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Chapter 17 Notes
Transcript
Therapeutic Kinesiology Instructor Manual: Ch17 p.1
TK INSTRUCTOR MANUAL: CHAPTER 17
The Arm and Hand
Chapter manuals include:
Objectives
Lecture Notes
Suggested Classroom and Student Development Activities
For other chapter-by-chapter resources, see:
Key Term Quizzes
Muscle Origin and Insertion Worksheets
Muscle OIAs List by Chapter
MyTest Test Bank
For additional resources see “Teaching Tips and Tools”:
7 research-based learning principles for kinesiology courses in massage
5-step self-directed learning cycle for body mechanics courses
Tools that build metacognitive skills: e.g., concept (mind) maps, grading rubrics, and self-assessments inventories
OBJECTIVES
Name and describe the three bones in the arm and the eight carpals, five metacarpals, and 14 phalanges of the wrist and hand.
Demonstrate the palpation of bony landmarks and primary movements of the arm and hand.
Name the origins, insertions, and actions of the major ligaments of the elbow, wrist, and hand.
List the four joints of the elbow and describe the structure and function of each one.
List the seven types of joints in the wrist and hand and describe the structure and function of each one.
Define supination and pronation and name the muscles that generate each action.
Demonstrate the four passive movement ranges for the wrist.
Describe the three arches and two types of grips of the hand.
Define the carpal tunnel and list the structures passing through it.
Identify the origins, insertions, and actions of the muscles acting on the elbow and their trigger points. Demonstrate the palpation of and resisted movement for each one.
Identify the origins, insertions, and actions of the muscles acting on the wrist and hand and their trigger points. Demonstrate the active movement of and palpation of each one.
LECTURE NOTES
BONES OF THE ARM AND HAND
Introduction
Has a complex and intricate anatomy
Is susceptible to repetitive-strain injuries
Parallel structure to foot, with several differences:
It has smaller bones
It evolved for prehensile, articulate movements rather than weight-bearing
It has eight carpal bones, foot has seven tarsal bones
Humerus
Long bone in upper arm
Bony landmarks of humerus related to elbow
Lateral and medial epicondyles
Supracondylar ridges
Olecranon fossa
Trochlea, capitulum, coronoid fossa
Infraglenoid tubercles
Radius, ulna in arm
Two long bones in forearm
Run parallel to each other
Proximal bony landmarks
Radial head
Olecranon
Radial notch
Trochlear notch
Coronoid process
Distal bony landmarks
Styloid process of radius
Posterior tubercle (Lister's tubercle)
Styloid process of humerus
Eight carpals in wrist in two rows
Four proximal carpals
Scaphoid: L-shaped, most frequently fractured carpal
Lunate: Most frequently dislocated carpal
Triquetrum
Pisiform: Pea-shaped carpal
Four distal carpals
Trapezium: At base of thumb
Trapezoid: At base of 2nd metacarpal
Capitate: Longitudinally stable position
Hamate: Has hook-like projection
Five metacarpals: Long bones in palm
Fourteen phalanges: Long bones in fingers.
