Clinical Examination of the Hand and Wrist

Clinical Examination of the Hand and Wrist
A.Mazaherinezhad MD. Sportsmedicine Department, Assistant professor, IUMS IUMS

OBJECTIVES Review the clinical anatomy and physical exam of the wrist and hand Formulate a pathoanatomic diagnosis in the clinical setting Discuss common clinical conditions that can be elicited from the physical exam IUMS

INTRODUCTION: Hand and Wrist
Series of complex, delicately balanced joints Function is integral to every act of daily living Most active portion of the upper extremity IUMS

INTRODUCTION The least protected joints Extremely vulnerable to injury
Difficult and complex examination Diagnosis often vague If no fracture = “wrist strain or sprain” Bilateral comparison useful IUMS

Bony Anatomy Phalanges: 14 Sesamoids: 2 Metacarpals: 5 Carpals
Proximal row: 4 Distal row: 4 Radius and Ulna Lister’s tubercle IUMS

ANATOMY Muscles /Tendons Nerves - 3 Arteries - 2 Volar wrist- 6
Dorsal wrist- 9 6 compartments Volar hand- 10 Dorsal hand- dorsal interossei Nerves - 3 Median Ulnar Radial Arteries - 2 IUMS

HISTORY Age Handedness Chief complaint Occupation Previous injury
Previous surgery Sx related to specific activities What exacerbates What improves Frequency Duration IUMS

HISTORY 4 principle mechanisms of injury Throwing Weight bearing
Twisting Impact IUMS

EXAMINATION OF THE HANDS, FINGERS AND WRIST
COMPARE OPPOSITE SIDE IUMS

PHYSICAL EXAM Inspection Palpation Range of Motion Neurologic Exam
Special Tests IUMS

INSPECTION Observe upper extremity as patient enters room
Examine hand in function Deformities Attitude of the hand IUMS

INSPECTION Palmar Surface
Creases Thenar and Hypothenar Eminence Arched Framework Hills and Valleys Web Spaces IUMS

Cascade sign Assure all fingers point to scaphoid area when flexed at PIPs IUMS

INSPECTION of Dorsal Hand and Wrist
Hills and Valleys Height of metacarpal heads Finger nails Pale or white=anemia or circulatory Spoon shaped=fungal infection Clubbed=respiratory or congenital heart Deformities IUMS

Ganglion Cystic structure that arises from synovial sheath
Discrete mass Dull ache Dorsal or Volar aspect IUMS

Boutonniere Deformity
Tear or stretch of the central extensor tendon at PIP Note: unopposed flexion at PIP Extension at DIP Trauma or inflammatory arthritis IUMS

Swan Neck Deformity Contraction of intrinsic muscles (trauma, RA)
NOTE: Extension at PIP IUMS

Osteoarthritis Heberden’s nodes: DIP Bouchard’s nodes: PIP IUMS

Rheumatoid Arthritis MCP swelling Swan neck deformities
Ulnar deviation at MCP joints Nodules along tendon sheaths IUMS

Mallet Finger Hyperflexion injury
Ruptured terminal extensor mechanism at DIP Incomplete extension of DIP joint or extensor lag Treatment: stack splint IUMS

Dupuytren’s Contractures
Palmar or digital fibromatosis Flexion contracture Painless nodules near palmar crease Male> Female Epilepsy, diabetes, pulmonary dz, alcoholism IUMS

RANGE OF MOTION Active range of motion
Passive range of motion if unable to actively move joint Bliateral comparison To determine degrees of restriction IUMS

RANGE OF MOTION Wrist Flexion Extension Radial deviation
Ulnar deviation Ulnar deviation is greater than radial IUMS

Mobility : (pronosupination)
To test pronosupination, the patient is asked to keep his or her elbows close to the body and to turn the palm up and down alternatively. One arm of the goniometer is placed parallel to the axis of the humerus, and the other along the distal part of the forearm (Figure 1 & 2). One should avoid measuring pronosupination with a stick in the patient's hands, as the pronosupination mobility is increased by the passive rotatory mobility of the carpus, which may be as high as 40°. If the neutral prono-supination position is defined as zero (with the elbow flexed and maintained against the chest, the thumb must be raised up): Normal pronation varies between 60 and 90°, Normal supination, between 45 and 80°. 4/20/2017

Measurement of pronation:
Figure 1: Measurement of pronation: The vertical arm of the goniometer is placed in the axis of the arm and the horizontal arm on the dorsal surface of the wrist, but not the hand. Figure 2: Measurement of supination. The horizontal arm is placed on the volar surface of the wrist. 4/20/2017

Flexion-extension Flexion-extension mobility is measured by placing the goniometer on the palm for wrist extension, and along the dorsum of the hand for wrist flexion, over the axis of the third metacarpal bone (figure 3 & 4). Normal values vary among individuals and may reach 85° of flexion or extension. Both inclinations are measured with one arm of the goniometer along the axis of the forearm, and the other along the axis of the third metacarpal, with the wrist in the neutral position of flexion or extension. These methods are simple and reproducible. Ulnar inclination varies between 30 and 45°, Radial inclination, between 15 and 25°. 4/20/2017

Masurement of extension:
Figure 4: Masurement of extension: The goniometer is placed anteriorly on the wrist. 4/20/2017

Measurement of strength
This should be done with a Jamar dynamometer, which is considered an international reference. Measurements should be done, either using each of the five handle positions, which is time-consuming, or using only one handle position, with three successive measurements. There are no standard values, and the contralateral hand serves as reference. The mean of three different measurements with maximum muscular contraction is noted. Usually, the curve for a single handle position is horizontal or slightly descending. Rapid alternating measurements changing from one hand to the other prevent patients from controlling their contraction and may reveal the absence of maximum contraction. 4/20/2017

