Tests For Length Of Lumbricales And Interossei

SHORTNESS OF INTRINSIC MUSCLES OF THE HAND

In this case, illustrated by the above photographs, a middle-aged woman presented with a complaint that her middle finger occasionally pained rather severely and that a constant, tight, "drawing" feeling was felt along the sides of this finger. She did not feel that the pain was actually in the joints of the finger. A medical checkup had revealed no arthritis. This person was an avid card player, and the condition was present in the left hand, which was the hand in which she held her cards.

Figure A shows the position of the subject's hand in holding a hand of cards. This position is one of strong lumbrical and interosseous action. Just as in holding a newspaper, the middle finger is the one that strongly opposes the thumb.

On testing for length of the intrinsic muscles, evidence of shortness was found, chiefly in the muscles in the middle finger.

The patient could close the fingers to make a fist, as shown in Figure B. This was possible even though some shortness existed in the lumbricales and interos-

sei, because the muscles were being elongated over the interphalangeal joints only, not over the metacarpopha-langeal joints.

When attempting to close the hand into a claw-hand position, as shown in Figure C, the shortness became apparent. In closing the fingers into this position, the lumbricales and interossei must elongate over all three joints at the same time. The middle finger shows the greatest limitation. The ring finger shows slight limitation, which is demonstrated by the lack of distal joint flexion as well by decreased hyperextension of the metacarpophalangeal joint.

The patient could extend the fingers, as shown in Figure D. This was possible because the muscles were being elongated over the metacarpophalangeal joints only, not over the interphalangeal joints. In Figure D, the distal phalanx of the middle finger, which opposes the thumb in holding the cards, is in slight hyperextension.

The fact that the fingers could be spread apart, as shown in Figure E, and closed sideways, as shown in Figure F, suggests that the shortness may have been in the lumbricales more than in the interossei.

Palmaris Longus
Palmaris longus

PALMARIS LONGUS

Origin: Common flexor tendon from the medial epi-condyle of the humerus and the deep antebrachial fascia.

Insertion: Flexor retinaculum and palmar aponeurosis.

Action: Tenses the palmar fascia, flexes the wrist, and may assist in flexion of the elbow.

PALMARIS BREVIS

Origin: Ulnar border of the palmar aponeurosis and palmar surface of the flexor retinaculum.

Insertion: Skin on the ulnar border of the hand.

TESTING OF PALMARIS LONGUS

Patient: Sitting or supine.

Fixation: The forearm rests on the table for support, in a position of supination.

Test: Tensing of the palmar fascia by strongly cupping the palm of the hand, and flexion of the wrist.

Pressure: Against the thenar and hypothenar eminences in the direction of the flattening of the palm of the hand, and against the hand in the direction of extending the wrist.

Weakness: Decreases the ability to cup the palm of the hand. Strength of wrist flexion is also diminished.

Action: Corrugates the skin on the ulnar side of the hand. Nerve: Ulnar, C(7), 8, Tl.

EXTENSOR INDICIS

Origin: Posterior surface of the body of the ulna distal to the origin of the extensor pollicis longus, and interosseous membrane.

Insertion: Into extensor expansion of the index finger with the extensor digitorum longus tendon.

Action: Extends the metacarpophalangeal joint, and in conjunction with the lumbricalis and interossei, extends the interphalangeal joints of the index finger. May assist in adduction of the index finger.

EXTENSOR DIGITI MINIMI

Origin: Common extensor tendon from the lateral epi-condyle of the humerus and deep antebrachial fascia.

Insertion: Into extensor expansion of the little finger with the extensor digitorum tendon.

Action: Extends the metacarpophalangeal joint, and in conjunction with the lumbricalis and interosseous, extends the interphalangeal joints of the little finger. Assists in abduction of the little finger.

EXTENSOR DIGITORUM

Origin: Common extensor tendon from the lateral epi-condyle of the humerus and deep antebrachial fascia.

Insertion: By four tendons, each penetrating a membranous expansion on the dorsum of the second through fifth digits and dividing over the proximal phalanx into a medial and two lateral bands. The medial band inserts into the base of the middle phalanx; the lateral bands reunite over the middle phalanx and insert into the base of the distal phalanx.

