferior relative to capitulum)
- Prevents displacement if radius
– causing lateral angulation
on ulna during pulling activities
Normal: 5-15 degrees
Male: 5-10 degrees
3. Annular ligament
Female: 10-15 degrees; bigger because
- AKA: orbicular ligament
of bigger hips
Abnormal: - Encircles the radial head
- (-5 degrees) Cubitus varus – d/t - Freely attached
Supracondylar fx - Stabilizes the radial head during
- (-15 degrees) Gun stock deformity – pronation/supination
more severe in angulation.
4. Medial Collateral ligament
- AKA: Ulnar collateral ligament
Joints - Primary stabilizer of the elbow
- Major soft tissue restraint for
1.Humero-ulnar joint - AKA: Trochlear joint valgus force; resists traction force
- Concave ulna (moving surface) articulates with Has 3 bands:
convex distal humerus  Anterior band: limits
- Main articulation of the elbow extension
- Hinge type of joint: Allows flexion/extension  Posterior band; limits
flexion
Biomechanics:  Transverse part/
- With elbow flexion – ulna supinates Cooper’s ligament:
- With elbow extension – ulna pronates appears to contribute
little to nothing in elbow
Open packed position: 70 flexion, 10 supination stability
Close packed position: Extension and supination
Capsular pattern: Flexion > Extension 5. Lateral collateral ligament
- AKA: radial collateral ligament
2.Humero-Radial joint - AKA: radiocapitellar joint - Resists varus stress
- Concave radius (moving bone) articulates with - Primary restraint to
the convex capitulum posterolateral instability (most
- Permits flexion/extension in association with common instability of the elbow)
Humeroulnar joint
- Histologically stronger than MCL;
- Permits pronation/supination in association
but blends with annular ligament
with PRU joint
making it weaker
Open packed position: Full flexion, Full supination
Close packed position: 90 elbow flexion, 5 forearm
supination
Capsular pattern: Flexion > Extension
 Bursa Brachialis

1. Olecranon bursa
- Main bursa of the elbow
- Most commonly injured because
it is superficially located
- Lies posteriorly between the skin
and olecranon process
Abnormality:
a. Olecranon bursitis - Aka: Dart
thrower’s elbow/ Draftsman elbow/
Miner’s elbow/ Students elbow Origin: Anterior midshaft of humerus
Insertion: Coronoid process/ ulnar tuberosity
Clinical manifestation: posterior elbow Action: Chief elbow flexor
pain, goose egg appearance behind the Innervation: Musculocutaneous nerve
elbow MMT position: Pronated Forearm

2. Deep intratendinous bursa and deep subtendinous - Active in all motions of the elbow regardless of
bursa the position of the forearm
- Between the triceps tendon and - Greatest moment arm: 90-100 degrees of elbow
olecranon flexion
- Most commonly affected in Myositis Ossificans
- Spurt muscle
Muscles
Brachioradialis
Major Elbow Flexor
Biceps Brachii

Origin: lateral supracondylar ridge

Insertion: Proximal to radial styloid process
Origin: Innervation: Radial nerve
Long head: supraglenoid tubercle Action: Flexes the elbow; rotates forearm to the midprone
Short head: coracoid process position
Insertion: radial tuberosity/bicipital tuberosity MMT: Forearm in neutral
Innervation: musculocutaneous nerve - Longest elbow flexor- Smallest cross section
Action: forearm supinator, elbow flexor & weak shoulder - Strong contributor in elbow flexion
flexor - Limited role in pronation/supination
MMT position: FA supinated - Greatest moment arm: 100 – 120 degrees elbow
- Strongest supinator: flexion
2x stronger when the elbow is extended - Activity increases:
4x stronger when elbow is flexed (90 degrees) Fast elbow flexion; Resisted elbow flexion
- Greatest moment arm: 90-110 degrees of elbow flexion - Shunt muscle
- Spurt muscle Acessory Muscles for Elbow Flexion

