Wrist and Hand Examination

Welcome to Temple University's Evidence-Based Practice project. This project was created by and for the students at Temple University in Philidelphia, and is part of the Orthopaedic curriculum. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Let me know if you need any assistance.Be the first to edit this page and have your name permanently included as the original editor, see the editing pages tutorial for help.

Original Editor - Your name will be added here if you created the original content for this page. Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Subjective

Thorough history taking is an important first step in treating the patient. Each physical therapist will develop their own style and technique, but a good interview will include the basic elements discussed below.

History

Clinical Presentation
        Mechanism of the injury-
                How the injury occurred and what was the cause.
        Location of the pain
        Timeline-
                When is the pain at its worse and when is it relieved?
        Presence and location of numbness and tingling.
        Aggravating and relieving factors.
        Were any diagnostic test/imaging performed and what were the results?

Red Flags

This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation.

Infections

• Heat
• Swelling
• Pain
• Redness
• Inflammation

Fracture/dislocation:

Top five physical findings which are most useful in screening for wrist fracture.1

• Localized tenderness (Sensitivity [Sn] 94%)
• Pain on active motion (Sn 97%)
• Pain on passive motion (Sn 94%)
• Pain on grip (Sn 71%)
• Pain on supination (Sn 68%)
• Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs

Colles fracture
Scaphoid fracture
Additional potentially serious conditions

• Scapholunate instability
• Arthritedes
• Rheumatoid Arthritis
• Lyme disease
• Tuberculosis

Peripheral Vascular Disease
Peripheral Neuropathy:

• Hx: Older age, >65. The risk is same for men/women.
• Risk factors include hypertension, hypercholesterolemia, obesity, diabetes, and smoking. Commonly affects lower extremity over upper extremity.

Upper extremity nerve injuries involving

• Median
• Radial
• Ulnar
  
  

Differential Diagnosis

Carpal Tunnel Syndrome
Anterior Interosseous Syndrome
Posterior Interousseous Syndrome
Fractures

• Distal Radial Fractures

Osteoarthritis

• First Carpometacarpal Osteoarthritis
•         Thumb CMC grind test
• Hand and Wrist Osteoarthritis

DeQuervain Syndrome

• Finklestein’s Test:

Radial Tunnel Syndrome
Compression of the Ulnar nerve at Guyon’s canal
Non-specific wrist pain (mechanical wrist pain)

• Can include wrist strain, sprain, joint dysfunction, repetitive injuries or h/o trauma without specific identified diagnosis.

Trigger Finger
Complex Regional Pain Syndrome
Triangular Fibrocartilaginous Complex
Dupuytren’s Contracture

Outcome Measures

• DASH:
• Quick DASH
• Symptom Severity Scale
• Patient Specific Functional Scale

Objective

Observation

Vital Signs
Posture

• During the posture examination the physical therapist should examine from the lateral, posterior, and anterior views looking at the position of the cervical and thoracic spine along with the shoulder, elbow, forearm, wrist, and hand.
• Carrying angle
• Shoulder height
• Muscle girth or presence of atrophy

Swelling
Muscle wasting

• Median Nerve (depending on area impingement)
• Muscle wasting in the first three and fingers and half the fourth fingers on radial side of the hand. The muscle involved LOAF) are:

1. Lumbricals
2. Oppenens pollicis
3. Adbuctor pollicis brevis,
4. Flexor pollicis brevis

Radial Nerve (depending on area of impingement)

• Common muscles that are affected by radial nerve entrapment are primarily on the dorsal aspect of the hand.

1. Supinator
2. Extensor carpi ulnaris
3. Extensor digitorum communis
4. Extensor digiti quinti
5. Abductor pollicis longus
6. Extensor pollicis brevis
7. Extensor indicis propius

Ulnar Nerve (depending on area of impingement)

• Muscle wasting in the hand for the ulnar nerve occurs primarily in the fifth and half the fourth fingers, in the hypothenar area. The muscles that are affected are:

1. Abductor digiti minimi
2. Opponens digiti minimi
3. Flexor digiti minimi
4. 3rd and 4th lumbrical
5. 1st -3rd palmar interosseous
6. 1st – 4th dorsal interosseous
7. Flexor pollicis brevis
8. Adductor digiti minimi

Screen Proximal Joints
When examining a patient with a distal upper extremity condition it is advisable for the therapist to screening proximal structures to determine if they are involved in the patient’s clinical presentation. Below are some common ways physical therapists may screen these proximal structures.

• Cervical

1. Accessory motion testing
2. ROM with over pressures
3. ULNT1(Upper limb neurodynamic test2

• Shoulder

1. Passive ROM with overpressure
2. Active ROM of glenohumeral, acromioclavicular, sternoclavicular
3. Muscle strength testing
4. Assess for glenohumeral internal rotation deficit (GIRD)

• Elbow

1. Passive ROM, active ROM with over pressure
2. Muscle strength testing

Palpation

• supine
• prone
• seated

Movement Testing

• AROM, PROM, and Overpressure
• Passive Intervertebral Motion
• Muscle Strength