Wrist and Hand Evaluations

1. Wrist and Hand Evaluations Supplemental Material

2. Evaluation Map • History • Location of pain • MOI • Relevant sounds • Relevant sensation • Duration of symptoms • Description of symptoms • Previous history • General medical health

3. Evaluation Map • Inspection • General • Posture of the hand – natural, relaxed position = slight flexion, with a slight arch in the palm • Gross deformity – note areas of swelling, discoloration, or gross deformity • Palmar creases – swelling in one or more of the hand compartments can obliterate the normal palmar creases • Areas of cuts or scars – because the tendons of the hand are superficial, they are vulnerable to even minor cuts

4. Evaluation Map • Inspection • Wrist and Hand • Continuity of the distal radius and ulna – observe symmetry • Continuity of the carpals and metacarpals – observe the metacarpal shafts for gross discontinuity • Alignment of the MCP joints –Normally aligned relative to the noninvolved side, a depressed or shortened knuckle may indicate a metacarpal fracture • Posture of the wrist and hands – • Trauma to the structures that lie between the cervical spine and wrist may cause the wrist and hand to assume an abnormal posture such as Volkmann’s ischemic contracture (flexion contracture of the wrist and fingers). • Inhibition of the radial nerve may result in paralysis of the wrist and finger extensors and cause drop-wrist deformity, indicating the inability to extend the wrist. • Ganglion cyst – collection of fluid or the formation of a mass

5. EvaluationMap • Inspection continued • Thumb and Fingers • Skin and fingernails • Subungual hematoma – characterized by discoloration beneath the fingernail • Observe for the presence of the crescent-shaped lumina (growth plate of a fingernail or toenail). • If the lumina is absent, the fingernail will eventually be lost • Felon – an infection or abscess at or distal to the DIP joints • Arise secondary to contusions or lacerations • Distal end of finger is red, enlarged, tender to touch and warm • Must be treated with antibiotics to prevent spreading • Paronychia – infection around the periphery of the fingernail • Results in redness, swelling and possible drainage around the nail bed • Should be treated with warm soaks • Antibiotics or drainage by a physician if necessary • Alignment of fingernails – a finger that deviates from the rest when flexed, may indicate a spiral fracture of a phalanx or metacarpal • Finger deformities – Irregular posture of one finger may indicate an acute injury or previous trauma

6. Evaluation Map • Palpation of Hand • Metacarpals • MCP collateral ligaments • Phalanges • IP collateral ligaments • Ulna • Ulnar styloid process – palpated on the distal posteromedial border for tenderness or crepitus • Radius • Radial styloid process – distal radius palpated on the anterior, lateral, and posterior sides of the forearm, the small styloid process can be located on the most distal aspect of the lateral radius

7. Evaluation Map • Carpals • Scaphoid – locate in floor of anatomical snuffbox. To differentiate between the scaphoid and trapezium bones, palpate the wrist just distal from the radius while the wrist is ulnarly deviated. The scaphoid bone will be felt to “pop” into position under the finger. • Trapezium • Lunate • Pisiform • Hamate • Capitate • Trapezoid

8. Evaluation Map • Range of Motion Tests • Wrist • AROM • PROM • RROM (pg 541) • Flexion • Start – forearm supinated and wrist extended • Stabilization – posterior portion of the midforearm • Resistance – Palmar surface of the hand • Extension • Start – forearm pronated and the wrist is flexed • Stabilization – anterior portion of the mid-forearm • Resistance –dorsal surface of hand • Radial deviation • Start – forearm is supinated with the wrist in neutral position • Stabilization – distal forearm • Resistance – Radial side of the hand • Ulnar deviation • Start – forearm is supinated with the wrist in a neutral position • Stabilization –Distal forearm • Resistance – Ulnar side of the hand

9. Evaluation Map • Thumb – CMC • AROM • PROM • RROM (pg 544) • Flexion • Start – neutral position • Stabilization – carpal bones • Resistance – palmar aspect of the first phalanx • Extension • Start – neutral position • Stabilization – carpal bones • Resistance – Dorsal aspect of the first phalanx • Abduction • Start – neutral position • Stabilization – wrist and lateral four metacarpals • Resistance – lateral border of the first metacarpal • Adduction • Start – neutral position • Stabilization – wrist and lateral four metacarpals • Resistance – medial border of the first metacarpal • Opposition • Start – the thumb and fifth fingers opposed • Stabilization – not applicable • Resistance – The examiner attempts to separate the fingers

