THE Healthy HAND PDF

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Within the main structures that man has to explore and communicate with the outside is the hand. This is not only the organ of work, it is also a product of it. Through this man has reached that degree of perfection that has made him capable of giving life to productions that can range...

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THE HEALTHY HAND

Within the main structures that man has to explore and communicate with the outside is the hand. This is not only the organ of work, it is also a product of it. Through this man has reached that degree of perfection that has made him capable of giving life to productions that can range from the paintings of Van Gogh, Picasso and others to the music of Mozart, Paganini or Strauss, to name a few. The hand is perhaps the most complete structure of the human body, therefore it reverts a considerable importance within all the necessities of life. He is capable of doing an activity of extreme violence, as well as doing another one of infinite delicacy. This organ performs three basic functions: it can grip in an infinite variety of ways, Among these functions, the main one is to take and hold objects, although many more are derived from this due to the great versatility of movement that it is capable of. Among these, for example, they are constituted as essential "utensils" to be able to eat and drink. They are also the hands used to gesture and there are even sign languages for communication with deaf or hard of hearing people. Some gestures can be especially obscene (depending on the country or setting), as is the case with verbal language. An example is the fist with the middle finger extended or with the index and little fingers extended.

Another common use is to be used as a measuring instrument. An outstretched hand is a span, although its length varies greatly depending on the person. For the blind they can be used as reading instruments by writing in Braille. In this writing, the sensitivity of the fingers comes into play as they have to be able to feel the small grooves in the paper of which it is composed. Similarly, the closed hand is a fist and can be used to hit or hold small objects. A closed hand with the index finger extended is used to point or touch something. You can also hold a pencil or other similar instrument for writing or drawing. Writing is an activity that really requires great precision and coordination of the various muscles and joints that make up the hand. The injury prevents the hand from all these fundamental functions, producing in the best of cases an alteration of its patterns of use and in the worst a disabled hand. The large number of conditions that injure the hand with the disability resulting from its appearance were the motivation for carrying out this work. The purpose of it is to recognize the most frequent causes of hand disability, capture the physical assessment of the hand and show the possibilities of rehabilitative treatment for those who suffer from injuries. The rehabilitation of the traumatized with affectation of the upper limb constitutes a chapter of vital importance for insurers, employers and social security institutions worldwide. The increasing curve of the accident rate in all the countries of the world has generated copious statistics of traumatic disabled people.

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Among the conditions with the highest incidence in diseases that affect the hands are rheumatoid arthritis and osteoarthritis. In the case of the former, it is a chronic disease, of variable course, of a systemic and inflammatory type of unknown etiology

and

multifactorial

etiopathogenesis,

with

autoimmune,

polyarticular,

symmetric, additive and progressive manifestations with soft tissue and extra-articular involvement. It has a universal distribution, but studies indicate somewhat lower rates in Asian populations. In the particular case of osteoarthritis, it is a chronic disease that can be inflammatory caused by the progressive wear of cartilage and joints. Affected joints cause pain, lose mobility, and become deformed. This document constitutes the thesis of culmination of studies of the applicant to the Specialty in Rheumatology, Dr. ENRIQUE CHÁZARO ESTAÑOL in the rheumatology study program at the National Institute of Rehabilitation and constitutes the fruit of a period of research on a topic of his specialty, in its particular case, the healthy hand in the Mexican adult population. That is why the following thematic sections can be found in this document: Chapter No 1: Theoretical conceptual framework of the anatomical and physiological characteristics of the hand and the main rheumatological diseases that affect it.

In this chapter you will find contents related to the anatomical characteristics of the hand. Biomechanical aspects of this organ are also addressed that allow characterizing its functioning. In the same way, there are contents related to the epidemiology, pathophysiology, etiology and clinical management of rheumatoid arthritis and osteoarthritis as the main rheumatological diseases of the hand. Chapter No 2: Methodological design of the research. This chapter defines the main methodological elements that allowed the study to be carried out. You can find the justification for the study, the definition of the research problem, its objectives and hypotheses, as well as the main research tasks and the procedures used to carry out the research. Chapter 3: Description, analysis and discussion of the results. This chapter describes the main results that were obtained during the research process. The statistical analyzes that allowed establishing patterns of results to be contrasted with similar studies are also described. Within this chapter are also the hypothesis tests carried out with the aim of demonstrating and refuting those that were established during the research process.

