Directions: The styloid process is a small protrusion of the bone at its distal end. To palpate, begin at the distal lateral aspect of the radius and simply feel the very end of the radius.
Muscles That Attach Here: Brachioradialis
Dorsal Tubercle of the Radius (Lister’s Tubercle)
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: Begin by palpating the posterior side of the distal aspect of the radius. Feel for a small bump located midway across the radius. Note that if you have gone to the middle of the wrist, you have gone too far.
Structure Located Near this Landmark: The tendon of the extensor pollicis longus muscle hinges around this skeletal landmark.
Ulna
Head of the Ulna
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: Locate the posterior side of the distal aspect of the ulna. The head of this bone is the large bulbous area at the distal end. The head is often visible prior to palpation.
Styloid Process of the Ulna
How to Palpate
Position of Partner: Sitting
Directions: The styloid process is a small protrusion of the bone at its distal end. To palpate, begin at the distal lateral aspect of the ulna and simply feel the very end of the ulna.
Carpals
Scaphoid
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: Begin by viewing the dorsal side of your partner’s hand. The best way to access the scaphoid bone is to feel the floor of the anatomical snuffbox. To locate this area, have your partner extend their thumb. View the tendon of the extensor pollicis longus, which is now popping out, along with the more lateral tendons of the extensor pollicis brevis and abductor pollicis longus. Palpate between these two sets of tendons to feel the floor of the snuffbox, where the scaphoid sits.
Muscles That Attach Here: Abductor pollicis brevis
Other Structures That Attach Here: Transverse carpal ligament
Lunate
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: Locate the extensor creases of the skin on the dorsal side of your partner’s wrist. Palpate immediately distal to these creases at the midline of the wrist, in line with the 3rd digit. While your partner’s wrist is extended, the lunate is not very palpable; however, when their wrist is flexed, this bone becomes easier to access and feel.
Pisiform
How to Palpate
Position of Partner: Sitting with a supinated forearm
Directions: Begin by viewing the palmar side of your partner’s hand. Identify the flexor creases of the skin along the wrist. Palpate immediately distal to these creases on the medial side of the hand. Essentially aim for palpating the very corner of the hand. The pisiform will feel like a very small ball-like structure.
Muscles That Attach Here: Flexor carpi ulnaris, abductor digiti minimi, and adductor digiti minimi
Other Structures That Attach Here: Transverse carpal ligament
Triquetrum
How to Palpate
Position of Partner: Sitting
Directions: The triquetrum is located deep to the pisiform so it can be palpated at the medial border of the hand, between the palmar and dorsal surfaces of the hand.
Trapezium
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: This bone is located distal to the scaphoid, so begin by palpating the scaphoid on the dorsal side of the hand. Move distal from the scaphoid until you feel a change in bony landmarks. The other way to approach this bone is to first palpate the 1st metacarpal until you reach the proximal end of this bone and begin to approach the trapezium.
Muscles That Attach Here: Abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis
Other Structures That Attach Here: Transverse carpal ligament
Trapezoid
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: Locate the trapezium first, and then move medially to reach the area of this carpal bone, which lies between the capitate and trapezium. Keep in mind this carpal bone is more in alignment with the 2nd metacarpal when you perform your palpation.
Muscles That Attach Here: Adductor pollicis
Capitate
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: This bone is located immediately distal to the lunate, so begin by finding the lunate from the dorsal side of the hand and move immediately distal to the bone. Stay in line with the 3rd metacarpal when moving distally, and once you have landed on a dome-shaped bone, you have found the capitate.
Muscles That Attach Here: Adductor pollicis
Hamate
How to Palpate
Position of Partner: Sitting with a supinated forearm
Directions: Begin by palpating the pisiform on the palmar side of the palm. Move about ½–1 inch on a diagonal to the 2nd digit. Press firmly into the hand to feel the hook of the hamate, which is a palpable protrusion of the bone.
Muscles That Attach Here: Flexor carpi ulnaris, flexor digiti minimi brevis, and opponens digiti minimi
Other Structures that Attach Here: Transverse carpal ligament
Metacarpals
How to Palpate: The metacarpals can be accessed most easily from the dorsal side. Begin at the head of an individual metacarpal and palpate, moving proximally until a change in the skeletal anatomy can be felt, indicating you are now palpating a carpal bone.