Each finger has three phalanges: Proximal, middle, distal
Thumb only has two phalanges
JOINTS AND LIGAMENTS OF THE ARM AND HAND
Elbow has two joints in one large, loose capsule
Humeroulnar joint: Hinge joint
Humeroradial joint: Hinge joint
Proximal radioulnar joint: Pivot joint
Distal radioulnar joint: Fibrous joint
Carrying angle of the elbow
Spool-shaped trochlea wider on one side
Causes ulna to join humerus at angle called "carrying angle”
Angle between long axis of humerus and forearm
Carrying angle averages 15 degrees
Causes forearm to hang at angle
Ligaments of the elbow
Lateral (radial) collateral ligament
Medial (ulnar) collateral ligament
Articular capsule
Annular ligament: Around head of radius
Range of motion in the elbow
Active flexion: 145 degrees, soft end-feel
Passive flexion: 160 degrees
Extension: 5 degrees, hard end-feel
Radioulnar joints mechanically linked with elbow
Proximal radioulnar joint: Pivot joint
Between radial head and ulna
Annular ligament wraps radial head
Cartilage underneath ligament allows radius to spin
Distal radioulnar joint: Fibrous joint
Gliding motion during supination and pronation
Fibrocartilage joint disk cushions gliding motion
Movement of forearm
Neutral position of forearm
With elbow flexion thumb points up
With elbow extension thumb points forward
Range of movement of forearm
Supination (palm turns up)
Pronation (palm turns down)
Joints of wrist
Radiocarpal joint: Ellipsoid joint
Called "true wrist joint"
Between distal radius and proximal carpals
Midcarpal joint: Gliding joints
Between proximal and distal rows of carpals
Moves with wrist joint
Many gliding joints in single joint capsule
Intercarpal joints: Gliding joints
Between the lateral surfaces of carpals
Minimal degree of motion
Contribute to lateral stability of wrist
Range of motion of the wrist
Flexion: 80 degrees
Extension: 70 degrees
Ulnar deviation (abduction): 45 degrees
Radial deviation (adduction): 20 degrees
Circumduction:
Combines all four movements
Example: stirring a bowl
Ligaments of the wrist
Radial collateral ligament
Binds styloid process of radius to scaphoid and trapezium
Restricts excessive ulnar deviation
Ulnar collateral ligament
Binds styloid process of ulna to pisiform and triquetrum
Restricts excessive radial deviation
Palmar radiocarpal and ulnocarpal ligaments
Bind distal radius and ulna to carpals
Restrict excessive wrist extension
Transverse carpal ligament (flexor retinaculum ligament)
Binds hamate and pisiform to scaphoid and trapezium
Covers and protects carpal tunnel
Carpal tunnel
On anterior side wrist, under transverse carpal ligament
Contains median nerve and 10 tendons
Four tendons of flexor digitorum profundus
Four tendons of flexor digitorum superficialis
Flexor carpi radialis tendon
Flexor pollicis longus tendon
Carpal tunnel syndrome
Narrowing and compression of carpal tunnel
Syndrome caused by repetitive hand movements
Common among assembly-line workers and computer operators
Symptoms of carpal tunnel syndrome
Inflammation and pain in hand and wrist
Numbness and tingling in the fingers
Weakness in hand, loss of grip strength
Joints and ligaments of the arm and hand
Carpometacarpal joints: Gliding joints
Between distal carpals and proximal metacarpals
Collectively called the midcarpal joint
First carpometacarpal joint: saddle joint
Between trapezium and first metacarpal at base of thumb
Allows opposition and reposition
Metacarpophalangeal joints: ellipsoid (condyloid) joints
Between metacarpals and proximal phalanges
Allows flexion, extension, abduction, adduction of knuckles
Interphalangeal joints: hinge joints
Between promiximal/middle (PIPs), middle/distal phalanges (DIPs)
Two in each finger; thumb only has one (Figure 17.30a-b)
Hand arches
Similar to arches of feet with several differences
Evolved for grasping rather than supporting weight
Thumb opposition allows shaping around objects
Three arches of hand
Distal carpal arch
Proximal carpal arch
Four longitudinal arches along metatarsals
Hand grips
Power grip: requires force
Cylindrical grip
Spherical grip