CHAPTER 1. THEORETICAL CONCEPTUAL FRAMEWORK OF THE ANATOMIC AND PHYSIOLOGICAL CHARACTERISTICS OF THE HAND AND OF THE MAIN RHEUMATOLOGICAL DISEASES THAT AFFECT IT

1.1

FOUNDATIONS

FROM

THE

MORPHOLOGY

ANATOMICAL,

ASPECTS PHYSIOLOGICAL AND MUSCULAR

CONSTITUTION OF THE HAND AS AN ORGAN The hands are fundamental organs for human beings. With them you can carry out countless actions ranging from work to entertainment. The use of them on a daily basis can lead to very painful injuries, which sometimes can cause temporary and partial loss of function or be chronic and affect the individual throughout his life. In this way, the human being acquires a dysfunctionality that affects the exchange with the external environment and is exposed to a range of injuries that can affect its function, often resulting in disabilities that lead an individual to have serious problems in their future life (Pereira, E. et al., 2016). The hand is an extremely complex organ morphologically as it is made up of very dissimilar structures, but functionally it is no less complex. This organ located in the distal extremity of the forearm and without which it cannot function because it articulates it to the rest of the body, allows the communication of the environment with different brain areas where the information is integrated and a response to be executed returns, this is the true essence of all the activity that the hand can perform. It is not possible to see the hand as just another organ, the

The development achieved by this as well as the different activities carried out is due to the functional needs that the brain has been demanding (Moog & Ochoa, 2003; García, R. et al., 2009). The most characteristic features of the human hand are the comparative length of the thumb and its associated, extrinsic and intrinsic muscles, which allow it great flexibility and efficiency along with the rest of the organ. The opposition of the thumb in man allows for a very specialized range of activities. The skeleton of the fingers is formed by small long bones called phalanges in number of three for each finger except the first finger that only has two, lacks the central one. The structure of the hand can be seen graphically in Image No 1: Hand. Anterior view (palmar) and in Image No. 2 Hand. Posterior (dorsal) view. The bones of the hand articulate with each other in a different way obeying the principle of morphological functionality, that is, each bone has articular surfaces covered with cartilage that allows the contiguity of the bones to maintain the internal framework of the hand, but that They are once endowed with passive and active soft elements that allow the joint to displace or not displace the articular bone segments. At the level of

Metacarpophalangeal joints, an ellipsoid joint is produced which therefore behaves the same as the radiocarpal joint with the same axes and movements. In interphalangeal joints we find trochoids, that is, monoaxile joints that only have one axis and plane of movement, in this case it is a frontal axis that only allows flexion and extension. This articulation is analogous in the five fingers (Schünke, Schulte, Schumacher, Ross & Lamperti, 2006; Netter, 2008).

Remember that the classic anatomical position is with the palm of the hand facing forward and the thumb located laterally. This is important, bearing in mind that each of these structures are susceptible individually or with the bones to which they are articulated, the evolution of traumas in each of them does not occur in the same way or during the same period of time. time, for this reason the location of each one must be known exactly to know their possible conditions and to be able to undertake the corresponding treatment.

1.1.1 Hand muscles From a muscular point of view, it is important to know the extrinsic and intrinsic muscles. Intrinsic muscles of the hand are called the short muscles that originate in it (thenars, hypothenars, interossei and lumbrical), and extrinsic muscles of the hand that come from above long flexors and extensors). It is convenient to distinguish within the grip, the hook (carrying a bucket), the grip (taking a tube). They are distributed in small groups in the hand on the palmar side. In the ulnar portion we find the hypothenar eminence where we are going to find small muscles all linked to the movements of the fifth finger and their action, like the others, is specified by name. From them we will point out the cutaneous palmar topographically, the short flexor the adductor and the opponent of the fifth finger as shown in Images No. 3 and 4: Muscles of the hand. Anterior vision (palmar) and muscles of the hand. Posterior view (dorsal) respectively. p. 497