The dominant hand is usually 5 to 10% stronger than the non-dominant hand.
4/20/2017

RANGE OF MOTION Fingers
Flexion/extension at MCP, PIP, DIP Tight fist and open Do all fingers work in unison ABDuction/ADDuction at MCP Spread fingers apart and then back together IUMS

CLINICAL EXAMINATION OF THE WRIST The normal wrist :
The key to correct examination of the wrist is precise location of the symptoms relating to the underlying anatomical structures, i.e., bones, articular spaces, ligaments or tendons. As in all clinical examinations, the most painful area is examined last. Comparative wrist examination is the rule, as there are no criteria of normality 4/20/2017

PALPATION of Skin Warmth? Dryness? Anhydrosis= nerve damage Scars IUMS

PALPATION of Wrist Dorsum
Ulnar Styloid TFCC Triquetrum Pisiform Hook of Hamate Guyon’s Tunnel Radial Styloid Scaphoid 1st MC/Trapezium jt Lunate Lister’s Tubercle IUMS

Conditions of examination :
The wrist must be examined with the forearm free of clothing and jewelry. For a satisfactory examination, the patient and the examiner should be comfortably seated. The ideal solution is to place the patient's forearm on a narrow examination table whose height may vary. In clinical practice, the easiest solution is to sit very close to the patient so that his or her hand rests on the examiner's knee, with the patient's elbow resting on his thigh. A "practical" position for wrist examination 4/20/2017

Physical examination usually begins on the dorsal surface of the wrist, with pronation of the forearm and wrist flexion, whereas the ulnar surface of the wrist is examined during maximum elbow flexion. For palpation, the examiner stabilizes the wrist with both hands and uses his (her) thumbs to palpate the anatomical structures. IUMS

Cutaneous projection of the anatomical structures
A beauty (the richness) of wrist examination is due to the fact that almost all bony, articular, tendinous or vascular structures may be palpated through the skin that covers it. To be compete, the physical examination should be methodical and whichever structure is examined first, the examination should cover the entire wrist. 4/20/2017

Dorsal surface: Proximal to the wrist, proceding from the radius to the ulna it is easy to identify the radial styloid. One cm proximal you will palpate the sharp bony ridge which limits the first extensor compartment. More ulnar is a dorsal bump on the distal radius which is Lister's tubercle, around which passes ulnarly the extensor pollicis longus tendon (figure 6 & 7). Closer to the ulna and ulnar to Lister`s tubercle, one can feel the flat dorsal surface of the radius and the ulnar head which protrudes in pronation. On the ulnar side of the wrist, the ulnar styloid can be palpated dorsally in supination, at the ulnar and volar surfaces in pronation and on the ulnar side of the wrist in neutral rotation. 4/20/2017

Ulnar Styloid palpation Lister’s Tubercle palpation

Figure 6: To examine a wrist correctly, one should mentally project the bones onto the skin. Figure 7: Main palpable bony structures on the dorsal surface of the wrist (redrawn after.) 4/20/2017

At the level of the carpus, the anatomical snuffbox is easy to locate radially: it is limited
radially by the extensor pollicis brevis and the abductor pollicis longus and ulnarly by the extensor pollicis longus. The scaphoid lies at the bottom of the snuffbox, with the radial artery crossing over it. 4/20/2017

In radial deviation the scaphoid disappears dorsally and one can palpate the scaphotrapezial joint palmarly (figures 8 & 9). Dorsally, at the distal end of the scaphoid there is a groove in which the examiner can place an index finger to palpate the trapezoid along the axis of the second metacarpal, and the trapezium along the axis of the first metacarpal . 4/20/2017

Radial Styloid palpation Scaphoid Bone palpation
IUMS

1st MC/Trapezium joint palpation
IUMS

The cutaneous projection of the anatomical snuffbox.
Figure 8: The scaphoid lies at the bottom of the anatomical snuffbox and distal to it lies the scaphotrapezial joint. Palpation of bony structures varies during radial and ulnar deviation. Figure 9: The cutaneous projection of the anatomical snuffbox. 4/20/2017

The radial part of this groove, just ulnar to the extensor pollicis longus tendon, is what is termed the STT entry point (scaphotrapeziotrapezoidal) for mid-carpal arthroscopy. Figure 10: The midcarpal joint can be palpated through the groove between the scaphoid and the trapezium and trapezoid bones. 4/20/2017

In the middle of the dorsal surface of the carpus, one centimeter distal to Lister's tubercle, lies the scapholunate interval. the scapholunate interval can be palpated just distal to the dorsal rim of the radius at the level of Lister`s tubercle, with flexion of the wrist. Flexion moves the lunate dorsally out of the lunate fossa as shown figure 5. Just radial to that point, the proximal pole of the scaphoid can be palpated if the wrist is in flexion. 4/20/2017

Lunate Bone palpation IUMS

Ulnar and distal to the scapholunate space lies a concavity which corresponds to the neck of the capitate . Figure 11: The posterior surface of the waist of the capitate is palpable through a depression easily found in the midportion of the dorsal surface of the wrist. 4/20/2017

(French anatomists use the term “the crucifixion groove” as it represents the place where you should place your nails if you plan to crucify somebody...) When the wrist is flexed, the lunate and the head of the capitate are more easily palpable. Figure 12: Wrist flexion allows palpation of the head of the capitate and the posterior horn of the lunate. 4/20/2017