Action: Extends the metacarpophalangeal joints, and in conjunction with the lumbricales and interossei, extends the interphalangeal joints of the second through fifth digits. Assists in abduction of the index, ring, and little fingers and in extension and abduction of the wrist.

Patient: Sitting or supine.

Fixation: The examiner stabilizes the wrist, avoiding full extension.

Test: Extension of the metacarpophalangeal joints of the second through fifth digits with the interphalangeal joints relaxed.

Pressure: Against the dorsal surfaces of the proximal phalanges, in the direction of flexion.

Weakness: Decreases the ability to extend the metacarpophalangeal joints of the second through fifth digits, and may result in a position of flexion of these joints. Strength of wrist extension is also diminished.

Contracture: Hyperextension deformity of the metacar-pophalangeal joints.

Shortness: Hyperextension of the metacarpophalangeal joints if the wrist is flexed, or extension of the wrist if the metacarpophalangeal joints are flexed.

Palmar view

Palmar view

FLEXOR DIGITORUM SUPERFICIALIS

Origin of Humeral Head: Common flexor tendon from the medial epicondyle of the humerus, ulnar collateral ligament of the elbow joint, and deep antebrachial fascia.

Origin of Ulnar Head: Medial side of the coronoid process.

Origin of Radial Head: Oblique line of the radius.

Insertion: By four tendons into the sides of the middle phalanges of the second through fifth digits.

Action: Flexes the proximal interphalangeal joints of the second through fifth digits, and assists in flexion of the metacarpophalangeal joints and in flexion of the wrist.

Patient: Sitting or supine.

Fixation: The examiner stabilizes the metacarpopha-langeal joint, with the wrist in neutral position or slight extension.

Test: Flexion of the proximal interphalangeal joint, with the distal interphalangeal joint extended, of the second, third, fourth, and fifth digits. (See Note.) Each finger is tested as illustrated for the index finger.

Pressure: Against the palmar surface of the middle phalanx, in the direction of extension.

Weakness: Decreases the strength of grip and of wrist flexion. Interferes with finger function in activities in which the proximal interphalangeal joint is flexed while the distal joint is extended, such as typing, playing the piano, and playing some stringed instruments. Weakness causes loss of joint stability at the proximal interpha-langeal joints of the fingers so that during finger extension, these joints hyperextend.

Contracture: Flexion deformity of the middle phalanges of the fingers.

Shortness: Flexion of the middle phalanges of the fingers if the wrist is extended, or flexion of the wrist if the fingers are extended.

Not©: // appears to be the exception rather than the rule to obtain isolated flexor superficialis action in the fifth digit.

Palmar view

Palmar view

FLEXOR DIGITORUM PROFUNDUS

Origin: Anterior and medial surfaces of the proximal 3/ 4 of the ulna, interosseous membrane and deep ante-brachial fascia.

Insertion: By four tendons into the bases of the distal phalanges, anterior surface.

Action: Flexes the distal interphalangeal joints of the index, middle, ring, and little fingers, and assists in flex ion of the proximal interphalangeal and metacarpophalangeal joints. May assist in flexion of the wrist.

Nerves:

First and second: Median, C7, 8, Tl. Third and fourth: Ulnar, C7, 8, Tl. Patient: Sitting or supine.

Fixation: With the wrist in slight extension, the examiner stabilizes the proximal and middle phalanges.

Test: Flexion of the distal interphalangeal joint of the second, third, fourth and fifth digits. Each finger is tested as illustrated above for the index finger.

Pressure: Against the palmar surface of the distal phalanx, in the direction of extension.

Weakness: Decreases the ability to flex the distal joints of the fingers in direct proportion to the extent of weakness because this is the only muscle that flexes the distal interphalangeal joints. Flexion strength of the proximal interphalangeal, metacarpophalangeal and wrist joints may be diminished.

Contracture: Flexion deformity of the distal phalanges of the fingers.