1. Pronator teres
- Weak elbow flexor
- Primary forearm pronator
- Stabilizes the proximal radio-ulnar joint
- Works synergistically with Pronator Quadratus
during pronation

2. Extensor Carpi Radialis Longus

- Substitute as an elbow flexor given that biceps,
brachialis,and brachioradialis are paralyzed.
Major Elbow Extensor Muscle Mobile WAD of Three
Triceps brachii
- AKA: Mobile wad of Henry or Radial group

Functions:
- Group of radial muscles found in the
posterior compartment of the proximal
forearm that can flex the elbow.

- Active during gripping, sawing and

hammering

Composed of:
ECRB
Insertion: Olecranon process ECRL
Principal extensor of the elbow Brachioradialis
Can extend elbow regardless of forearm position
Greatest moment arm: 70-90 degrees of elbow flexion “After 15 degrees of elbow flexion, their line of pull moves
- Acts concentrically to extend the elbow anterior to the axis, so the wrist extensors also become
- Acts eccentrically as major elbow stabilizer during elbow flexors”
elbow flexion and during functional closed chain
activity
Terrible triad of the elbow
Has 3 heads:
Lateral head Triad:
Most muscular portion; strongest Radial head fx
Origin: upper half of posterior Coronoid Fx
humeral shaft Rupture of the collateral ligaments

Medial head Cubital fossa

Workhorse of elbow extension
Damage cause severe weakness
Origin: Lower half of Posterior
Humeral shaft

Long head
Longest Contents: My Brother Biceps is
Origin: Infraglenoid tubercle Restless (Medial to lateral)
>Median nerve
>Brachial artery
>Biceps long head
Accessory Muscle for Elbow Extension Lateral: Bracioradialis
>Radial nerve
Medial: Pronator teres
1. Anconeus Superior: Imaginary line between the epicondyles
- Provides 10-15% of required extensor force Floor: Supinator
Roof: Skin and Fascia
- Important function: Initiator of elbow extension

- Initiates most low load elbow extension motions

- Act as stabilizer during forearm rotation

 WRIST AND
WristHAND COMPLEX
and Hand Joints

- 90% of UE function is attributed to the wrist and hand 1. Distal Radioulnar joint
- double pivot joint that unites the distal radius, ulna
and articular disc
Carpal Bones
- lie in two transverse rows.
Open Pack Position - 10 degrees supination
Close Pack Position - 5 deg sup
1. Proximal Carpal Row (Lateral to Medial) Capsular Pattern - pain at extremes of motion
PJM - Pronation - volar/ ant roll and ant glide to
a) Scaphoid - aka. Navicular increase
- largest at the proximal carpal row
- MC fractured carpal bone Triangular Fibrocartilage Complex (TFCC) - aka Articular Disc
- 2nd MC diclocated - main stabilizer of the Distal Radioulnar Joint
- serves as the floor of the anatomical - assists in the binding the distal radius to the ulnar
- May lead to avascular necrosis (Preisser’s Dse) styloid process.
- improves joint congruency and cusions against
b) Lunate - aka. Semilunar Bone compressive forces
- MC dislocated - made up of the:
- 2nd MC fractured dorsal radioulnar ligament
- special test: Murphy’s Test ulnar collateral ligament
- Avascular Necrosis (Keinbock’s Dse) ulnar articular cartilage
volar radioulnar ligament
c) Triquetrum ulnocarpal meniscus
- fulcrum for the flexion and extension sheath of the extensor carpi ulnaris.
- 3rd MC fractured and dislocated
2. Radiocarpal Joint - aka. Wrist Joint
d) Pisiform - Bi-axial and ellipsoidal
- formed under the tendon of FCU - articulation between the radius and the proximal
- increases the leverage during flexion and carpal row
extension.
- only attaches to the triquetrum Open Pack Position: neutral with slight ulnar deviation.
- Last to ossify Close Pack Position: Extension
Capsular Pattern: F=E
2. Distal Carpal Row (Lateral to Medial) PJM: To increase Flexion: Anterior Roll; Post Glide
To increase Ulnar Deviation: Medial/Ulnar Roll;
a) Trapezium - aka. Greater Multangular Lateral/Radial Glide
-articulates with the CMC of the thumb
3. Midcarpal joint
b) Trapezoid - aka. Lesser Multangular - Lies between the 2 rows of carpals
- smallest bone in the distal carpal bone - “compound articulation”
- least commonly fractured bone - Each row has both concave and convex segment