Hook grip
Precision grip: requires fine motor control
MUSCLES OF THE ARM AND HAND
Overview
Elbow flexors and extensors
Wrist and finger flexors and extensors
Supinators and pronators
Muscles of the thumb
Extrinsic (long)
Intrinsic (short)
Muscles of the hand
Between metacarpals
Acting on little finger
Elbow flexors
Biceps brachii
O: Short head – Coracoid process
Long head – Supraglenoid tubercle
I: Tuberosity of radius, deep fascia of forearm
A: Flexes elbow and supinates forearm, flexes GH joint against resistance
Brachialis
O: Lower half of anterior humerus
I: Coronoid process and tuberosity of ulna
A: Flexes the elbow
Brachioradialis
O: Upper two-thirds of lateral supracondylar ridge
I: Base of styloid process of radius
A: Flexes elbow under load and during rapid motion, stabilizes elbow during rapid motion
Elbow extensors
Triceps brachii
O: Long head – Infraglenoid tubercle of the scapula
Medial head – Distal half of posterior humerus
Lateral head – Proximal half of posterior humerus
I: Olecranon
A: All heads extend elbow, long head assists GH joint extension and adduction
Anconeus
O: Posterior surface of lateral epicondyle
I: Posterior surface of proximal ulna below olecranon
A: Stabilizes elbow, assists slow elbow extension
Supinators
Biceps brachii: Assists supination with elbow in flexion
Supinator: Primary supinator in elbow extension
O: Lateral epicondyle, annular and radial collateral ligaments, supinator crest along lateral, proximal ulna
I: Anterior, lateral surface of proximal third of radius
A: Supinates forearm
Pronators
Pronator teres
O: Superior to medial epicondyle, medial border of coronoid process
I: Middle of lateral surface of radius
A: Pronates forearm, assists elbow flexion
Pronator quadratus
O: Anterior surface of distal ulna
I: Anterior surface of distal radius
A: Pronates forearm
Wrist and finger flexors
Share common flexor tendon attached to medial epicondyle
Flexor carpi ulnaris
O: Medial epicondyle of humerus
I: Base of fifth metacarpal and pisiform
A: Flexes wrist, adducts wrist (ulnar deviation)
Flexor carpi radialis
O: Medial epicondyle of humerus
I: Base of second and third metacarpals
A: Flexes wrist, abducts wrist (radial deviation)
Palmaris longus: Weak flexor, missing in 10% of population
O: Medial epicondyle of humerus
I: Palmar aponeurosis
A: Assists wrist flexion, tenses palmar fascia
Flexor digitorum superficialis
O: Medial epicondyle, medial aspect of coronoid process, anterior shaft of radius
I: Sides of middle phalanges of the four fingers
A: Flexes proximal interphalangeal joints of four fingers, assists wrist flexion
Flexor digitorum profundus
O: Anterior proximal surface of three-fourths of ulna, interosseous membrane
I: Base of distal phalanges of four fingers
A: Flexes distal interphalangeal joints of four fingers, assists wrist flexion
Wrist and finger extensors
Share common extensor tendon attached to lateral epicondyle
Extensor carpi radialis longus
O: Medial epicondyle of humerus
I: Palmar aponeurosis
A: Assists wrist flexion, tenses palmar fascia
Extensor carpi radialis brevis
O: Lateral epicondyle of humerus
I: Base of third metacarpal
A: Extends wrist, assists wrist abduction
Extensor carpi ulnaris
O: Lateral epicondyle of humerus
I: Base of fifth metacarpal
A: Extends wrist, assists wrist adduction
Extensor digitorum
O: Lateral epicondyle of humerus
I: Base of distal phalanges of four fingers
A: Extends fingers, assists wrist extension
Extensor indicis
O: Distal posterior surface of ulna, interosseous membrane
I: Base of proximal phalanx of index (first) finger
A: Extends index finger
Epicondylitis
Cumulative trauma from forceful, repeated contractions
Creates microscopic tears in common flexor/extensor tendon
Tendon becomes inflamed and weakened
Treatment: Rest, ice, cross-fiber stretching when inflammation subsides
Two types
Medial epicondylitis
Injury to common flexor tendon
Nicknamed “golfer’s elbow”
Lateral epicondylitis
Injury to common extensor tendon
Nicknamed “golfer’s elbow”
Muscles of the thumb
Extrinsic (long)
Flexor pollicis longus
