THE HAND
COMPLEX
DR. DIGVIJAY SHARMA
DEPARTMENT OF PHYSIOTHERAPY
U.I.H.S
KANPUR
THE HAND-
The hand complex consists of 19 bones and 19 joints distal to the
carpals.
There are 5 digits or 4 fingers and 1 thumb.
Each digit has a carpometacarpal (CMC) joint and a metacarpo-
phalangeal (MCP) joint.
Each fingers have 2 interphalangeal joint and the thumb has only
one.
STRUCTURE OF FINGERS-
CMC JOINTS
The CMC joints are composed of articulation between the distal carpal row and the bases of 2 nd to 5th
metacarpals.
The proximal portion of 4 metacarpals of fingers articulate with distal carpal to form the 2 nd through 5th CMC
joint
The 2nd metacarpal articulates with trapezoid primarily and secondarily with trapezium and capitates.
The 3rd articulate with capitates .
The 4th articulate with capitates and hamate
And 5th metacarpal articulate with hamate.
Each of Metacarpal also articulate at its base with the contiguous metacarpal.
All CMC joint are supported by a strong transverse and weaker longitudinal ligament Volarly and dorsally.
FUNCTIONS-
• CMC joint from 2nd to 4th are plane synovial joint with 10 of
freedom flexion/extension.
• The 2nd and 3rd are essentially immobile and may be considered
to have 00 of freedom.
• The 4th have perceptible movement while 5th is a saddle joint
with 20 of freedom,
• Flexion/extension, abduction/adduction and a limited amount
of opposability.
MCP Joints of the Fingers-
These are joint formed by articulation between the convex
metacarpal head proximally and the concave base of the first
phalanx distally.
It is of condyloid type with 20 of freedom, “flexion/extension and
abduction/adduction’’.
The large MC head has 1800 of articular surface which is opposed
to approximately 200 of articular surface of the phalanx.
The joint is surrounded by a capsule that is considered to be lax in
extension and allows some passive axial rotation in this position.
The joint is incongruent because of
difference in its articular surface so
their must be an accessory structure
to enhance stability, which is served
by the volar plate.
The volar plate is an unique structure
at MCP joint that increases joint
congruence.
It is composed of fibro cartilage and is
firmly attach to the base of the
proximal phalanx.
The plate becomes membranous
proximally to blend with the capsule.
The capsule is also strengthen by 2 collateral ligament.
The collateral ligament of MCP joint are slack in extension
permitting full range of abduction/adduction.
They are considered in close pack position when the joint are in
full flexion and permitting minimal amount of
abduction/adduction.
This is more because of bony block rather than tension in
collateral ligament.
Range of motion-
The R.O.M. available at MCP joint varies with each finger.
The flexion/extension increases radially to ulnarly with the index
finger having approx. 900 of MCP flexion and little 1100.
The abduction/adduction is maximal when the joint is in the
extension and minimal in full flexion.
IP Joints of the Fingers
It consist of head of the proximal phalanx and the base of the distal
phalanx to it .
It is a true hinge joint with 10 of freedom.
The joint Is strengthen by a joint capsule, a volar plate and collateral
ligament.
ROM
The total ROM of flexion and extension available at PIP joint (1000-
1100) is greater than DIP joint (800). The radially to ulnarly and
reaches to 1350 and 900 respectively.
STRUCTURE OF THUMB-
CMC JOINT-
It is the articulation between the trapezium and
base of the 1st metacarpal.
It is a saddle joint with 2 degree of freedom.
Flexion/Extension
Abduction/Adduction
The joint also permits some axial rotation.
The CMC joint surface consist not only of the
traditionally described saddle shaped surfaces
but also of a spherical portion.
The saddle shaped portion of the trapezium is
concave in sagittal plane (abduction/adduction)
and convex in frontal plane (flexion/extension).
The spherical portion is convex in all direction. The base of 1st metacarpal
has a reciprocal shape to that of the trapezium.
Flexion/extension and abduction/adduction occurs on the saddle shape
surface, where as axial rotation that accompanies opposition occurs on
the spherical surface.
Flexion and Extension occurs nearly parallel to the palm around a oblique
AP axis and adduction/abduction nearly perpendicular around oblique
coronal axis.
This obliquity of motion occurs because of inclination of the trapezium.