c) Capitate - aka. OS Magnum

- largest of all carpal bone 4. Intercarpal joint
- 1st carpal to ossify - Type of joint: Plane synovial joint
- attaches to all the carpal bones - Allows gliding movement
- Articulates between individual bones of the
d) Hamate - has special structure: Hook of Hamate proximal and distal carpal rows
- formes part of the tunnel of guyon thru 5. Carpometacarpal Joints
pisohamate ligament; 2nd carpal bone to ossify
Carpal Bones Ossification a) CMC Joint of the Thumb / 1st CMC
Come Home to Luneta To See Philippines - Type of joint: saddle/sellar joint
- MC site of OA of the hand
- Very mobile
- Mobilization: UFDAb ->
increase Flexion: Ulnar glide ;
increase Abduction: Dorsal glide
 b) CMC Joint of the 4 fingers 2. Extensor Retinaculum
- Type of joint: Plane/Gliding Joint - AKA: Dorsal carpal ligament/ Posterior carpal
- CMC joint progresses in mobility from 2nd ligament
to 4th - Thickened part of the antebrachial fascia at the
>2nd and 3rd CMC (immobile) -> dorsum of the wrist
provide strength of grip
>4th and 5th CMC (mobile) -> - Functions:
adjust shape ▪ Prevent tendons from “bow-stringing”

6. Metacarpophalangeal Joints ▪ Secure the extensor tendons in place

a) MCP Joint of the Thumb Extensor Compartments of the wrist (12 tendons)
- Type of joint: Hinge joint- Resembles the
interphalengeal joints
- Main function: Ensure stability of the
grips between the thumb and fingers.
- Prone to injury: “skier’s thumb”

b) MCP Joints of the 4 Fingers

- Type of joint: Condyloid/ ellipsoidal joint
- Allows:
1st – EPB and APL (De Quervain Tenosynovitis): lateral
▪ Flexion/ Extension
boundary of anatomical snuffbox
▪ Abduction/ Adduction 2nd - ECRB and ECRL: Mobile WAD of Three
- Forms the knuckles 3rd – EPL (Extensor pollicis longus): medial boundary of
- Function: Optimize gripping function of anatomical snuffbox
the hand 4 – ED & EIP (Extensor Digitorum and Extensor Indicis
th

Propius)
7. Interphalangeal Joints 5th – EDM (Extensor Digiti Minimi)
- The proximal (PIP), distal (DIP), and the IP joint of 6th – ECU (Extensor Carpi Ulnaris)
thumb are all hinge joints
3. Flexor Retinaculum
Proximal IP joints - Spans the area between the pisiform, hamate,
▪ Allows flexion and extension scaphoid, and trapezium
- Transforms the carpal arch into a tunnel, through
▪ Stable in all positions which pass the median nerve and some of the
Distal IP joints tendons of the hand
▪ Less stable and allows some
hyperextension Contents
Superficial Contents
1. Flexor Carpi Ulnaris tendon
Cascade sign – assures all fingers point to the “ scaphoid
2. Ulnar nerve
tubercle” when IP joints are
3. Ulnar artery
flexed = normal; if not fx in the fingers
4. Palmar Cutaneous branch of the ulnar nerve
5. Palamaris longus (if present)
Ligaments/Fascial Compartments 6. Palmar cutaneous of the median nerve