Muscles That Attach Here:
All Metacarpals: Palmar and dorsal interossei
1st Metacarpal: Abductor pollicis longus and opponens pollicis
2nd Metacarpal: Flexor carpi radialis, extensor carpi radialis longus, and brevis and abductor pollicis
3rd Metacarpal: Flexor carpi radialis, extensor carpi radialis longus and brevis, and abductor pollicis
5th Metacarpal: Flexor carpi ulnaris, extensor carpi ulnaris, and opponens digiti minimi
Palmar and dorsal Interossei also attach to different areas of the digits.
Phalanges
How to Palpate: Prior to palpating the proximal, middle, or distal phalanx of a digit, view Figure 4.4 of the skeletal anatomy of the hand. Ensure your ability to name and locate the phalanges, and then palpate the general area of each individual bone.
Distal Phalanges of Digits 2–5: Flexor digitorum profundus
Middle Phalanges of Digits 2–5: Flexor digitorum superficialis
Proximal Phalanx of Digit 5: Abductor digiti minimi, flexor digiti minimi brevis, and adductor digiti minimi
Palmar and dorsal Interossei also attach to different areas of the digits.
Joints
How to Palpate: The individual metacarpophalangeal and interphalangeal joints can be palpated. First, using Figure 4.4, identify which joint to palpate and feel around the joint surfaces from all accessible points.
Origin(s): Ulna, radius, and interosseous membrane
Insertion(s): 1st metacarpal
Action(s): Abduction and extension of the 1st digit
Innervation(s): Posterior interosseous nerve
How to Palpate
Position of Partner: Sitting with a neutral or pronated forearm
Directions: This smaller muscle can be difficult to distinguish from surrounding musculature but can be palpated as it wraps over the distal radius. Have your partner extend their thumb to make the tendons of the anatomical snuffbox more apparent. This muscle tendon helps create the lateral border of this landmark and can be a guide to palpating the distal end of this muscle.
Extensor Pollicis Brevis
Origin(s): Radius and interosseous membrane
Insertion(s): Proximal phalanx of the 1st digit
Action(s): Extension of the 1st digit
Innervation(s): Posterior interosseous nerve
How to Palpate
Position of Partner: Sitting with a neutral or pronated forearm
Directions: The orientation of this muscle is similar to the abductor pollicis longus. It begins in the posterior forearm and then wraps around the radius. Its distal tendon is the other tendon helping create the lateral border of the anatomical snuffbox. Begin your palpation midway in the posterior forearm, and then follow the direction of the muscle to insertion.
Extensor Pollicis Longus
Origin(s): Ulna and interosseous membrane
Insertion(s): Distal phalanx of the 1st digit
Action(s): Extension of the 1st digit
Innervation(s): Posterior interosseous nerve
How to Palpate
Position of Partner: Sitting with a neutral or pronated forearm
Directions: Because of the depth and size of this muscle, it proves difficult to palpate. When attempting to do so, travel from the origin of the distal posterior forearm to the end of the first digit. The tendon of this muscle creates the medial border of the anatomical snuffbox.
Flexor Pollicis Longus
Origin(s): Radius and interosseous membrane
Insertion(s): Distal phalanx of the 1st digit
Action(s): Flexion of the 1st digit
Innervation(s): Anterior interosseous nerve
How to Palpate
Position of Partner: Sitting with a neutral or pronated forearm
Directions: Because this muscle is located deep to the anterior forearm musculature, it can be very difficult to palpate. When attempting to do so, begin midway on the anterior forearm on the radial side. Then travel down the forearm to the end of the 1st digit.
Thenar Muscles
Abductor Pollicis Brevis
Origin(s): Scaphoid and trapezium
Insertion(s): Proximal phalanx of the 1st digit
Action(s): Abduction of the 1st digit
Innervation(s): Recurrent branch of the median nerve
Flexor Pollicis Brevis
Origin(s): Trapezium and flexor retinaculum
Insertion(s): Proximal phalanx of the 1st digit
Action(s): Flexion of the 1st metacarpophalangeal joint
Innervation(s): Recurrent branch of the median nerve
Opponens Pollicis
Origin(s): Trapezium and transverse carpal ligament
Insertion(s): 1st metacarpal
Action(s): Opposition
Innervation(s): Recurrent branch of the median nerve
Adductor Pollicis
Origin
Transverse Head: 3rd metacarpal
Oblique Head: 2nd and 3rd metacarpals, trapezoid, and capitate
Insertion(s): 1st proximal phalanx
Action(s): Adduction of the 1st digit
Innervation(s): Deep branch of the ulnar nerve
How to Palpate the Thenar Muscles:
Position of Partner: Sitting with a supinated forearm
Directions: To palpate this group of muscles, first identify the soft tissue pad at the base of the thumb called the thenar eminence. Palpate this bulge of soft tissue to collectively examine these muscles.