Slightly radial to the neck of the capitate and one cm distal to the scapholunate interval is the radial entry point of the midcarpal space. The prominence of the third metacarpal base, the third metacarpal styloid, is located one to one and a half cm distal to that point, between the capitate and the trapezoid. It is more or less developed depending on the individual and may sometimes be hidden by the insertion of the extensor carpi radialis brevis tendon. 4/20/2017

form a continuous line on the ulnar side of the wrist
When the wrist is in neutral position, with the third metacarpal in the axis of the radius i.e. without flexion or extension or radial or ulnar deviation: the ulnar head, triquetrum, hamate and fifth metacarpal form a continuous line on the ulnar side of the wrist 4/20/2017

Figure 8: The scaphoid lies at the bottom of the anatomical snuffbox and distal to it lies the scaphotrapezial joint. Palpation of bony structures varies during radial and ulnar deviation. Figure 9: The cutaneous projection of the anatomical snuffbox. Figure 10: The midcarpal joint can be palpated through the groove between the scaphoid and the trapezium and trapezoid bones. Figure 11: The posterior surface of the waist of the capitate is palpable through a depression easily found in the midportion of the dorsal surface of the wrist. 4/20/2017

Triquetrum Bone palpation
IUMS

The triquetrolunate joint and triquetrum
may be palpated during radial deviation of the wrist. The triquetrum is palpated just distal to the ulnar head and disappears with ulnar deviation. The triquetrohamate space whose mobility can be appreciated lies distal to the dorsal tubercle of the triquetrum (Figure 13). On the ulnar side of the wrist lies the "ulnar snuffbox" between the extensor and the flexor carpi ulnaris tendons. At the base of this snuffbox one can palpate the triquetrum during radial inclination, as well as the triquetrohamate joint distal to it, which is a drainage portal for mid-carpal arthroscopy (Figure 14). 4/20/2017

Figure 13: The ulnar "anatomical snuffbox".
4/20/2017

PALPATION Palmar Aspect
Pisiform and Hamate Tunnel of Guyon Ulnar Artery Carpal Tunnel Flexor Carpi Radialis Flexor Carpi Ulnaris IUMS

The palmar surface : The bony structures on this surface are too deep to be palpated. However, it is possible to palpate not only the radial and ulnar styloid processes but also, radially, the trapezial ridge which lies at the base of the thenar eminence, as well as the scaphotrapezial space and proximal to the distal tuberosity of the scaphoid. 4/20/2017

pisiform when the wrist is in extension (Figure 15). Ulnarly, the pisiform is easily palpated, just distal to the distal wrist crease. Figure15: Main palpable bony structures on the anterior side of the wrist (redrawn after) 4/20/2017

Pisiform and Hamate palpation
Tunnnel of Guyon

The hamate hook (hamulus ossi hamatum)
lies just along the radial edge of the pisiform, on a line from the pisiform to the second metacarpal head. The articular spaces of the carpus are not accessible to palpation, but the radiocarpal joint is located at the level of the middle part of the proximal wrist flexion crease, while the midcarpal joint is located at the level of the middle of the distal flexion wrist crease. Figure 16: The hamulus ossi hamatum (hook of the hamate) is palpated deeply, 2 cm below the pisiform bone, on a line joining the pisiform to the head of the second metacarpal bone. 4/20/2017

Hamate Hook Fracture Frequently misdiagnosed as tendonitis or sprain
Pain, swelling, and tenderness over hypothenar eminence Suspect when patient complains of painful griping and swinging IUMS

Tunnel of Guyon Depression between pisiform and hook of hamate
Contains ulnar nerve and artery Site of compression injuries unusually tender if pathology is present IUMS

COMPRESSIVE NEUROPATHIES
NOT ALL HAND NUMBNESS IS CARPAL TUNNEL IUMS

Ulnar Nerve Compression
Tunnel of Guyon Seen in direct or repetitive trauma, fractures of hamate or pisiform, or sports related Operating a jackhammer repetitive power gripping (ex. Cycling) Sx= pain, weakness, paresthesias in ulnar sensory distribution IUMS

Volar flexor tendons Flexor carpi ulnaris Palmaris longus
Flexor carpi radialis Volar flexor tendons

Capitate popping is rare in Gilula's experience, and Gilula also pointed out that in the great majority of the cases with popping that he sees, fluoroscopic exam is normal and he does not know what ligaments or anatomic structures cause the popping. The popping seems to be related to moving of tendons or other soft tissue structures. Ulnar inclination combined with anterior translation places a load on the dorsal part of the scapholunate ligament and a snap may suggest partial tears [Masquelet, personal communication]. The snap may be reproduced during ulnar deviation combined with axial compression . The various provocative maneuvers reported in the literature include the following: 4/20/2017

Thumb CMC Joint Arthritis
Painful pinch or grasp “Grind Test” Axial pressure to thumb while palpating CMC joint IUMS

Scapholunate Dissociation
Diagnosis often missed Pain, swelling, and decreased ROM Pressure over scaphoid tuberosity elicits pain Greatest pain over dorsal scapholunate area, accentuated with dorsiflexion X-ray shows widening of scapholunate joint space by at least 3 mm IUMS

Ulnar Styloid palpation Lister’s Tubercle palpation
IUMS

Triangular Fibro-Cartilage Complex palpation (TFCC)
IUMS

Triangular Fibrocartilage Complex Injuries
Thickened pad of connective tissue that functions as a cushion for the ulnar carpus as well as a sling support for the lunate and triquetrum Injury from compression between lunate and head of ulna Breaking fall with hand Rotational forces-racket and throwing sports IUMS

Triangular Fibrocartilage Complex Injuries(axial load test)
Ulnar sided wrist pain, swelling, loss of grip strength “Click” with ulnar deviation Point tenderness distal to ulnar styloid TFCC load test IUMS

