Clinical Examination of the Hand and Wrist

1
Clinical Examinationof the Hand and Wrist

• A.Mazaherinezhad
• MD. Sportsmedicine Department, Assistant
  professor, IUMS

2
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

3
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

4
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

5
Bony Anatomy

• Phalanges 14
• Sesamoids 2
• Metacarpals 5
• Carpals
• Proximal row 4
• Distal row 4
• Radius and Ulna

Listers tubercle
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
ANATOMY

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

10
HISTORY

• Age
• Handedness
• Chief complaint
• Occupation
• Previous injury
• Previous surgery

• Sx related to specific activities
• What exacerbates
• What improves
• Frequency
• Duration

11
HISTORY

• 4 principle mechanisms of injury
• Throwing
• Weight bearing
• Twisting
• Impact

12
EXAMINATION OF THE HANDS, FINGERS AND WRIST
COMPARE OPPOSITE SIDE
13
PHYSICAL EXAM

• Inspection
• Palpation
• Range of Motion
• Neurologic Exam
• Special Tests

14
INSPECTION

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

15
INSPECTION Palmar Surface

• Creases
• Thenar and Hypothenar Eminence
• Arched Framework
• Hills and Valleys
• Web Spaces

16
Cascade sign

• Assure all fingers point to scaphoid area when
  flexed at PIPs

17
INSPECTION of Dorsal Hand and Wrist

• Hills and Valleys
• Height of metacarpal heads
• Finger nails
• Pale or whiteanemia or circulatory
• Spoon shapedfungal infection
• Clubbedrespiratory or congenital heart
• Deformities

18
Ganglion

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

19
Boutonniere Deformity

• Tear or stretch of the central extensor tendon at
  PIP
• Note unopposed flexion at PIP
• Extension at DIP
• Trauma or inflammatory arthritis

20
Swan Neck Deformity

• Contraction of intrinsic muscles (trauma, RA)
• NOTE Extension at PIP

21
Osteoarthritis

• Heberdens nodes DIP

• Bouchards nodes PIP

22
Rheumatoid Arthritis

• MCP swelling
• Swan neck deformities
• Ulnar deviation at MCP joints
• Nodules along tendon sheaths

23
Mallet Finger

• Hyperflexion injury
• Ruptured terminal extensor mechanism at DIP
• Incomplete extension of DIP joint or extensor lag
• Treatment
• stack splint

24
Dupuytrens Contractures

• Palmar or digital fibromatosis
• Flexion contracture
• Painless nodules near palmar crease
• Malegt Female
• Epilepsy, diabetes, pulmonary dz, alcoholism

25
RANGE OF MOTION

• Active range of motion
• Passive range of motion if unable to actively
  move joint
• Bliateral comparison
• To determine degrees of restriction

26
RANGE OF MOTIONWrist

• Flexion
• Extension
• Radial deviation
• Ulnar deviation
• Ulnar deviation is greater than radial

27
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.

28
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.
29
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.

30
Figure 4 Masurement of extension The
goniometer is placed anteriorly on the wrist.
31
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.

32

• The dominant hand is usually 5 to 10 stronger
  than the non-dominant hand.

33
RANGE OF MOTIONFingers

• 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

34
CLINICAL EXAMINATION OF THE WRISTThe 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

35
PALPATION of Skin

• Warmth?
• Dryness?
• Anhydrosis nerve damage
• Scars

36
PALPATION of Wrist Dorsum

• Ulnar Styloid
• TFCC
• Triquetrum
• Pisiform
• Hook of Hamate
• Guyons Tunnel

• Radial Styloid
• Scaphoid
• 1st MC/Trapezium jt
• Lunate
• Listers Tubercle

37
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
38

• 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.

39
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.

40

• 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 Listers
  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.

41
Ulnar Styloid palpationListers Tubercle
palpation
Ulnar styloid
42
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.)
43

• 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.

44

• 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 .

45
Radial Styloid palpation Scaphoid Bone palpation
Radial styloid
46
1st MC/Trapezium joint palpation
47
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.
48

• The radial part of this groove, just ulnar to the
  extensor pollicis longus tendon, is what is
  termed the STT entry point (scaphotrapeziotrapezoi
  dal) for mid-carpal arthroscopy.

Figure 10 The midcarpal joint can be palpated
through the groove between the scaphoid and the
trapezium and trapezoid bones.
49

• 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 Listers 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.

50
Lunate Bone palpation
51

• 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.
52
(No Transcript)
53

• (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.
54

• 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.

55

• 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

56
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.
57
Triquetrum Bone palpation
58
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).

59
Figure 13 The ulnar "anatomical snuffbox".
60
PALPATIONPalmar Aspect

• Pisiform and Hamate
• Tunnel of Guyon
• Ulnar Artery
• Carpal Tunnel
• Flexor Carpi Radialis
• Flexor Carpi Ulnaris

61
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.