The capsule of CMC joint is relatively lax but is reinforced by radial, volar
and dorsal ligaments. The CMC joint ROM as an average of 530 of
flexion/extension, 420 of adduction/abduction and 170 of rotation.
FUNCTION OF 1ST CMC JOINT
The unique range and direction of motion at the 1st CMC
produces opposition of the thumb.
The opposition is sequentially, abduction, flexion and
adduction of the 1st metacarpal.
The functional significance of the CMC joint is
appreciated when thumb is used against a finger in
almost all forms of prehension.
MCP and IP Joint of Thumb
The MCP joint is the articulation between the head of 1 st metacarpal and the
base of its proximal phalanx.
It is condyloid type of joint with 20 of freedom : flexion/extension and
abduction/adduction.
The IP joint of the thumb is the articulation between the head of the proximal
phalanx and the base of distal phalanx. It is structurally and functionally identical
to the IP joint of finger.
The main function of MCP is provide to additional flexion range to the thumb in
opposition and to allow the thumb to grasp and contour to the object. Despite
the structural similarities the ROM at 1st MCP is for more restricted then finger
MCP joint.
Although the ROM varies among individuals the 1st MCP rarely has more
than ½ flexion available at fingers and little finger and little if any
hyperextension.
Adduction/abduction and rotation is extremely restricted.
This limitation is because of the structural difference between the 1st
MCP and other MCP joints.
The first MCP joint is reinforced intra capsularly on its volar surface by
two sesamoid bones.
These are maintained in position by collateral fibers and inter sesamoid
ligament.
PREHENSION
It is defined as holding or grasping of an object between any two
surfaces in the hand.
The thumb participates in most but not all prehension activity.
Prehension is categorized as :-
1. Power Grip
2. Precision handling
Power Grip:-
Power grip is the result of a sequence of opening the hand, positioning the fingers,
approaching the fingers to the objects and maintaining a static phase that actually
constitutes the grip.
It is generally a forceful act resulting in flexion at all fingers joint. When the thumb is
used it acts as a stabilizer to the object held between the finger and the palm.
The power grip can be categorized as-
I. Cylindrical Grip
II. Spherical Grip
III. Hook Grip
IV. Lateral Prehension
Cylindrical Grip:-
This Grip exclusively uses flexors to carry the fingers around
and maintain grasp on an object.
The function especially in dynamic closing action is
performed mainly by flexors digitorum profundus.
The FDS assists when greater force is required in the static
phase.
Traditionally power grip was considered as an extrinsic
activity but recent studies have shown and considerable
involvement of interosseus muscle activity.
In strong grip the magnitude of force of the interossei in
MCP flexion has been found nearly equal that of the
extrinsic flexors.
The interossei may also position the MCP joint in
adduction or abduction to ulnarly deviate the MCP joint
and align the distal phalanges of thumb and fingers.
The joint compression of joint stability during power grip
is enhanced by active or passive contraction of Extensor
Digitorum Communes.
The thumb usually comes around the object then flexes
and adducts to close the object.
The Flexor Pollicis Longus and the thenar muscles are all active.
The Extensor Pollicis Longus may be variably active as an MCP stabilizer or
as an adductor.
In cylindrical grips the wrist is in neutral flexion and extension and slight
ulnar deviation. The heavier the object more likely it is that the wrist is
ulnarly deviated.
Regardless the position of the wrist. The percent of total IP flexor force
allocated for each finger is relatively constant.
The ring and little finger can generate only 70% of flexor force of the middle
and index finger.
The contribution of little finger can be increased in an object that is wider
ulnarly than radially.
SPHERICAL GRIP-
The main distinction between spherical and cylindrical grip is greater
spread of the finger to encompass the object.
So it requires more interossei activity compared to other power grip.
MCP joint do not deviate in the same direction but tend to abduct. The
phalanges are not parallel to each other.
The MCP abductors must be joined by the adductors to stabilize the
joint which is in semi flexed position.
Other activities are same as cylindrical grip.
Although the flexor activity predominate, the extensors do have their
role in providing a balancing force for the flexor and also essential for
smooth and controlled opening of the hand and release of the object.
HOOK GRIP-
It is included in the power group because it has more characteristics of
power grip than precision handling.
It is a function primarily of the fingers. It may include the palm but
never include thumb.
It can be sustained for prolonged period of time as anyone carrying
briefcase.