PALPATION of HAND Bone Metacarpals - 5 Phalanges - 14
Palpate for swelling, tenderness Assess for symmetry IUMS

PALPATION Soft tissue 6 Dorsal Compartments 2 Palmar Tunnels
Transport extensor tendons 2 Palmar Tunnels Transport nerves, arteries, flexor tendons IUMS

1st Dorsal Compartment Abductor Pollicis Longus and Extensor Pollicis Brevis Radial border of Anatomic Snuff Box Site of stenosing tenosynovitis De Quervain’s Tenosynovitis Finkelstein’s Test IUMS

DeQuervain’s Tenosynovitis
Inflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendons Tenderness st Dorsal Compartment Finkelstein’s Test IUMS

DeQuervain’s Tenosynovitis

2nd Dorsal Compartment Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis Make fist—becomes prominent IUMS

Intersection Syndrome (Squeaker Wrist)
Similar to DeQuervain’s tenosynovitis Peritendinitis related to bursal inflammation at the junction of the 1st and 2nd dorsal compartments Overuse of the radial extensor of the wrist IUMS

Intersection Syndrome (Squeaker Wrist)
Seen in gymnasts, rowers, weightlifters, racket sports Proximal to DeQuervain’s- 4-6 cm from radiocarpal joint Crepitation or squeaking can be heard with passive or active ROM IUMS

3rd Dorsal Compartment Extensor Pollicis Longus
Ulnar side of Anatomic Snuff Box Can rupture secondary to Colles’ Fracture or Rheumatoid Arthritis Extensor Pollicis Longus Tenosynovitis IUMS

4th Dorsal Compartment Extensor Digitorum Communis and Extensor Indicis Palpate from the carpus to the metacarpophalangeal joints Frequent site of ganglion cysts IUMS

5th Dorsal Compartment Extensor Digiti Minimi
May become involved in rheumatoid arthritis May be subject to attrition friction due to dorsal dislocation of the ulnar head synovitis IUMS

6th Dorsal Compartment Extensor Carpi Ulnaris
Tendinitis -repetitive wrist motion or snap of wrist May dislocate over the styloid process of the ulna Seen with Colles’ fracture with associated fracture of the distal ulnar styloid Audible snap IUMS

Extensor Carpi Ulnaris Tenosynovitis and Subluxation
6th Dorsal Compartment Second most common site of tenosynovitis (after DeQuervain’s) Common in racket and rowing sports Pain and tenderness with ulnar deviation Suspect subluxation when clicking on ulnar side of forearm IUMS

Carpal Tunnel Deep to palmaris longus
Contains median nerve and finger flexor tendons Most common overuse injury of the wrist IUMS

Carpal Tunnel Syndrome
Entrapment of the median nerve Phalen’s and Tinel’s Test 2 point discrimination Symptoms Aching in hand and arm Nocturnal or AM paresthesias “Shaking” to obtain relief IUMS

Carpal Tunnel Tests Neurologic exam
Median nerve sensation and motor Phalen’s Test: both wrists maximally flexed for 1 minute Tinel’s Test IUMS

PALPATION Palm of Hand Thenar Eminence Hypothenar Eminance
3 muscles of thumb Atrophy seen in carpal tunnel syndrome Hypothenar Eminance 3 muscles of little finger Atrophy with ulnar nerve compression Palmar Aponeurosis Dupuytren’s Contracture IUMS

PALPATION of Fingers Finger Flexor Tendons Extensor Tendons
Trigger Finger- sudden audible snapping with movement of one of the fingers Extensor Tendons Tufts of Fingers Felon- local infection Paronychia- hangnail infection IUMS

SPECIAL TESTS Long Finger Flexor Test
Flexor Digitorum Superficialis Test Flex finger at PIP The only functioning tendon at the PIP Flexor Digitorum Profundus Test Flex at DIP Inability to flex= tendon cut or denervated IUMS

Flexor Tendon Injury “Jersey Finger”
Avulsion injury from rapid passive extension of the clenched fist Loss of flexion at PIP and/or DIP “+” sublimus or profundus tests IUMS

Trigger Finger Stenosing flexor tenosynovitis Painful snap or lock
Palpate nodule as digit flexed and extended IUMS

Flexor Tenosynovitis Tendon sheath infection
Usually due to a puncture wound Bacterial skin flora Relative surgical emergency IUMS

Flexor Tenosynovitis 4 Cardinal Signs of Kanavel
Uniform swelling of the finger Sensitivity along the course of the tendon sheaths Pain upon passive extension Fingers held in flexion IUMS

RANGE OF MOTION Thumb Thumb flexion/extension at MCP and IP
Touch pad at base of little finger Thumb ABD/ADD at carpometacarpal joint Opposition Touch tip of thumb to tip of each finger IUMS

Skier’s Thumb Gamekeeper’s Thumb
Ulnar Collateral Ligament rupture of the thumb MCP joint Instability, weak and ineffective pinch Radially directed stress at MCP joint-stable if opens <35 degrees IUMS

NEUROLOGIC EXAM Muscular assessment using grading system
Sensation testing Bilateral comparison IUMS