Hypothenar Muscles
Abductor Digiti Minimi
Origin(s): Pisiform and flexor retinaculum
Insertion(s): Proximal phalanx of the 5th digit
Action(s): Abduction of the 5th digit
Innervation(s): Deep branch of the ulnar nerve
Flexor Digiti Minimi Brevis
Origin(s): Hamate
Insertion(s): Proximal phalanx of the 5th digit
Action(s): Flexion of the 5th digit
Innervation(s): Deep branch of the ulnar nerve
Opponens Digiti Minimi
Origin(s): Hamate and flexor retinaculum
Insertion(s): 5th metacarpal
Action(s): Opposition
Innervation(s): Deep branch of the ulnar nerve
Adductor Digiti Minimi
Origin(s): Pisiform and flexor retinaculum
Insertion(s): Proximal phalanx of the 5th digit
Action(s): Abduction of the 5th digit
Innervation(s): Deep branch of the ulnar nerve
How to Palpate the Hypothenar Muscles:
Position of Partner: Sitting
Directions: To palpate this group of muscles, first identify the soft tissue pad at the base of the pinkie called the hypothenar eminence. Palpate this bulge of soft tissue to collectively examine these muscles.
Lumbricals
Origin(s): Flexor digitorum profundus
Insertion(s): Extensor expansion
Action(s): Flexion of metacarpophalangeal joints and extension of interphalangeal joints
Innervation(s): Median nerve (1st and 2nd lumbrical) and deep branch of the ulnar nerve (3rd and 4th lumbrical)
How to Palpate
Position of Partner: Sitting
Directions: Because these muscles are located very deep, they can be very difficult to palpate. When attempting to do so, follow from the origin of the flexor digitorum profundus tendons and work your way distally to their insertions on the extensor expansion of the digits.
Palmar and Dorsal Interossei
Origin(s): Metacarpals
Insertion(s): Proximal phalanxes and extensor expansions
Action
Palmar Interossei: Adduction
Dorsal Interossei: Abduction
Innervation(s): Deep branch of ulnar nerve
How to Palpate
Position of Partner: Sitting
Directions: Because these muscles are located very deep, they can be very difficult to palpate. When attempting to do so, follow their origin along the metacarpals to the proximal phalanxes and extensor expansions. The first dorsal interossei is the most prominent of all these muscles as it’s located between the 1st and 2nd digit on the dorsal side between the metacarpal bones.
Figure 4.7. Thenar and Hypothenar Eminences; Palmar View by Dan Silver is used under a CC BY 4.0 license.
Figure 4.8 Anatomical Snuffbox; Dorsal View by Dan Silver is used under a CC BY 4.0 license.
Thenar Eminence
How to Palpate
Position of Partner: Sitting with a supinated forearm
Directions: The thenar eminence is the enlarged mound of soft tissue at the base of the thumb on the palmar side. This enlarged area of soft tissue is created by the muscle bellies of some of the smaller thumb muscles. To palpate, simply identify this enlarged area on the palmar side of the hand and fully palpate the region.
Hypothenar Eminence
How to Palpate
Position of Partner: Sitting with a supinated forearm
Directions: Similar to the thenar eminence, this area is created by muscle bellies of some of the smaller pinkie muscles. Identify the enlarged mound of soft tissue at the base of the pinkie on the palmar side and palpate fully.
Anatomical Snuffbox
How to Palpate
Position of Partner: Sitting with a pronated forearm
Directions: This depression is found on the dorsal side of the hand, at the base of the thumb, between several tendons of the hand. Medially, the extensor pollicis longus creates a border while the lateral border is created by the extensor pollicis brevis and abductor pollicis longus. While moving the thumb in the appropriate directions, these tendons will become activated and more apparent while creating a soft tissue depression between them, which is the anatomical snuffbox. When palpating into the snuffbox, the scaphoid can be felt.