62
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)
63
Pisiform and Hamate palpation
Tunnnel of Guyon
64
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.
65
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

66
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

67

• COMPRESSIVE NEUROPATHIES
• NOT ALL HAND
• NUMBNESS IS
• CARPAL TUNNEL

68
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

69
Volar flexor tendons
Flexor carpi ulnaris Palmaris longus Flexor carpi
radialis
70

• 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

71
Thumb CMC Joint Arthritis

• Painful pinch or grasp
• Grind Test
• Axial pressure to thumb while palpating CMC joint

72
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

73
(No Transcript)
74
Ulnar Styloid palpationListers Tubercle
palpation
Ulnar styloid
75
Triangular Fibro-Cartilage Complex palpation
(TFCC)
76
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

77
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

78
PALPATION of HAND Bone

• Metacarpals - 5
• Phalanges - 14
• Palpate for swelling, tenderness
• Assess for symmetry

79
PALPATIONSoft tissue

• 6 Dorsal Compartments
• Transport extensor tendons
• 2 Palmar Tunnels
• Transport nerves, arteries, flexor tendons

80
1st Dorsal Compartment

• Abductor Pollicis Longus and Extensor Pollicis
  Brevis
• Radial border of Anatomic Snuff Box
• Site of stenosing tenosynovitis
• De Quervains Tenosynovitis
• Finkelsteins Test

81
DeQuervains Tenosynovitis

• Inflammation of EXT Pollicis Brevis and ABD
  Pollicis Longus tendons
• Tenderness - 1st Dorsal Compartment
• Finkelsteins Test

82
DeQuervains Tenosynovitis
83
2nd Dorsal Compartment

• Extensor Carpi Radialis Longus and Extensor Carpi
  Radialis Brevis
• Make fistbecomes prominent

84
Intersection Syndrome(Squeaker Wrist)

• Similar to DeQuervains tenosynovitis
• Peritendinitis related to bursal inflammation at
  the junction of the 1st and 2nd dorsal
  compartments
• Overuse of the radial extensor of the wrist

85
Intersection Syndrome(Squeaker Wrist)

• Seen in gymnasts, rowers, weightlifters, racket
  sports
• Proximal to DeQuervains- 4-6 cm from radiocarpal
  joint
• Crepitation or squeaking can be heard with
  passive or active ROM

86
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

87
4th Dorsal Compartment

• Extensor Digitorum Communis and Extensor Indicis
• Palpate from the carpus to the metacarpophalangeal
  joints
• Frequent site of ganglion cysts

88
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

89
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

90
Extensor Carpi Ulnaris Tenosynovitis and
Subluxation

• 6th Dorsal Compartment
• Second most common site of tenosynovitis (after
  DeQuervains)
• Common in racket and rowing sports
• Pain and tenderness with ulnar deviation
• Suspect subluxation when clicking on ulnar side
  of forearm

91
Carpal Tunnel

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

92
Carpal Tunnel Syndrome

• Entrapment of the median nerve
• Phalens and Tinels Test
• 2 point discrimination
• Symptoms
• Aching in hand and arm
• Nocturnal or AM paresthesias
• Shaking to obtain relief

93
Carpal Tunnel Tests

• Neurologic exam
• Median nerve sensation and motor
• Phalens Testboth wrists maximally flexed for 1
  minute
• Tinels Test

94
(No Transcript)
95
PALPATIONPalm of Hand

• Thenar Eminence
• 3 muscles of thumb
• Atrophy seen in carpal tunnel syndrome
• Hypothenar Eminance
• 3 muscles of little finger
• Atrophy with ulnar nerve compression
• Palmar Aponeurosis
• Dupuytrens Contracture

96
PALPATION of Fingers

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

97
SPECIAL TESTSLong 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

98
Flexor Tendon InjuryJersey Finger

• Avulsion injury from rapid passive extension of
  the clenched fist
• Loss of flexion at PIP and/or DIP
• sublimus or profundus tests

99
Trigger Finger

• Stenosing flexor tenosynovitis
• Painful snap or lock
• Palpate nodule as digit flexed and extended

100
Flexor Tenosynovitis

• Tendon sheath infection
• Usually due to a puncture wound
• Bacterial skin flora
• Relative surgical emergency

101
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

102
RANGE OF MOTIONThumb

• 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

103
Skiers ThumbGamekeepers Thumb

• Ulnar Collateral Ligament rupture of the thumb
  MCP joint
• Instability, weak and ineffective pinch
• Radially directed stress at MCP joint-stable if
  opens lt35 degrees

104
NEUROLOGIC EXAM

• Muscular assessment using grading system
• Sensation testing
• Bilateral comparison