NEUROLOGIC EXAM Muscle Testing
FINGERS EXT C7 FLEX C8 ABD T1 ADD T1 WRIST EXT C6 FLEX C7 IUMS

Sensation Testing Dorsal hand Radial hand

C-5 NEUROLOGIC LEVEL SHOULDER ABDUCTION BICEPS LATERAL ARM IUMS

C-6 NEUROLOGIC LEVEL WRIST EXTENSION BRACHIORADIALIS LATERAL FOREARM
108 IUMS

C-7 NEUROLOGIC LEVEL IUMS WRIST FLEXION FINGER EXTENSION TRICEPS
MIDDLE FINGER IUMS

C-8 NEUROLOGIC LEVEL FINGER FLEXION MEDIAL FOREARM IUMS

T-1 NEUROLOGIC LEVEL FINGER ABUCTION MEDIAL ARM IUMS

MAJOR PERIPHERAL NERVES
MOTOR TEST SENSATION TEST RADIAL N WRIST AND THUMB EXTENSION DORSAL WEB SPACE BETWEEN THUMB AND INDEX FINGER ULNAR N ABDUCTION – LITTLE FINGER DISTAL ULNAR ASPECT – LITTLE FINGER MEDIAN N THUMB PINCH OPPOSITION OF THUMB ABDUCTION OF THUMB DISTAL RADIAL ASPECT – INDEX FINGER AXILLARY N DELTOID LATERAL ARM – DELTOID PATCH ON UPPER ARM MUSCULOCUTANEOUS N BICEPS LATERAL FOREMAN IUMS

THE ALLEN TEST 4 1 2 3 4 PURPOSE – TO EVALUATE BLOOD SUPPLY TO THE HAND METHOD – ASK PATIENT TO OPEN AND CLOSE THEIR WRIST (1) WITH THE PATIENTS WRIST CLOSED, APPLY PRESSURE TO THE ULNAR AND RADIAL ARTERY (2) ASK THE PATIENT TO OPEN THEIR HAND, RELEASE ONE OF THE ARTERIES (3), THE HAND SHOULD FLUSH IMMEDIATELY, IF NOT THEN THE ARTERY IS PARTIALLY OR COMPLETELY OCCLUDED (4) IUMS

RADIOLOGIC STUDIES AP and Lateral of hand and wrist
Consider Obliques and special views if fracture suspected but not seen on AP and Lateral IUMS

EXAMINATION OF RELATED AREAS
Referred pain can be due to: Herniated cervical discs Osteoarthritis Brachial plexus outlet syndrome Elbow and shoulder entrapment syndrome IUMS

Sites of Pain and Common Pathology
Dorsal pain Ganglion (#1 cause of dorsal pain) Extensor tendonitis (overuse) Kienbach’s Disease Volar Pain Ganglion Flexor tendinitis Carpal tunnel syndrome Thumb CMC joint arthritis IUMS

Site of Pain and Common Pathology
Radial pain Thumb CMC DJD DeQuervain’s tendinitis Scaphoid fracture Ulnar pain EXT carpi ulnaris tendinitis Synovitis Triangular fibrocartilage complex tear IUMS

Examination of the Upper Extremity
A detailed history should include: Patient’s age Handedness Occupation Hobbies Chief complaint Description of how and when the problem started Duration of symptoms Aggravating and alleviating factors IUMS

Examination of the Upper Extremity
If an injury is involved: The environment in which the injury or insult occurred should be determined. If crush injury, are heat or chemicals involved? Was the environment clean or dirty? Past medical history is useful in the presence of systemic conditions that have manifestations in the hand. IUMS

Anatomy Review Bones Distal radius and ulna Carpals metacarpals
Phalanges Proximal Middle Distal IUMS

Anatomy Review Joints DRUJ Carpal-Metacarpal Metacarpal-Phalangeal
Proximal Interphalangeal Distal Interphalangeal DIP PIP M-P C-M DRUJ IUMS

Anatomy Review Muscles & Tendons Extrinsic Flexor tendons
Flexor carpi ulnaris Flexor carpi radialis Palmaris longus Flexor pollicis longus (FPL) Flexor digitorum profundis (FDP) Flexor digitorum superficialis (FDS) The flexor carpi ulnaris and the flexor carpi radialis are the main flexors of the wrist and are located on the radial and ulnar side of the wrist, respectively. The palmaris longus, a rudimentary muscle that runs down the center of the forearm, inserts the palmar fascia in the palm. The remaining flexors of the hand pass beneath the transverse carpal ligament within the carpal canal and include the flexor pollicis lungus (FPL), flexor digitorum profundus (FDP), the flexor digitorum superficialis (FDS). The FPL inserts on the distal phalynx and flexes the IP joint of the thumb. Each finger, excluding the thumb, has a flexor profundus and flexor superficialis. The FDP inserts on each distal phalanx and flexes all three joints in the finger. The superficialis tendon insert on the middle phalanx and flexes the PIP. IUMS

Anatomy Review Muscles & Tendons Extrinsic Extensor tendons
Abductor pollicis longus Extensor pollicis brevis Extensor carpi radialis longus and brevis Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris IUMS

Anatomy Review Muscles & Tendons Extrinsic Intrinsic Extension of MP
Flex of IP Intrinsic Abduct and adduct fingers Flexion of MP Extension of IP The intrinsic muscles of the hand are the interosseous muscles, the lumbricals, and muscles of the thenar and hypothenar region. The intrinsic muscles of the hand provide the fingers with the ability to abduct and are involved with flexion at the MP joint and extension of the IP joints. The extrinsic muscles extend the MP joint and flex the IP joints. When the intrinsic system is weakened, the hand will take on an intrinsic minus posture (extension at the MP joints and flexion of the MPO joints). An intrinsic plus posture is the reverse (flexion at the MP joints and extension of the IP joints). IUMS

Anatomy Review Nerves Median Ulnar Radial IUMS

Examination of the Hand and Wrist
Complete exam: Observation Palpation Range of motion Neurologic testing Vascular assessment Stability testing IUMS

Observation Hands at rest Curved posture Look for one finger curved
Asymmetry Color Spooning or clubbing Muscle atrophy IUMS