Shortness: Flexion of the fingers if the wrist is extended, or flexion of the wrist if the fingers are extended.

FLEXOR CARPI RADIALIS Action: Flexes and abducts the wrist, and may assist in pronation of the forearm and in flexion of the elbow.

Origin: Common flexor tendon from the medial epi- Nerve: Median, C6, 7, 8. condyle of the humerus and deep antebrachial fascia. (Fascia are indicated by parallel lines.)

Insertion: Base of the second metacarpal bone and a slip to the base of the third metacarpal bone.

Patient: Sitting or supine.

Fixation: The forearm is in slightly less than full supination and either rests on the table for support or is supported by the examiner.

Test: Flexion of the wrist toward the radial side. (See Note on the facing page.)

Pressure: Against the thenar eminence, in the direction of extension toward the ulnar side.

Weakness: Decreases the strength of wrist flexion, and pronation strength may be diminished. Allows an ulnar deviation of the hand.

Shortness: Wrist flexion toward the radial side.

Note: Thepalmaris longus cannot be ruled out in this test.

FLEXOR CARPI ULNARIS

Origin of Humeral Head: Common flexor tendon from the medial epicondyle of the humerus.

Origin of Ulnar Head: By aponeurosis from the medial margin of the olecranon, proximal h of the posterior border of the ulna and from the deep antebrachial fascia.

Insertion: Pisiform bone and, by ligaments, to the hamate and fifth metacarpal bones.

Action: Flexes and adducts the wrist, and may assist in flexion of the elbow.

Patient: Sitting or supine.

Fixation: The forearm is in full supination and either rests on the table for support or is supported by the examiner.

lest: Flexion of the wrist toward the ulnar side.

Pressure: Against the hypothenar eminence, in the direction of extension toward the radial side.

Weakness: Decreases the strength of wrist flexion, and may result in a radial deviation of the hand.

Shortness: Wrist flexion toward the ulnar side.

Note: Normally, the fingers will be relaxed when the wrist is flexed. If the fingers actively Hex as wrist flexion is initiated, however, the finger flexors (profundus and superficialis) are attempting to substitute for the wrist flexors.

EXTENSOR CARPI RADIALIS LONGUS

Origin: Distal h of the lateral supracondylar ridge of the humerus and lateral intermuscular septum.

Insertion: Dorsal surface of the base of second metacarpal bone, radial side.

Action: Extends and abducts the wrist, and assists in flexion of the elbow.

EXTENSOR CARPI RADIALIS BREVIS

Origin: Common extensor tendon from the lateral epi condyle of the humerus, radial collateral ligament of elbow joint, and deep antebrachial fascia.

Insertion: Dorsal surface of the base of the third metacarpal bone.

Action: Extends and assists in abduction of the wrist Nerve: Radial, C6, 7, 8.

EXTENSOR CARPI RADIALIS LONGUS AND BREVIS

Patient: Sitting with the elbow approximately 30° from zero extension (Figure A).

Fixation: The forearm is in slightly less than full pronation and rests on the table for support.

Test: Extension of the wrist toward the radial side. (Fingers should be allowed to flex as the wrist is extended.)

Pressure: Against the dorsum of the hand, along the second and third metacarpal bones, in the direction of flexion toward the ulnar side.

Weakness: Decreases the strength of wrist extension, and allows an ulnar deviation of the hand.

EXTENSOR CARPI RADIALIS BREVIS

Patient: Sitting with the elbow fully flexed (Figure B). (Have the subject lean forward to flex the elbow.)

Fixation: The forearm is in slightly less than full pronation and rests on the table for support.

Test: Extension of the wrist toward the radial side. Elbow flexion makes the extensor carpi radialis longus less effective by placing it in a shortened position.

Pressure: Against the dorsum of the hand, along the second and third metacarpal bones, in the direction of flexion toward the ulnar side.

Shortness: Wrist extension with radial deviation.

Note: See Note on the following page.

EXTENSOR CARPI ULNARIS

Origin: Common extensor tendon from the lateral epicondyle of the humerus, by the aponeurosis from the posterior border of the ulna and deep antebrachial fascia.