105
NEUROLOGIC EXAMMuscle Testing

• FINGERS
• EXT C7
• FLEX C8
• ABD T1
• ADD T1

• WRIST
• EXT C6
• FLEX C7

106
Sensation TestingDorsal hand Radial hand
107
C-5 NEUROLOGIC LEVEL
SHOULDER ABDUCTION
BICEPS
LATERAL ARM
108
C-6 NEUROLOGIC LEVEL
WRIST EXTENSION
BRACHIORADIALIS
LATERAL FOREARM
108
109
C-7 NEUROLOGIC LEVEL
WRIST FLEXION FINGER EXTENSION
TRICEPS
MIDDLE FINGER
110
C-8 NEUROLOGIC LEVEL
FINGER FLEXION
MEDIAL FOREARM
111
T-1 NEUROLOGIC LEVEL
FINGER ABUCTION
MEDIAL ARM
112
MAJOR PERIPHERAL NERVES
NERVE 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
113
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)
114
RADIOLOGIC STUDIES

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

115
EXAMINATION OF RELATED AREAS

• Referred pain can be due to
• Herniated cervical discs
• Osteoarthritis
• Brachial plexus outlet syndrome
• Elbow and shoulder entrapment syndrome

116
Sites of Pain and Common Pathology

• Dorsal pain
• Ganglion (1 cause of dorsal pain)
• Extensor tendonitis (overuse)
• Kienbachs Disease
• Volar Pain
• Ganglion
• Flexor tendinitis
• Carpal tunnel syndrome
• Thumb CMC joint arthritis

117
Site of Pain and Common Pathology

• Radial pain
• Thumb CMC DJD
• DeQuervains tendinitis
• Scaphoid fracture
• Ulnar pain
• EXT carpi ulnaris tendinitis
• Synovitis
• Triangular fibrocartilage complex tear

118
Examination of the Upper Extremity

• A detailed history should include
• Patients age
• Handedness
• Occupation
• Hobbies
• Chief complaint
• Description of how and when the problem started
• Duration of symptoms
• Aggravating and alleviating factors

119
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.

120
Anatomy Review

• Bones
• Distal radius and ulna
• Carpals metacarpals
• Phalanges
• Proximal
• Middle
• Distal

121
Anatomy Review

• Joints
• DRUJ
• Carpal-Metacarpal
• Metacarpal-Phalangeal
• Proximal Interphalangeal
• Distal Interphalangeal

DIP
PIP
M-P
C-M
DRUJ
122
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)

123
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

124
Anatomy Review

• Muscles Tendons
• Extrinsic
• Extension of MP
• Flex of IP
• Intrinsic
• Abduct and adduct fingers
• Flexion of MP
• Extension of IP

125
Anatomy Review

• Nerves
• Median
• Ulnar
• Radial

126
Examination of the Hand and Wrist

• Complete exam
• Observation
• Palpation
• Range of motion
• Neurologic testing
• Vascular assessment
• Stability testing

127
Observation

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

128
Palpation

• Lateral epicondyle
• Radial head
• Groove of ulnar nerve
• Listers tubercle
• Radial/ulna styloid
• Snuffbox
• Carpals
• Metacarpals
• Phalanges

129
Neurologic Testing

• Sensory
• Light touch pin prick
• Two-point descrimination
• Motor
• Median
• Ulnar
• Radial

130
Neurologic Testing

• Motor testing
• OK sign
• FDP
• FDS
• FPL

131
Vascular Examination

• Radial artery
• Located radial to the FCR
• Ulnar artery
• Located radial to the FCU
• Allen test

132
Stability Testing

• Ulnar collateral ligaments
• Radial collateral ligaments
• Gamekeepers/ skiers thumb

133
Special Tests

• Finklesteins test
• Froments sign
• Watson test
• Shuck test
• Basal joint grind
• Compression test
• Phalens test
• Tinels sign

134
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 .

135
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.
136
(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 .

137
(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.

138

• 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.

139
(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.
140
(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.

141

• 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)

142

• 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.

143
Figure 22 The Watson's test.
144
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 .

145
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.

146
Figure 23 The lunotriquetral ballottement test
(Reagan's test)
147
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.
148
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.

149
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.

150
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.
151
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.

152

• 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.

153
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.

154
Figure 29 The radioulnar ballottement test.
155

• 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.

156

• 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.
157
Common Traumatic Injuriesof the Hand

• Bone and Soft Tissue

158
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

159
Referrals

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

160
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

161
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

162
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

163
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

164
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

165
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

166
Complications

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

167
TINELS SIGN STRIKE THE PATIENTS 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 20002833110-3117 MOSBYS GUIDE TO THE
PHYSICAL EXAMINATION 5TH ED.
168
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
169
QUESTIONS