In the thenar region, which is the one that we appreciate in the radial region of the palmar aspect of the hand, we will find the abductor brevis, the flexor brevis, the opponent and the abductor, all linked to the activity of the first finger, performing the action as they are nominated. . In addition to these two groups, we find others that are found between the metacarpals, which is why they are called interossei and lumbricals that are located next to the corresponding tendon of the deep flexor from where a small tendon starts that when joining with the interossei are directed by a

band towards the proximal phalanx of each finger inserting into the corresponding extensor tendon. The extrinsic muscles are responsible for the movements

of great amplitude and power of the fingers, these are located in the forearm in its upper third It is important to note that all these muscles, including those not located in the hand but in the forearm, are those that guarantee the motility of the hand (Schünke, Schulte, Schumacher, Ross & Lamperti, 2006).

1.1.2 Innervation and circulation of the hand From the nervous point of view, it can be said that the hand is innervated by three peripheral nervous trunks of mixed composition because they have fibers of sensitive, motor and neurovegetative types. These trunks are known by the names radial, median and ulnar and are metamerically distributed. The knowledge of this allows to diagnose specific conditions of each one of them. In the case of the radial nerve that supplies all the extensors of the carpus and the fingers, as well as those of the radial group of the forearm. The paralysis of the same produces the inability to extend the hand downwards flaccidly. As shown below in Image No. 5: Innervation of the hand (Vision

Another case is the ulnar nerve, which supplies the two ulnar muscle bellies of the deep flexor of the fingers, the anterior ulnar, the muscles of the hypothenar region, the medial interossei and lumbrical, as well as the abductor of the first finger. Finally, the median nerve innervates the two medial bellies of the deep flexor of the fingers, in the hand it innervates the two lateral lumbricals, the abductor brevis, part

of the short flexor and the opponent of the first finger. It should be noted that this description is not always taken literally, since many of the anatomical descriptions come from dissections of cadavers and from analyzes of times when there was no great use of statistical methods (Javier-Zepeda, 2007; Camacho, Gil, del Cueto & Pérez Casabella, 2005). Another important aspect is that the hand is supplied by the radial and ulnar arteries, which in turn are branches of the brachialis. At the level of the hand, there is a mechanism that guarantees blood circulation through the superficial and deep arterial arches made up of the terminal branches of the radial and ulnar artery, from which the digital branches also start, which are directed in number of two as collateral branches. of each finger (Yalin, Cavdar & Ercan, 1994; Elizondo-Omaña et al., 2007).

1.2 MAIN BIOMECHANICAL AND HAND FUNCTIONAL ASPECTS The grip acquires its degree of perfection in the man, thanks to the articular arrangement of the thumb, which allows it to oppose the remaining fingers. The hand represents the executing limb of the upper limb, being also a sensory receptor of extreme precision and sensitivity. To grasp an object, the hand is hollowed out and forms a dome, an anterior concave channel, whose edges are limited by three points: the thumb that forms the outer edge and the index and little finger that limit the inner edge. When the fingers are separated, the axis of each of them

converges at the level of the scaphoid tubercle. In the hand, the movements of the fingers are carried out in relation to the axis of the hand (third metacarpal and middle finger) and not to the plane of symmetry of the body. When we make a fist with the distal interphalangeals extended, the axes of the last phalanges of the last four fingers and the axis of the thumb, except its last phalanx, converge at a point in the distal part of the pulse channel. The thumb is abducted (it is placed at 90º with the palm depending on the radial nerve), opposition (O sign, depends on the median nerve), and adduction (the thumb approaches the median axis of the hand, depends on the ulnar nerve) . These movements are performed at the trapezius-metacarpal joint, which is of the reciprocal socket type. In addition, the thumb has flexoextension in its metacarpophalangeal joints (flexes the short flexor of the thumb, median and ulnar nerves, extends the extensor pollicis brevis, radial nerve), and interphalangeal (flexes the long flexor of the thumb: median nerve, extends extensor thumb length: radial nerve); in the metacarpophalangeal, it also has laterality and axial rotation movements (Von Schroeder & Botte, 1997). In the last four digits, the metacarpophalangeal fingers have flexion and lateral inclination, and the interphalangeal fingers only flexoextension. The extension in the metacarpophalangeal is performed by the extensor, the interosseous-lumbrical extend the interphalangeal; If the metacarpophalangeal is in flexion due to the action of the interosseous-lumbrical muscles, it is the extensor tendon that extends the interphalangeal tendons.