Insertion: Base of the fifth metacarpal bone, ulnar side. Action: Extends and adducts the wrist. Nerve: Radial, C6, 7, 8.

Patient: Sitting or supine.

Fixation: The forearm is in full pronation and either rests on the table for support or is supported by the examiner.

Test: Extension of the wrist toward the ulnar side.

Pressure: Against the dorsum of the hand, along the fifth metacarpal bone, in the direction of flexion toward the radial side.

Weakness: Decreases the strength of wrist extension, and may result in a radial deviation of the hand.

Shortness: Ulnar deviation of the hand with slight extension.

Note: Normally, the fingers will be in a position of passive flexion when the wrist is extended. If the fingers actively extend as wrist extension is initiated, however, the finger extensors (digitorum, in-dicis, and digiti minimi) are attempting to substitute for the wrist extensors.

PRONATOR TERES

Origin of Humeral Head: Immediately above the medial epicondyle of the humerus, common flexor tendon and deep antebrachial fascia.

Origin of Ulnar Head: Medial side of the coronoid process of the ulna.

Insertion: Middle of the lateral surface of the radius.

Action: Pronates the forearm, and assists in flexion of the elbow joint.

Weakness: Allows a supinated position of the forearm, and interferes with many everyday functions, such as turning a doorknob, using a knife to cut meat, and turning the hand downward in picking up a cup or other object.

Contracture: With the forearm held in a position of pronation, interferes markedly with many normal functions of the hand and forearm that require moving from pronation to supination.

PRONATORS TERES AND QUADRATUS

Patient: Supine or sitting.

Fixation: The elbow should be held against the patient's side or be stabilized by the examiner to avoid any shoulder abduction movement.

Test: Pronation of the forearm, with the elbow partially flexed.

Pressure: At the lower forearm, above the wrist (to avoid twisting the wrist), in the direction of supinating the forearm.

Note: Avoid squeezing the radius and ulna together because this may be painful.

PRONATOR QUADRATUS

Origin: Medial side, anterior surface of the distal xk of the ulna.

Insertion: Lateral side, anterior surface of the distal h of the radius.

Action: Pronates the forearm. Nerve: Median, C7, 8, Tl.

j Pronator I I quadratus j Pronator I I quadratus

Patient: Supine or sitting.

Fixation: The elbow should be held against the patient's side (either by the patient or by the examiner) to avoid shoulder abduction.

Test: Pronation of the forearm, with the elbow completely flexed to make the humeral head of the pronator teres less effective by being in a shortened position.

Pressure: At the lower forearm, above the wrist (to avoid twisting the wrist), in the direction of supinating the forearm.

Note: Avoid squeezing the radius and ulna together because this may be painful.

SUPINATOR

Origin: Lateral epicondyle of the humerus, radial collateral ligament of the elbow joint, annular ligament of the radius and supinator crest of the ulna.

Insertion: Lateral surface of the upper h of the body of the radius, covering part of the anterior and posterior surfaces.

Action: Supinates the forearm. Nerve: Radial, C5, 6, (7).

SUPINATOR AND BICEPS

Patient: Supine.

Fixation: The elbow should be held against the patient's side to avoid shoulder movement.

Test: Supination of the forearm, with the elbow at a right angle or slightly below.

Pressure: At the distal end of the forearm, above the wrist (to avoid twisting the wrist), in the direction of pronating the forearm.

Weakness: Allows the forearm to remain in a pronated position. Interferes with many functions of the extremity, particularly those involved with feeding oneself.

Contracture: Elbow flexion with forearm supination. Interferes markedly with functions of the extremity that involve the change from a supinated to a pronated position of the forearm.

SUPINATOR

Tested with the biceps elongated. Patient: Sitting or standing.

Fixation: The examiner holds the shoulder and elbow in extension.

lest: Supination of the forearm.

Pressure: At the distal end of the forearm, above the wrist, in the direction of pronation. The subject may attempt to rotate the humerus laterally to make it appear that the forearm remains in supination as pressure is applied and the forearm starts to pronate.