10. Evaluation Map • Range of Motion Tests • Fingers • AROM • PROM • RROM (pg 546) • Flexion – MCP • Start – joint being tested is placed in neutral position • Stabilization – at the joint (or joints) proximal to the joint being tested • Resistance – on the palmar aspect of the phalanx distal to the joint being tested • Extension – MCP • Start –joint being tested is placed in the neutral position • Stabilization – at the joint (or joints) proximal to the joint being tested • Resistance – on the dorsal aspect of the phalanx distal to the joint being tested • ABD – MCP • Start – the joint being tested is placed in the neutral position • Resistance – on the dorsal aspect of the phalanx distal to the joint being tested • ADD – MCP • Start – the joint being tested is placed in the neutral position • Resistance 0 on the dorsal aspect of the phalanx distal to the joint being tested • Flexion – IP joints • Extension – IP joints • Grip dynamometry

11. Evaluation Map • Ligamentous Tests • Valgus stress testing – radiocarpal joint (pg 549) • Patient Position – Sitting, elbow flexed to 90 degrees, forearm pronated, and the fingers assuming the relaxed position of flexion • Position of Examiner – Sitting or standing lateral to the wrist being tested, one hand grips the distal forearm and the other grasps the hand across the metacarpals • Procedure –a valgus stress is applied, radially deviating the wrist • Positive test – pain or laxity (or both) compared with the same ligament on the opposite wrist • Varus stress testing – radiocarpal joint (pg 549) • Patient Position – Sitting, elbow flexed to 90 degrees, forearm pronated, and the fingers assuming the relaxed position of flexion • Position of Examiner – Sitting or standing lateral to the wrist being tested, one hand grips the distal forearm and the other grasps the hand across the metacarpals • Procedure – a varus stress is applied, ulnarly deviating the wrist • Positive test – pain or laxity (or both) compared with the same ligament on the opposite wrist

12. Evaluation Map • Ligamentous Tests • Glide testing of the wrist (pg 550) • Patient Position – Sitting, elbow flexed to 90 degrees, the forearm pronated, and the fingers assuming the relaxed position of flexion • Position of examiner – sitting or standing lateral to the wrist being tested, one hand grips the distal radius and the other hand grasps the proximal carpal row • Procedure – a shear force is applied to the wrist by gliding the distal segment in a radial and ulnar direction and then in a volar and dorsal direction • Positive test –Pain or significant change in glide compared with the opposite side

13. Evaluation Map • Ligamentous Tests • Valgus & Varus stress testing - IP joints (pg 551) • Patient – sitting or standing, joint being tested is in extension • Position of examiner – standing in front of the patient, stabilizing the phalanx proximal to the joint being tested • Procedure – examiner grasps the phalanx distal to the joint being tested and applies a valgus stress to the joint, then applies a varus stress to joint • Positive test – increased gapping, compared with the same motion on the same finger of the opposite hand; pain

14. Evaluation Map • Ligamentous tests • Ulnar collateral ligament – thumb • Patient position – sitting or standing • Position of examiner – standing in front of the patient • Procedure – • The examiner stabilizes the fist metacapral with one hand and its Proximal phalanx with the other • While stabilizing the first metacarpal with the thumb slightly ABD and extended, the examiner applies a valgus stress to the ulnar collateral ligament • The test is repeated with the joint in varying degrees of flexion to evaluate the dorsal capsule of the joint • Positive test – the ulnar side of the first metacarpophalangeal joint gaps farther than the uninjured side or the patient describes pain (or both)

15. Evaluation Map • Neurologic Tests • Radial N • Median N • Ulnar N

16. Evaluation Map • Special Tests • Carpal Tunnel Syndrome • Phalen’s test (pg 555) [Modified version described] • Patient Position – Standing or seated • Examiner – standing in front of patient • Procedure • Examiner applies overpressure during passive wrist flexion and holds the position for 1 min • This procedure is then repeated for the opposite extremity • Positive test – tingling in the distribution of the median N distal to the carpal tunnel

17. Evaluation Map • Special Tests • DeQuervain’s Syndrome (tenosynovitis of the extensor pollicis brevis and abductor pollcis longus tendons) • Finkelstein test • Patient position – seated or standing • Examiner – standing in front of the patient • Procedure • Patient tucks the thumb under the fingers by making a fist • The patient then ulnarly deviates the wrist • Positive test – increased pain in the area of the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons