Wrist and Hand Examination: Difference between revisions
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== Subjective == | == Introduction == | ||
[[File:1024px-1121 Intrinsic Muscles of the Hand Superficial sin.png|right|frameless]] | |||
The hand and wrist is a series of complex, delicately balanced joints. Function is integral to every act of daily living. It is the most active portion of the upper extremity. A hand and wrist examination done in a structured manner will lead to a correct diagnosis. Remembering that the hand and wrist examination will take in and appreciate that: | |||
• 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<ref name=":0" /> | |||
== Subjective History == | |||
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. | 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. | ||
Clinical Presentation | |||
Clinical Presentation | |||
#Mechanism of the injury - How the injury occurred and what was the cause eg fall on outstretched hand | #Mechanism of the injury - How the injury occurred and what was the cause eg fall on outstretched hand | ||
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#Functional limitations. | #Functional limitations. | ||
#Were any diagnostic test/imaging performed and what were the results? | #Were any diagnostic test/imaging performed and what were the results? | ||
== <u></u>Objective == | == <u></u>Objective Examination == | ||
=== Screen Proximal Joints === | === Screen Proximal Joints === | ||
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* Height of metacarpal heads | * Height of metacarpal heads | ||
* Deformities. | * Deformities. | ||
[[File:Swan-neck deformity.jpg|right|frameless]] | |||
Ganglions - Cystic structure that arises from synovial sheath | Ganglions - Cystic structure that arises from synovial sheath | ||
Boutonniere Deformity | [[Boutonniere Deformity|Boutonniere]] Deformity | ||
[[Swan-neck deformity|Swan Neck]] Deformity (see image) | |||
[[Wrist and Hand Osteoarthritis|Osteoarthritis]] - Heberden’s nodes: DIP, Bouchard’s nodes: PIP | |||
Rheumatoid Arthritis - MCP swelling, Swan neck deformities, Ulnar deviation at MCP joints, Nodules along tendon sheaths.<ref>Shane Cass, DO UNM Primary Care Sports Medicine [http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf Clinical Examination of the Hand and Wrist Available] from:http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf</ref> | [[Dupuytren’s Contracture|Dupuytren’s]] Contractures | ||
[[File:RA Hand 2.png|right|frameless]] | |||
[[Hand Rheumatoid Arthritis|Rheumatoid Arthritis]] - MCP swelling, Swan neck deformities, Ulnar deviation at MCP joints, Nodules along tendon sheaths.<ref name=":0">Shane Cass, DO UNM Primary Care Sports Medicine [http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf Clinical Examination of the Hand and Wrist Available] from:http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf</ref> (see R) | |||
<br>3. Muscle wasting due to nerve disfunction<br> | <br>3. Muscle wasting due to nerve disfunction<br> | ||
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Radial Styloid | Radial Styloid | ||
Scaphoid | [[Scaphoid]] | ||
1st MC/Trapezium jt | 1st MC/Trapezium jt | ||
Lunate | [[Lunate]] | ||
Lister’s Tubercle | Lister’s Tubercle | ||
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Ulnar Styloid | Ulnar Styloid | ||
TFCC | [[Triangular Fibrocartilage Complex Injuries|TFCC]] | ||
Triquetrum | Triquetrum | ||
Pisiform | [[Pisiform]] | ||
Hook of Hamate | Hook of [[Hamate]] | ||
Guyon’s Tunnel | Guyon’s Tunnel<ref name=":0" /> | ||
'''Palpation of Hand''' | |||
'''Bone''' - Metacarpals - 5, Phalanges - 14, Palpate for swelling, tenderness | '''Bone''' - Metacarpals - 5, Phalanges - 14, Palpate for swelling, tenderness | ||
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Hypothenar Eminance (3 muscles of little finger, Atrophy with ulnar nerve compression) | Hypothenar Eminance (3 muscles of little finger, Atrophy with ulnar nerve compression) | ||