SUPINATOR

Tested with the biceps in a shortened position. Patient: Supine.

Fixation: The examiner holds the shoulder in flexion, with the elbow completely flexed. It is usually advisable to have the subject close the fingers to keep them from touching the table, which may be done in an effort to brace the forearm in the test position.

Test: Supination of the forearm.

Pressure: At the distal end of the forearm, above the wrist, in the direction of pronation. Take care to avoid maximum pressure because, as strong pressure is applied, the biceps comes into action and, in this shortened position, goes into a cramp. A severe cramp may leave the muscle sore for several days. This test should be used merely as a differential diagnostic aid.

Note: In a radial nerve lesion involving the supinator, the test position cannot be maintained. The forearm will fail to hold the fully supinated position even though the biceps is normal.

Brachialis

BICEPS BRACHII

Origin of Short Head: Apex of the coracoid process of the scapula.

Origin of Long Head: Supraglenoid tubercle of the scapula.

Insertion: Tuberosity of the radius and aponeurosis of the biceps brachii (lacertus fibrosus).

Action: Flexes the shoulder joint. The short head assists with shoulder adduction. The long head may assist with abduction if the humerus is laterally rotated. With the origin fixed, flexes the elbow joint, moving the forearm toward the humerus and supinates the forearm. With the insertion fixed, flexes the elbow joint, moving the humerus toward the forearm, as in pull-up or chinning exercises.

Nerve: Musculocutaneous C5, 6. BRACHIALS

Origin: Distal k of the anterior surface of the humerus and both medial and lateral intermuscular septa.

Insertion: Tuberosity and coronoid process of the ulna.

Action: With the origin fixed, flexes the elbow joint, moving the forearm toward the humerus. With the insertion fixed, flexes the elbow joint, moving the humerus toward the forearm, as in pull-up or chinning exercises.

Nerve: Musculocutaneous, small branch from radial, C5, 6.

BICEPS BRACHII AND BRACHIALIS

Patient: Supine or sitting.

Fixation: The examiner places one hand under the elbow to cushion it from table pressure.

Test: Elbow flexion slightly less than or at a right angle, with the forearm in supination.

Pressure: Against the lower forearm, in the direction of extension.

Weakness: Decreases the ability to flex the forearm against gravity. Interferes markedly with daily activities such as feeding oneself or combing the hair.

Shortness: Flexion deformity of the elbow.

Note: If the biceps and brachialis are weak, as in a musculocutaneous lesion, the patient will pronate the forearm before flexing the elbow using the bra-chioradialis, extensor carpiradialislongus, pronator teres and wrist flexors.

Pronator Teres Muscle Length Test
Elbow flexion with the forearm supinated.
Elbow flexion with the forearm pronated.

The lower figure illustrates that against resistance, the biceps acts in flexion even though the forearm is in pronation. Because the brachialis is inserted on the ulna, the position of the forearm, whether in supination or in pronation, does not affect the ac tion of this muscle in elbow flexion. The brachio-radialis appears to have a slightly stronger action in the pronated position of the forearm during the elbow flexion test than in the supinated position, although its strongest action in flexion is with the forearm in midposition.

TRICEPS BRACHII

Origin of Long Head: Infraglenoid tubercle of the scapula.

Origin of Lateral Head: Lateral and posterior surfaces of the proximal k. of the body of the humerus and lateral intermuscular septum.

Origin of Medial Head: Distal h> of the medial and posterior surfaces of the humerus below the radial groove and from the medial intermuscular septum.

Insertion: Posterior surface of the olecranon process of the ulna and antebrachial fascia.

Action: Extends the elbow joint. The long head also assists in adduction and extension of the shoulder joint.

ANCONEUS

Origin: Lateral epicondyle of the humerus, posterior surface.

Insertion: Lateral side of the olecranon process and upper 'A of the posterior surface of the body of the ulna.

Action: Extends the elbow joint, and may stabilize the ulna during pronation and supination.

TRICEPS BRACHII AND ANCONEUS

Patient: Prone.