Palpation Lateral epicondyle Radial head Groove of ulnar nerve
Lister’s tubercle Radial/ulna styloid Snuffbox Carpals Metacarpals Phalanges IUMS

Neurologic Testing Sensory Motor Light touch – pin prick
Two-point descrimination Motor Median Ulnar Radial IUMS

Neurologic Testing Motor testing OK sign FDP FDS FPL IUMS
The median nerve is responsible for pronation of the forearm, wrist flexion, flexion of the thumb IP joint, and flexion of the DIP joint to the index finger as well as for opposition of the thumb. Resistive testing of thumb IP flexion best isolates median nerve function. The uInar nerve is responsible for flexion of the DIP joint to the ring and little finger. It innervates most of the intrinsic muscles of the hand, which provides grip strength and the ability to abduct and adduct the fingers. The radial nerve is responsible for wrist and finger extension. It is important to note that even in the presence of a complete radial nerve palsy, the fingers can be extended by the uInar innervated intrinsic muscles. Therefore, testing for radial nerve function must be performed with the wrist and MP joints supported in extension, which eliminates the effect of the intrinsics. Testing the ability to give the OK sign is a quick, easy way to test the function of all three nerves (Fig. 16). At this point in the examination, test for the integrity of the tendons to the hand and wrist. Begin with resistive testing of wrist flexion and extension followed by radial and uInar deviation. In the hand, test the integrity of the FDP by having the patient bend at the DIP joint of each finger while holding the MP and PIP joints in full extension. The FDS to each finger is tested by having the patient bend at the PIP joint while holding the other fingers extended (Fig. 17). At the thumb, test the FPL by resistive testing at the thumb IP joint. The intrinsic tendons are tested by resistive testing of finger abduction and adduction. IUMS

Vascular Examination Radial artery Ulnar artery Allen test
Located radial to the FCR Ulnar artery Located radial to the FCU Allen test IUMS

Stability Testing Ulnar collateral ligaments
Radial collateral ligaments Gamekeeper’s/ skier’s thumb Stability Testing There are certain joints in the upper extremity that are prone to injury and subsequent instability. Careful attention should be given to these joints as part of a routine examination. The elbow should be examined for both varus instability (laxity of the lateral ligaments) and valgus instability (laxity of the medial ligaments). One hand is placed on the patient's humerus as a post, and the elbow is stressed laterally and medially in both the fully extended position and in 30' of flexion. Excessive opening of the joint or reproduction of pain is noted. Instability of the DRUJ is confirmed by pain at the site and a prominence of the ulna head dorsally as compared to the other side. With the patient's arm in a pronated position, the examiner should press on the uInar head and note the amount of ballotment as it reduces into the radius. At the wrist, instability can occur either between bones of the carpus (dissociative) or between carpal rows (nondissociative). The most common intercarpal instability is between the scaphoid and lunate, which is confirmed by pain in the scapholunate region and with a positive Watson test (see Special Tests). Lunotriquetral instability is characterized by pain over the ligament between the lunate and triquetrurn and with a positive shuck test (see Special Tests). For the small joints of the hand, stability testing is performed by stabilizing the proximal bone and placing medial and lateral stress on the bone distal to the joint in question. Gamekeepers or skier's thumb is an injury of the uInar collateral ligament of the thumb MP joint. Opening of the thumb MP joint to lateral stress on the proximal phalanx is diagnostic (Fig. 18). IUMS

Special Tests Finklestein’s test Froment’s sign Watson test Shuck test
Basal joint grind Compression test Phalen’s test Tinel’s sign TAP IUMS

Scapholunate instability:
The mechanism of scapholunate injury includes a fall onto a hyperextended wrist with the forearm in pronation and the impact point on the thenar eminence . Radial pain and progressive loss of strength are usual . Loss of mobility appears much later. Patients may sometimes complain of a snapping wrist which usually occurs during the passage from radial deviation to neutral with the wrist in flexion. In ulnar deviation, the snap represents the action of the scaphoid on the lunate bone and the sudden correction of the proximal carpal row into dorsiflexion. With wrist flexion, a snap may represent penetration of the capitate into the scapholunate interval (rare), or the dorsal subluxation of the scaphoid on the posterior margin of the radius . 4/20/2017

1-The synovial irritation sign of the scaphoid.
To elicit this sign, pain is induced by exerting pressure on the scaphoid through the anatomical snuffbox (Figure 19). This sign is usually positive in patients with scaphoid instability, but its specificity is very low. 4/20/2017

(2) The scaphoid bell sign.
This is performed by palpation of the scaphoid tuberosity anteriorly through the radial groove while placing the index finger in the anatomical snuffbox. With ulnar deviation of the wrist, the anterior protrusion of the distal scaphoid tuberosity disappears and the proximal pole appears in the snuffbox. With radial deviation, the proximal pole disappears in the snuffbox and the protrusion of the distal scaphoid tuberosity reappears in the radial groove. Any disruption of this normal mechanism is suggestive of instability, but the sensitivity of this test seems very low . 4/20/2017

(3) The scapholunate ballottement test.
This test is designed to highlight any abnormal motion between the scaphoid and lunate bones. With one hand the examiner holds the scaphoid between his thumb (placed distally over the scaphoid tuberosity on the palmar side) and index finger . (placed posteriorly and proximally over the proximal pole of the scaphoid). The other hand holds the lunate). The hands then move in opposite directions and appreciate the ballotement between the two bones. It may be difficult to appreciate instability as the normal laxity of the scapholunate joint varies greatly among individuals . However, if the test induces pain, this is a good sign. This test, as all tests, may be compared to the opposite wrist to appreciate normal variations. 4/20/2017