Normally, the degree of flexion and extension is 0 to 90º in the proximal metacarpophalangeal and interphalangeal, and 0 to 70º in the distal interphalangeal; the active extension in the metacarpophalangeal can reach 30º and the passive one reaches almost 90º; the extension in the proximal interphalangeal is null or very little (5º), in the distal ones. The lateral movements of the last four metacarpophalangeals are performed in extension, being zero in flexion. The separation of the last three fingers indicates indemnity of the ulnar nerve (innervate interossei and internal lumbricals) (Von Schroeder & Botte, 1997). The arrangement of the first finger that has 90 degrees with respect to the position of the palm of the hand and the other fingers from the second to the fifth makes that the hand can perform peculiar movements that are only possible thanks to this and the arrangement of each muscle with respect at your finger, which allows each one in coordination with the rest to carry out all the activities that are specific to the hand, such as those detailed below: To hook: It is the act or movement that the hand performs to hold objects that have a handle, it will be carried out by the flexor muscles of the fingers as shown in Image No 6: Hand functionality. Hitch motion below:

Picture No 6: Hand functionality. Hooking movement. Source: Author's photo.

Grab: It is the act, movement or posture that we adopt when a person is standing on a bus and holds onto the tube that is attached to the roof of the bus, intended for people who do not have a seat, as shown in Image No 7: Hand functionality. Grabbing motion below:

Picture No 7: Hand functionality. Grabbing movement. Source: Author's photo. Clamp: It integrates a group of acts or movements, it is necessary to make a breakdown of its different variants, that is to say, the claw-toe, toe-toe, lateral, trident and multiple. Each of them has a specific objective that can only be achieved if the muscles that must intervene in each of them are fit and trained. In Image No 8: Functionality of the hand. Grabbing movement will be seen as an example clearly.

Image No 8: Hand functionality. Gripper movement. Source: Author's photo.

The hand, as we pointed out, is an organ that is located in the most distal portion of the upper limb with which it articulates through the distal portion of the radius and the proximal row of the carpus, from the forearm it receives most of the tendons that guarantee the activity of the organ although the muscular bellies are in the neuromuscular forearm that guarantees the activity of the hand. The hand also receives its irrigation from arteries whose origin is in the root of the upper limb, so any injury to this will affect the blood supply of the limb with distal ischemic injuries that will manifest in the hand (Yalin, Cavdar & Ercan, 1994) .

1.3 FUNDAMENTALS OF THE PRESSURE FORCE The grasping power of the human hand is a highly specialized and complex function, the result of perfect motor and sensory integration. The knowledge of science on this subject has undergone further development in the last 100 years, one of the aspects that has generated the most interest in recent decades is the development of functional assessment methods that allow quantifying the magnitude of deficits in the function of grasp of the hand and especially those directed to the analysis of the grip strength. In the first attempts to quantify the grip strength, the use of manual tests should be pointed out and coinciding with the development of rudimentary dynamometric machines (Hamilton, McDonald, & Chenier, 1992; Hislop, Montgomery, Daniels & Worthingham, 2002). It is in this way that a purely qualitative scale began to be used, called the Lowett Scale (Hislop, Montgomery, Daniels & Worthingham, 2002), this instrument defined muscle function according to six possible categories: normal, good, regular, bad, vestiges of activity and complete paralysis. Following this line of action, new contributions were made trying to improve the quality of the measure. In the 1930s, the scholars Herry and Florence Kendall described a scale for measuring muscle function that was based on the expression of muscle strength as a percentage of normal muscle. After 1946 the researchers Lucille Daniels, Marian Williams and