Fixation: The shoulder is at 90° abduction, neutral with regard to rotation, and with the arm supported between the shoulder and the elbow by the table. The examiner places one hand under the arm near the elbow to cushion the arm from table pressure.

Test: Extension of the elbow joint (to slightly less than full extension).

Pressure: Against the forearm, in the direction of flexion.

TRICEPS BRACHII AND ANCONEUS (CONTINUED)

Patient: Supine.

Fixation: The shoulder is at approximately 90° flexion, with the arm supported in a position perpendicular to the table.

Test: Extension of the elbow (to slightly less than full extension).

Pressure: Against the forearm in the direction of flexion.

Weakness: Results in the inability to extend the forearm against gravity. Interferes with everyday functions that involve elbow extension, such as reaching upward toward a high shelf. Results in loss of ability to throw objects or to push them with the extended elbow. Also handicaps the individual in using crutches or a cane because of inability to extend the elbow and transfer weight to the hand.

Contracture: Extension deformity of the elbow. Interferes markedly with everyday functions that involve elbow flexion.

Note : When the shoulder is horizontally abducted (see facing page), the long head of the triceps is shortened over both the shoulder and elbow joints. When the shoulder is flexed (horizontally ad-ducted), the long head of the triceps is shortened over the elbowjoint but elongated over the shoulderjoint. Because of this two-joint action, the long head is made less effective in the prone position by being shortened over both joints, with the result that the triceps withstands less pressure when tested in the prone position than when tested in the supine position.

The triceps and anconeus act together in extending the elbowjoint, but it may be useful to differentiate these two muscles. Because the belly of the anconeus muscle is below the elbowjoint, it can be distinguished from the triceps by palpation. The branch of the radial nerve to the anconeus arises near the midhumeral level and is quite long. It is possible for a lesion to involve only this branch, leaving the triceps unaffected. Paralysis of the anconeus reduces the strength of elbow extension. One may find that a grade of good elbow extension strength is actually the result of a normal triceps and a paralyzed anconeus.

BRACHIORADIALIS

Origin: Proximal 2k of the lateral supracondylar ridge of the humerus, and lateral intermuscular septum.

Insertion: Lateral side of the base of the styloid process of the radius.

Action: Flexes the elbow joint, and assists in pronating and supinating the forearm when these movements are resisted.

Patient: Supine or sitting.

Fixation: The examiner places one hand under the elbow to cushion it from table pressure.

Test: Flexion of the elbow, with the forearm neutral between pronation and supination. The belly of the bra-chioradialis (Figure B) must be seen and felt during this test because the movement can also be produced by other muscles that flex the elbow.

Pressure: Against the lower forearm, in the direction of extension.

Weakness: Decreases the strength of elbow flexion and of resisted supination or pronation to midline.

Kendall

Palmer (17)

Heese HS»

Clarkson (19)

AAOS (20)

AMA (21)

Joint

Thumb

CMC

Flexion

15

0-15

o-15

0-15

0-15

Extension

20

0-70

0-20

0-20

0-20

Abduction

60

0-60

0-70

0-70

0-70

0-50

Opposition

Pad of thumb to

pad of 5th digit

MCP

Flexion

50

0-50

0-50

0-50

0-50

0-60

Extension

0

50-0

0 J

0

0

IP

Flexion

80

0-80

0-65

0-80

0-80

0-80

Extension

0

80-0

0-10-20

0-20

0-10

2nd- 5th D

igits

MCP

Flexion

90

0-90

0-90

0-90

0-90

0-90

Extension

0

90-0

0-20

0-45

0-45

Abduction

20

0-20

'IP

Flexion

00

0-120

0-100

0-100

0-100

(M00

Extension

0

120-0

0

0

DIP

Flexion

70

0-80

0-70

0-90

0-90

0-70

Extension

0

80-0

0

0

The references in this chart demonstrate the lack of consensus regarding normative values for thumb and finger range of motion. The authors have chosen ranges that are representative of both established sources and clinical practice. When mobility is limited, the measurement should be documented in parenthesis, and when it is excessive, hypermobility should be indicated by a circle around the measured number.

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