Scapholunate ballottement is more marked when the wrist is in slight flexion, and, in this position, dorsal protrusion of the second row is sometimes visible . Flexing the wrist also brings the lunate more dorsal and distal to the dorsal rim of the radius making it easier to palpate the lunate. Another technique to palpate the scapholunate interval is to place the index finger on the dorsal and distal pole of the lunate and then move the index finger radially while moving the wrist in flexion and extension. One can sometimes feel a groove corresponding to the scapholunate interval, or more often a slight protrusion of the proximal pole of the scaphoid. The limitations of these tests are connected with the difficulty to hold the lunate bone correctly. 4/20/2017

(4) The wrist-flexion finger-extension
maneuver was described by Watson. With the elbow resting on the table, the wrist is placed in flexion and the patient is asked to extend the fingers. Application of pressure on the nails may reveal pain in the scapholunate interval. Figure 21: The wrist-flexion finger-extension maneuver. This maneuver induces loads into the carpus that arouses pain at the scapholunate space. 4/20/2017

(5) Watson's test or the scaphoid shear test
The examiner and patient face each other as for arm wrestling. The examiner's fingers are placed dorsally on the distal radius, while the thumb is placed on the palmar distal tuberosity of the scaphoid. The other hand holds the metacarpals. Firm pressure is applied to the palmar tuberosity of the scaphoid while the wrist is moved in ulnar deviation which places the scaphoid in extension. While the wrist is moved in radial deviation the scaphoid cannot flex, as it is blocked from flexing by the examiner's thumb. 4/20/2017

In case of scapholunate tear, or in lax wrist patients, the scaphoid will move dorsally under the posterior margin of the radius and will reach the examiner's index finger, thus inducing pain (Figure 22). Sometimes this test may only be painful, without any perception of dorsal scaphoid displacement. When pressure on the scaphoid is removed, the scaphoid goes back into position with what Watson described as a "thunk" (a clunk) 4/20/2017

In certain patients, the absence of normal mobility compared to the uninjured wrist may be due to swelling and/or synovitis. To avoid false-positive testing, the examiner should first place his fingers on the posterior surface of the scaphoid to detect spontaneous pain. Lane suggested modifying the Watson's test by moving the scaphoid only from an anterior to a posterior position (he called it the Scaphoid shift test). This modification would enhance the test's sensitivity by using simple movements. 4/20/2017

Figure 22: The Watson's test.
4/20/2017

Lunotriquetral instability:
Lunotriquetral instability may appear after a hyperpronation injury ,but more often after a hyperextension injury with an impact on the ulnar side. Ninety per cent of patients complain of ulnar pain, and lunotriquetral joint palpation is usually painful . Active prono-supination movements against resistance are painful if the resistance causes twisting of the carpus . A feeling of instability or loss of strength is present in rare cases. A snap or clunk may be observed in half of the patients during ulnar deviation or extension . 4/20/2017

The lunotriquetral ballottement test or Reagan's test (also called the Shuck or shear test, depending on the authors): as in the scapholunate ballottement test, the clinician holds the lunate bone between his thumb and index finger with one hand, and moves the triquetrum with the pisiform dorsal and palmar (Figure 23). The aim is to appreciate instability (very difficult) and above all the arousal of pain [30-32]. The sensitivity of this test varies from 33 to 100%, depending on the authors, and its specificity is still unknown. 4/20/2017

The lunotriquetral ballottement test (Reagan's test)
Figure 23: The lunotriquetral ballottement test (Reagan's test) 4/20/2017

Kleinman's shear test (which some authors call the shuck test!)
With the patient's forearm in a vertical position, the examiner places one finger on the posterior part of the lunate and with his contralateral thumb placed palmar, pushes the pisiform dorsal which arouses pain in the lunotriquetral joint. This test might be more sensitive and more specific than the Reagan's test. Figure 24: The Kleinman's test. 4/20/2017

The ulnar snuff box compression test (Linscheid's test)
This test may be the least specific according to Kleinman The thumb placed on the ulnar side of the triquetrum exerts an axial pressure directed toward the lunate, which arouses pain. 4/20/2017

The raised triquetrum test
was recently proposed by Zradkovic and Sennwald (personal communication). The examiner holds the patient's hand proximal to the wrist and places his thumb on the triquetrum. From the neutral position, without flexion or extension, he performs radial and ulnar deviation movements and appreciates the dorsal and palmar movements of the triquetrum, which should be compared to those of the other wrist (Figures 26 a,b,c). The sensitivity and specificity of this test are still unknown, as are the anatomical lesions which cause the test to be positive. As pointed out by Gilula, the triquetrum is very prominent or dorsal with radial deviation, and moves palmarly and may even disapear with ulnar deviation. On plain radiographs, the triquetrum is located "onto" or proximal on the hamate with radial deviation (superposed), and "lateral" or ulnar to it with ulnar deviation (juxtaposed) [Laredo, personal communication]. 4/20/2017

The raised triquetrum test
Fig 26a (26b) (26c) In Fig 26a, the examiner places the wrist in radial deviation while palpating the triquetrum. He then moves the wrist in neutral (26b) and ulnar (26c) deviation to appreciate the depression of the triquetrum with ulnar deviation and prominence of the triquetrum with radial deviation that should be compared to the contralateral wrist. 4/20/2017