O: Middle anterior shaft of radius, interosseous membrane
I: Base of distal phalanx of thumb
A: Flexes interphalangeal joint of thumb
Extensor pollicis longus
O: Middle third of posterior ulnar shaft, interosseous membrane
I: Base of distal phalanx of thumb
A: Extends interphalangeal joint of thumb, assists wrist extension, assists extension of saddle joint of thumb
Extensor pollicis brevis
O: Middle of lateral part of posterior radius, interosseous membrane
I: Base of proximal phalanx of thumb
A: Extends thumb and abducts hand
Abductor pollicis longus
Intrinsic (short): Form thenar eminance
Opponens pollicis
O: Flexor retinaculum and tubercle of trapezium
I: Shaft of first metacarpal
A: Thumb opposition
Abductor pollicis brevis
O: Middle of posterior surface of radius and ulna, interosseous membrane
I: Base of first metacarpal
A: Abducts and extends thumb, assists wrist extension
Adductor pollicis
O: Shaft of second and third metacarpal, capitate
I: Medial base of proximal phalanx of thumb
A: Adducts thumb, assists hand adduction
Flexor pollicis brevis
O: Flexor retinaculum and trapezium
I: Base of proximal phalanx of thumb
A: Flexes the proximal phalanx and first carpometacarpal joint of thumb
Muscle of the hand
Muscles between metacarpals
Palmar interossei
O: Base of first metacarpal, proximal anterior shaft of second, fourth, and fifth metacarpals
I: Base of first, second, fourth, and fifth proximal phalanges
A: Adduct the fingers, assist flexion of the metacarpophalangeal joints
Dorsal interossei
O: Posterior shafts of metacarpals
I: Base of second, third, and fourth proximal phalanges
A: Abduct the second, third, and fourth fingers
Lumbricals
O: Flexor digitorum profundus tendons in the palm
I: Lateral sides of extensor expansion tendons at base of proximal phalanges
A: Flex metacarpophalangeal joints while extending proximal and distal interphalangeal joints
Muscles acting on little finger: Form hypothenar eminance
Extensor digiti minimi
O: Lateral epicondyle of humerus
I: Base of first phalanx of fifth finger
A: Extends little finger
Abductor digiti minimi
O: Pisiform and tendon of flexor carpi ulnaris
I: Medial side of base of fifth proximal phalanx
A: Abducts little finger, assists flexion of proximal phalanx of little finger
Opponens digiti minimi
O: Flexor retinaculum and hook of hamate
I: Medial side of shaft of fifth metacarpal
A: Draws little finger to thumb in opposition, assists flexion of fifth carpometacarpal joint
Flexor digiti minimi brevis
O: Flexor retinaculum and hook of hamate
I: Base of fifth proximal phalanx
A: Flexes fifth metacarpophalangeal joint
SUGGESTED LEARNER AND STUDENT DEVELOPMENT ACTIVITIES
PROVIDE AN OVERVIEW OF THE CLASS
Before class, write a short schematic overview of the class on the board, then go over it at the beginning of class. For example:
Today's class covers:
Bones of the arm and hand
Joints and ligaments
Muscles of the arm and hand
Activities: Review, lecture and assessments, palpation exercises, recap
PALPATION EXERCISES
Elbow and forearm (p. 612)
Carpals (p. 616)
Metacarpals and phalanges (p. 620)
Biceps brachii, brachialis, and brachioradialis (p. 636)
Triceps brachii and anconeus (p. 640)
Supinator and pronator teres (p. 644)
Flexor carpi ulnaris and radialis, palmaris longus, and flexor digitorum superficialis and profundus (p. 648)
Extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digitorum, extensor indicis (p. 653)
Flexor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus (p. 658)
Adductor pollicis, flexor pollicis brevis, abductor pollicis brevis, and opponens pollicis (p. 661)
Interossei and lumbricals (p. 665)
Abductor digiti minimi, opponens digiti minimi, and flexor digiti minimi brevis (p. 667)
EXPLORING TECHNIQUE EXERCISE
Passive range of motion for the wrist (p. 627)
SELF-CARE EXERCISES
Grip strength and joint alignment for massage (p. 631)
Stretching the wrists and thumbs (p. 668)
© 2013 by Education, Inc. Foster, Instructor Resources for Therapeutic Kinesiology
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