Radial Artery
How to Palpate
Position of Partner: Sitting with a supinated forearm
Directions: Locate the most superficial point of the radial artery, which runs along the anterior side of the wrist toward the lateral side. Palpate over the flexor creases of the hand at the most lateral aspect of the anterior wrist with your 2nd and 3rd digits to feel the pulse of this artery.
Try to isolate these movements as much as possible when assessing these ranges to ensure they’renot compensating with the use of otherarm musculature.
Ulnar Deviation and Radial Deviation
When assessing these ranges, it’simportant to recognize they are very limitedand it’snormal to have a smallrange of motion for both radial and ulnardeviation.It’salso important to make sure the hand is moving in the frontal plane and that there is no rotation of the forearm, or flexion and extension of the wrist,occurring when performing these movements.
Abduction andAdduction of the Fingers
Abduction and adduction of the fingers occurs at the metacarpophalangeal joints.The midline for these motions is defined as being through the third finger,and the other fingers either move toward this midline (adduction) or away from this midline (abduction).
Flexion and Extension of the Fingers
Flexion and extension can be performed at the metacarpophalangeal or interphalangeal joints. These ranges can be assessed one digit and even one joint at a time or all together. The goal or purpose of the assessment will determine your approach. Either way, it’s important to always maintain a neutral wrist during these ranges to ensure no extra tension is being placed on some of these muscles.
Background: The carpal tunnel is a small area within the wrist that is enclosed by surrounding carpal bones and ligaments. Located within the narrow tunnel are several tendons along with the median nerve.
When the tendons within the tunnel become inflamed, due to overuse of the muscle, the median nerve can become compressed. Carpal tunnel syndrome refers to the compression of this nerve, along with the many symptoms that result from the nerve not properly functioning, such as numbness and weakness of the innervated areas of the hand.
Background: The term palsy refers to the paralysis, or loss of ability to move, of the muscles innervated by a provided nerve.
A common site of damage to the ulnar nerve occurs within the hand where the ulnar nerve runs through a small tunnel around the area of the hypothenar eminence. Prolonged pressure on this area of the hand can cause transient, and sometimes more severe, neurological dysfunction, including numbness and tingling along with weakness of the muscles this nerve innervates.
Jersey Finger
Background: There are several tendons located along the palmar and dorsal sides of the fingers. Excessive movements of finger joints can cause injury to these tendons.
When an athlete grabs the jersey of a player who is getting away, their distal interphalangeal joint can be pulled into hyperextension, causing damage to the flexor digitorum profundus tendon, which is located on the palmar side of the finger. A notable decrease or lack of ability to flex the distal interphalangeal joint is a sign this injury has occurred.
Review Questions: Skeletal Landmarks of the Wrist and Hand
The dorsal tubercle of the radius is located on the (anterior / posterior) side of the wrist.
A proximal phalanx articulates with a bone proximally.
A distal interphalangeal is located between two bones, a and a .
Which two carpal bones can be found in line with the 3rd digit?
The scaphoid bone should be accessed on the (palmar / dorsal) side of the hand when palpating.
The head of the radius is (proximal / distal) while the head of the ulna is (proximal / distal).
The fifth digit is more commonly referred to as the .
Which two carpal bones are found at the base of the thumb?
The head of a metacarpal is located at the (proximal / distal) end, while the base is located at the (proximal / distal) end.
What mnemonic helps you remember the order of the carpal bones in the wrist?
Review Questions: Musculature of the Wrist and Hand
The lumbricals act to the metacarpophalangeal joints and the interphalangeal joints.
The extensor indicis muscle is located on the (anterior / posterior) side of the forearm.
The term pollicis refers to which numbered digit?
The thenar eminence is located at the base of the (5th digit / 1st digit), while the hypothenar eminence is located at the base of the (5th digit / 1st digit).
Which digit serves as the midline of the hand?
A muscle with the term digitorum in the name acts on which digits of the hand?
Describe the action of opposition.
The palmar interossei act to the fingers, while the dorsal interossei act to the fingers.
Which muscle of the thumb has both a transverse and an oblique head?
The abductor digiti minimi originates on which carpal bone?