Distal radioulnar joint (DRUJ) instability :
As the ulna is fixed, the radius is the dislocated bone, but we have kept the usual convention which describes "dislocation of the ulna". A traumatic movement in supination is responsible for anterior DRUJ instability, while posterior DRUJ instability follows a pronation injury. Dorsal ulnar dislocation is responsible for loss of supination and protrusion of the ulnar head. In case of dorsal ulna subluxation, the protrusion of the ulnar head may be clearly visible when viewed laterally, and unlike what occurs in the normal wrist, does not disappear if the injured wrist is flexed. Anterior ulnar dislocation makes the dorsal skin depress and limits pronation. In anterior subluxation, the usual protrusion of the ulnar head is reduced or disappears. 4/20/2017

Pain secondary to DRUJ instability is located on the ulnar side of the wrist and is intensified by pronation or supination. In such cases the examiner stabilizes the patient's forearm with one hand while with the other hand, he grasps the patient's hand as if for a vigorous handshake. When the patient resists forced passive rotation, or when there is active rotation against resistance, pain usually is elicited. If the pain is caused by compressing the ulna against the radius, it is mostly suggestive of chondromalacia . Patients may also complain of a snap which occurs during pronation or supination and corresponds to either dislocation of the ulnar head or to its reduction. 4/20/2017

radioulnar ballottement test
Radioulnar instability is tested by the radioulnar ballottement test, in which the patient's elbow is flexed, and the examiner uses his thumb and index finger to stabilize the radius radially and the ulnar head ulnarly (Figure 29). Normally, there is no mobility in the anterior or posterior direction in maximum pronation or supination. Pain or mobility is very suggestive of radioulnar instability. The ballottement test must not only be done during extreme motions of pronation and supination, but also in various intermediate pronation and supination positions, because instability may only appear in some of these positions. 4/20/2017

The radioulnar ballottement test.
Figure 29: The radioulnar ballottement test. 4/20/2017

TFCC lesions are usually of degenerative origin, but may also constitute the first stage of radioulnar instability. Pain is always ulnar and is intensified by wrist movements but not necessarily by pronation or supination. It is usually aggravated by ulnar inclination or rotational loads: thus, in the screwdriver test, the examiner holds the patient's hand while performing screwing and unscrewing movements. 4/20/2017

Extensor carpi ulnaris tendon dislocation is not a ligamentous injury but occurs after combined hypersupination and ulnar inclination. Passive pronation and supination are usually painful and may be accompanied by a visible and palpable snap which can be reproduced by placing the wrist in flexion and supination. Figure 30: Displacement of the extensor carpi ulnaris is more visible when the wrist is placed in flexion and supination. 4/20/2017

Common Traumatic Injuries of the Hand
Bone and Soft Tissue IUMS

Considerations on Treating Hand Injuries
Type of injury The patient Associated diseases Socioeconomic factors Ability to cooperate with treatment plan Motivation to get well Managing the patient Recognizing the injury Making the proper diagnosis Initiating the appropriate care plan IUMS

Referrals Emergent referrals Open fractures
Fractures with neurovascular compromise Significant soft tissue injury Irreducible dislocations or fractures with significant deformity IUMS

Referrals Urgent referrals (next day or two)
Closed flexor or extensor tendon injuries Displaced, angulated, or malrotated closed fractures Carpal bone and distal radius fractures IUMS

History Complete history Hand dominance Occupation Avocations
Circumstances surrounding the injury When and where Mechanism of injury Location and character of pain Numbness or tingling IUMS

Radiographs Examine prior to ordering films
Stress views are useful in demonstrating injuries not present on plain views Occasionally CT scan or MRI are needed to evaluate an injury IUMS

Description of Fractures
Be able to accurately describe a radiograph to a colleague Correct name of bone or joint involved Open or closed fracture Intraarticular or extraarticular Whether the fracture is shortened, displaced, malrotated, or angulated Fracture pattern IUMS

Description of Dislocations
Be able to accurately describe a dislocation Described with the position of the distal bone relative to the proximal bone Dorsal vs volar dislocation Radial vs ulnar dislocation Can have a combination of two IUMS

Complications By far, the largest potential problem with any hand or wrist injury is stiffness. Soft tissue complications: Tendon adhesions Capsular contractures Fracture healing time Hand: 3-4 weeks Distal radius: 5-7 weeks IUMS

Complications Bony complications: Malunion Angulation Malrotation
Shortening Intra-articular step-off Nonunion is uncommon in hand or wrist IUMS

TINEL’S SIGN PHALEN TEST
STRIKE THE PATIENT’S WRIST AS SHOWN. A TINGLING SENSATION RADIATING DOWN THE WRIST TO THE HAND IN THE DISTIBUTION OF THE MEDIAN NERVE IS A POSITIVE SIGN. PHALEN TEST HAVE THE PATIENT HOLD THEIR WRISTS AS SHOWN FOR ONE MINUTE. NUMBNESS AND PARAESTHESIA IN THE DISTRIBUTION OF THE MEDIAN NERVE IS A POSITIVE TEST. JAMA 2000;283: MOSBY’S GUIDE TO THE PHYSICAL EXAMINATION 5TH ED. IUMS

THUMB ABDUCTION TEST TESTS THE STRENGTH OF THE ABDUCTOR POLLICIS BREVIS WHICH IS INERVATED BY THE MEDIAN NERVE. HAVE THE PATIENT PLACE THEIR PALM UP WITH THEIR THUMB PERPENDICULAR TO IT. APPLY DOWNWARD PRESSURE ON THE THUMB. WEAKNESS IS ASSOCIATED WITH CARPAL TUNNEL SYNDROME IUMS

QUESTIONS IUMS

Clinical Examination of the Hand and Wrist

Similar presentations

Presentation on theme: "Clinical Examination of the Hand and Wrist"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Clinical Examination of the Hand and Wrist

Similar presentations

Presentation on theme: "Clinical Examination of the Hand and Wrist"— Presentation transcript:

Similar presentations

About project

Feedback