Palmar Aponeurosis (Dupuytren’s Contracture)<br>[[File:Palpation.jpg|right|frameless|427x427px]] | Palmar Aponeurosis (Dupuytren’s Contracture)<ref name=":0" /><br>[[File:Palpation.jpg|right|frameless|427x427px]] | ||
=== Neurologic Assessment === | === Neurologic Assessment === | ||
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[[Dermatomes]] - C5-T1 | [[Dermatomes]] - C5-T1 | ||
=== Movement Testing === | === Movement Testing === | ||
[[File:Digit ROM Exercise Handout.jpg|right|frameless]] | |||
If patient is pain free to end range, the physical therapist may choose to apply overpressure. | If patient is pain free to end range, the physical therapist may choose to apply overpressure. | ||
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=== Red [[The Flag System|Flags]] === | === Red [[The Flag System|Flags]] === | ||
[[File:Red Flag Framework Level Concern.JPG|right|frameless]] | |||
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. <br>'''Infections''' | 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. <br>'''Infections''' | ||
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=== Conclusion === | === Conclusion === | ||
Hand and wrist complaints are common presentations to physiotherapy clinics. Some practices are special "hand" clinics. Being able to perform a thorough examination is vital. | Hand and wrist complaints are common presentations to physiotherapy clinics. Some practices are special "hand" clinics. Being able to perform a thorough examination is vital. | ||
* Common acute problems include fractures, tendonitis and trigger finger. | *[[File:Carpal tunnel splint.jpg|thumb]]Common acute problems include fractures, tendonitis and trigger finger. | ||
* Common chronic problems include carpal tunnel syndrome, ganglions and arthritis. | * Common chronic problems include carpal tunnel syndrome, ganglions and arthritis. | ||
* There are three main conditions commonly examined on in this station – osteoarthritis, rheumatoid arthritis and psoriatic arthritis. | * There are three main conditions commonly examined on in this station – osteoarthritis, rheumatoid arthritis and psoriatic arthritis. |
Revision as of 08:34, 3 April 2020
Original Editor - Adam Ruff and Christian Filer as part of the Temple University EBP Project
Top Contributors - Christian Filer, Lucinda hampton, Kim Jackson, Admin, Anas Mohamed, Rachael Lowe, Laura Ritchie, Kai A. Sigel, Tony Lowe, Alan Jit Ho Mak, Shaimaa Eldib, Scott A Burns, Temitope Olowoyeye, Claire Knott, Adam Ruff, Evan Thomas, Scott Buxton, Naomi O'Reilly, WikiSysop, Fasuba Ayobami, Vidya Acharya and Wanda van Niekerk
Introduction[edit | edit source]
The hand and wrist is a series of complex, delicately balanced joints. Function is integral to every act of daily living. It is the most active portion of the upper extremity. A hand and wrist examination done in a structured manner will lead to a correct diagnosis. Remembering that the hand and wrist examination will take in and appreciate that:
• 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[1]
Subjective History[edit | edit source]
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.
Clinical Presentation
- Mechanism of the injury - How the injury occurred and what was the cause eg fall on outstretched hand
- Insidious or sudden injury.
- Handedness, occupation, previous injury
- Location of the pain
- Presence and location of numbness and tingling.
- Aggravating and relieving factors.
- Functional limitations.
- Were any diagnostic test/imaging performed and what were the results?
Objective Examination[edit | edit source]
Screen Proximal Joints[edit | edit source]
Screen proximal structures to determine if they are involved in the patient’s clinical presentation. ie Cervical Shoulder Elbow
Observation[edit | edit source]
Start by watching this 8 minute video of a wrist and hand examination.
Observe upper extremity as patient enters room
- Examine hand in function
- Deformities
- Attitude of the hand
Palmar Surface
- Creases
- Thenar and Hypothenar Eminence
- Arched Framework
- Hills and Valleys
Doral surface
- Hills and Valleys
- Height of metacarpal heads
- Deformities.