1. Antebrachial fascia Deep Contents (10 structures in the Carpal Tunnel)

- Aka: Palmar aponeurosis/ fascia 1. Flexor digitorum superficialis (4)
- A dense connective tissue “bracelet” that encases 2. Flexor digitorum profundus tendons (4)
the forearm 3. Flexor pollicis longus (1)
- Function: protect the underlying structure from 4. Medial Nerve (1)
getting pinched
- Pathology: Dupuytren’s Contracture
▪ (+) thickening of the palmar fascia
▪ MC affects: 4th and 5th digits in Normal
individuals
▪ In patients with DM: 3rd and 4th digits
 Nerve Entrapments Intermediate Forearm Flexor

1. Flexor Digitorum Superficialis

1. Carpal Tunnel - Innervation: Median nerve
- Located deep of flexor retinaculum - Insertion: middle phalanx
- Deep structures of flexor retinaculum are affected - Action: Flexes wrist, MCP, PIP
- Median nerve is impinged - “Light hand closure”
- Thenar eminence is spared
Deep Forearm Flexors (Innervated by Anterior interosseous
If compresses: nerve = pure motor nerve)
▪ Altered sensation from the thumb and
lateral half of the ring finger 1. Flexor Digitorum Profundus
- Innervation: lateral -> Anterior interosseous nerve;
▪ Deformity: Ape hand deformity
medial: ulnar
- Insertion: distal phalanx
2. Tunnel of Guyon - Action: flexes wrist, MCP, PIP, DIP
- A depression superficial to the flexor retinaculum - “Forceful hand closure”
- Located between the hook of hamate and pisiform
- Ulnar artery and ulnar nerve passes through the 2. Flexor Pollicis Longus
canal - Action: Flexes the thumb
- Substitute the adductor pollicis when there is ulnar
nerve pathology
If compresses:
▪ Altered sensation at the little finger and medial 3. Pronator Quadratus
half of the ring finger - Action: Forearm pronation
▪ Affected muscles:
1. AFO digiti minimi ❖ Pinch Grip Test
2. Adductor pollicis - Pinch thumb and index finger together
3. Interossei - Positive: inability to touch fingers together (pulp-
4. Medial half of the lumbricals to-pulp)
- Indicates entrapment of anterior interosseous
Muscles nerve between the heads of pronator muscle

Superficial Forearm Extensors

- All flexors: originates at medial epicondyle
- All extensors: originates at lateral epicondyle and 1. Extensor Carpi radialis brevis
innervated by radial nerve - Most active in grasping’
- Most commonly affected in tennis elbow
Superficial Forearm Flexors - Extends and radially deviates the wrist