The major muscles that is working are FDP and FDS.
If the load is carried more distally so the DIP function is required the
FDP must participate and if it is carried more in the middle Phalanx the
FDS is sufficient.
The interossei is also active but exact function is not known.
The thumb is held in the moderate to full extension by the thumb
extrinsic.
Lateral prehension-
it is a unique form of grasp in which contact occurs
between two adjacent fingers.
The MCP and IP joints are usually remains in the
extension as the contiguous MCP joint simultaneously
abduct and adduct.
This is the only form of prehension in which extensors
plays a part in maintenance of the posture.
The EDC and Lumbricals are active to extend the
phalanges.
The MCP abduction and adduction is performed by
interossei.
It is included in power grip because it involves the
static holding of the object and then moved by the
more proximal joint of upper extremity although not
a powerful grip neither it is used to manipulate the
object in the hand.
Example- holding cigarette
Precision Handling-
It is the skilful placement of an object between fingers or finger
and thumb.
The palm is not involved.
Precision handling does not contain a static phase of the grip,
here the fingers and thumb grasp the object with intention of
manipulating it within hand, Whereas in power grip the object is
grasp so that it can be moved through space by the more
proximal joints.
Precision handling in contrast to the power grip requires much
fine motor control and are more dependent on intact sensation
In a 2 jaw chuck, the thumb is 1 jaw while the second and
opposing jaw is formed by either the distal tip, the pad or the side
of a finger.
Here, the thumb is generally abducted and rotated from the palm
when two fingers oppose the thumb it is called a Three Jaw
Types of precision handling-
[Link] Tip
[Link] to Pad
[Link] to Side
Pad to Pad Prehension-
It involves the opposition of pad or pulp of the thumb to the pad or pulp of the finger.
80% of precision handling uses this mode of prehension, where mainly the pad of the
distal phalanx of each digit is used.
If it is 2 jaw chuck usually index finger is used and in three jaw chuck the middle
finger added.
The MCP and PIP joint of fingers are partially flexed, with the degree of flexion
depends upon the size of object being held.
The DIP joint may be fully extended or in slight flexion. The DIP extension is caused
by the pull of the FDS down on the middle phalanx against the pressure of thumb on
the distal phalanx.
When the partial DIP flexion is required by the task, the FDP must be activated.
MCP flexion and MCP adduction or abduction, which is required for the manipulation
of object is provided by interosseus.
In a dynamic manipulation, the palmer and dorsal interossei work reciprocally while
in a firm pad to pad pinch they may co-contract.
The thumb is held in CMC flexion, abduction and rotation.
The MCP and IP joints are
partially flexed to fully extended.
These activity of the thumb is
assisted by thenar muscles.
In full extension of finger DIP
and thumb IP contacts occur on
the proximal portion of the distal
phalanx. As the flexion increases
the contact moves distally
towards the nails.
The extensor muscles is used for
opening the hand to grasp, for
release and for stabilization
when necessary.
The wrist is held in neutral,
radial/ulnar deviation and slight
extension.
Tip to tip prehension-
In this the IP joint of the finger and thumb are nearly
fully flexed.
The MCP of finger must be a ulnarly deviated to the
prevent the tip of the finger to the thumb.
In first finger the ulnar deviation occurs as an
adduction while in other as abduction.
The muscular activity required for tip to tip
prehension is same as pad to pad prehension and
additionally it requires activity of FDP, the FPL and
the interossei. Although these muscles may assist in
pad to pad prehension but not required.
Pad to Side prehension-
It is also known as key grip because a key is hold
between the pad of the thumb and side of the index
finger. It is differ from the other forms of precision
handling in that the thumb is more adducted and less
rotated.
The activity level of FPB and adductor pollicis increases
and that of the opponences pollicis decreases as
compared with tip to tip prehension or pad to pad
prehension.
Slight flexion of the distal phalanx of the thumb is
required.
it is the least precise form of precision handling and it
can actually perform by the person with paralysis of all
hand muscles.
if this prehension is used for turning a key the wrist will
Functional position of the wrist and hand-
WRIST COMPLEX-
Slight extension (20°)
Slight ulnar deviation (10°)
FINGERS-
MCP joint moderated flexed (45°)
PIP joint = slightly flexed (30°)
DIP joint = slightly flexed
