Therapeutic Kinesiology:Musculoskeletal Systems, Palpation, and Body Mechanics

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