1. Pronator teres 2. Extensor Digitorum Communis

- Innervation – Median nerve - Inserts at the middle and distal phalanx
- Flexes the elbow when forearm is pronated-
▪ 1 Central slip – middle phalanx
Synergist with pronator quadrates during pronation
(botouniere deformity)
2. Flexor Carpi radialis ▪ 2 lateral bands – distal phalanx (mallet
- Innervation: Median Nerve finger)
- Flexes and radially deviates the wrist - Extends the digits
- Radial artery is palpated lateral to the FCR
3. Extensor Digiti minimi
3. Palmaris longus - Inserts at base of the 5th digit
- Innervation: Median nerve - Extends the little finger
- Flexes the wrist
- Most commonly absent = No functional effect 4. Extensor Carpi Ulnaris
- Extends and ulnarly deviates the wrist
4. Flexor carpi ulnaris
- Innervation: Ulnar nerve Thenar and Hypothenar muscles
- Flexes and ulnarly deviates the wrist
- Ulnar artery is palpated medial to the FCU
- Only superficial which is innervated by ulnar nerve
 Intrinsic muscles of the hand Extensor Tendon Zones
1. Interossei
I – DIP joint
- Innervated by the ulnar nerve
II – Middle phalanx
- PADDAB
III – PIP joint
Volar – adduction of the hand
IV – Proximal phalanx
Dorsal – abduction of the hand
2. Lumbricals
- Innervated by lateral half: median nerve and
medial half: ulnar nerve
- Flexes the MCP, extends IP joint (intrinsic plus)
- Muscles for “quick hand closure” Functional Movements of the hand
- If no function, the patient will have “claw hand
deformity or intrinsic minus deformity
➢ Power Grip
Anatomic snuffbox - Incorporates the entire hand
- Uses gross activities to grasp an object
- Involves holding an object between the partially
- Site for scaphoid palpation flexed fingers and palm while the
thumb usually applies counter-pressure
Boundaries:
Lateral: APL and EPB Types:
Medial: EPL
Floor: Scaphoid 1. Fist grip
Contents: Radial artery - AKA: Digital Palmar Prehension Pattern
- Tenderness to the floor of the - Palm and fingers flex around the object and the thumb
anatomical snuffbox indicates wraps around to
scaphoid fx enclose the object
- Used for powerful grasps of objects
- Example: Holding a broom, baseball bat, hammer or rake

2. Hook Grip
Tenodesis Effect - The finger digits provide this grip
- Used primarily to support or carry an object
- Use for grasping; especially for C6 SCI - Does not need the function of the thumb
- When the wrist is actively extended, passive tendon is - Example: Carry a briefcase
placed on the finger flexor tendons because of the length-
tension relationship. Extending the wrist shortens the flexor 3. Cylindrical grip
tendons (FDP) to produce finger flexion - Grasp objects that are cylindrical in shape and large enough
that the thumb does not touch the fingers
Flexor Pulleys - Thumb position flexes and adducts to secure the object to
the fingers and palm
- Example: Holding a tumbler or telephone
- AKA: Annular pulleys, Vaginal ligament
- Holds the FDS and FDP tendons to prevent bowstringing 4. Spherical grip- Grasp round objects
A1 – MCP - Fingers are spread apart more than the cylinder grip, so
A2 – Shaft of the PP- A3 – PIP joint interossei muscles will work more on this grip
A4 – Shaft of the Mid Phalanx - The adductor pollicis and other thenar muscles are active
A5 – DIP - Example: Holding a ball or an apple

Flexor Tendon Zones

I – DIP joints
II – No man’s land
> Poor blood supply &
Poor healing
III – Metacarpals
IV – Carpal tunnel
V – Distal Forearm
T(thumb)1 – IP joint
T(thumb)2 – MCP joint
➢ Precision grips
- An object is pinched between the flexor surfaces of
one or more fingers and the opposing thumb
- Used when accuracy and refinement of touch are
needed to manipulate or use an object

Types:

1. Lateral Pinch
- AKA: Key pinch
- Least precise of the precision grips
- Small object is placed between the index finger and thumb
- Example: placing a key in the ignition, grasping papers

2. Three prong chuck

- AKA: pad to pad; palmar prehension; three jaw chuck
- The pads of distal #2-3 digits contract the pad of the distal
thumb for the purpose of picking up or grasping objects
- Example: Grasping a coin, using a writing pencil/pen

3. Tip-to-tip grip
- AKA: Tip prehension grip
- Thumb faces one of the fingers (index)
- Used to pick up or manipulate small objects
- Deep Forearm Flexor Muscles are used
- Example: Picking up a small object such as pin, bead, or
strand of hair

Magic Nine Joints

-Convex moving surface (OKC)

1. Temporomandibular Joint
2. Sternoclavicular Joint
3. Glenohumeral Joint
4. Proximal Radioulnar Joint
5. Wrist (Radiocarpal Joint)
6. 1st CMC
7. Hip
8. Talocrural Joint
9. Subtalar Joint

Dermatome, Myotome & Reflex

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