Ganglions - Cystic structure that arises from synovial sheath
Boutonniere Deformity
Swan Neck Deformity (see image)
Osteoarthritis - Heberden’s nodes: DIP, Bouchard’s nodes: PIP
Dupuytren’s Contractures
Rheumatoid Arthritis - MCP swelling, Swan neck deformities, Ulnar deviation at MCP joints, Nodules along tendon sheaths.[1] (see R)
3. Muscle wasting due to nerve disfunction
- Median Nerve (depending on area impingement)
Muscle wasting in the thenar eminence, first three and fingers and half the fourth fingers on radial side of the hand.
- 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.
- 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:
Functional Tests[edit | edit source]
Goals - to obtain and quantify an asterisk to assess/reassess after intervention is performed. eg turning door knob, holding a key, initial pain free grip or key grip, opening a jar, turning on tap, lifting saucepan. Grip strength can also be good reliable tool to use (available cheaply on internet).
Palpation[edit | edit source]
Wrist, Dorsal to Volar
Radial Styloid
1st MC/Trapezium jt
Lister’s Tubercle
Ulnar Styloid
Triquetrum
Hook of Hamate
Guyon’s Tunnel[1]
Palpation of Hand
Bone - Metacarpals - 5, Phalanges - 14, Palpate for swelling, tenderness
Soft tissue
- 6 Dorsal Compartments – Transport extensor tendons
!st compartment- De quervains
2nd compartment - Intersection syndrome
Compartment 1 (Most radial) | Compartment 2 | Compartment 3 | Compartment 4 | Compartment 5 | Compartment 6 (Most ulnar) |
---|---|---|---|---|---|
Abductor pollicis longus | Extensor carpi radialis longus | Extensor pollicis longus | Extensor indicis | Extensor digiti minimi | Extensor carpi ulnaris |
Extensor pollicis brevis | Extensor carpi radialis brevis | Extensor digitorum communis |
- 2 Palmar Tunnels – Transport nerves, arteries, flexor tendons
Palmar Aspect - Pisiform and Hamate, Tunnel of Guyon, Carpal Tunnel, Flexor Carpi Radialis, Flexor Carpi Ulnaris
Palm 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 (Dupuytren’s Contracture)[1]
Neurologic Assessment[edit | edit source]
Upper Extremity Nerve Palpation: Goal To reproduce symptoms if a peripheral nerve entrapment diagnosis is suspected.[4]
To palpate the 3 major nerves of the upper extremity refer to the figure below.
Median: Position patient supine, 90 degrees of shoulder abduction and elbow extension. Palpate medially to the bicep (mid humeral). Palpate distally at wrist.
Radial: Upper arm (0 degrees of abduction, palpate proximal to the lateral epicondyle), distal radius, and snuffbox
Ulnar: Upper arm (medial mid humeral area, shoulder 90 degrees of abduction, elbow 120 degrees of flexion) and cubital tunnel
(Adapted from Schmid et al 2009)
Reflexes - C5-C7
Myotomes - C5-T1
Dermatomes - C5-T1
Movement Testing[edit | edit source]
If patient is pain free to end range, the physical therapist may choose to apply overpressure.
Wrist
- Flexion/Extension
- Radial/Ulnar deviation
- 1st CMC
- Extension
- Abduction
- Opposition
Metacarpal-phalangeal (MCP)
- Flexion
- Extension
- Abduction/Adduction
Inter-phalangeal (IP)/Distal IP/Proximal IP
- Flexion
- Extension
Strength Testing[edit | edit source]
- Wrist flexion/extension
- Forearm pronation and supination
- Grip strength
- Key and pinch grip strength
Special Tests[edit | edit source]
The physical therapist may elect to perform various special tests during the physical examination of an individual with wrist or hand complaints. Below are potential tests that may be utilized categorized by possible diagnosis or tissue involvement.
Scaphoid Fracture clinical examination (Anatomical snuff box tenderness; Scaphoid tubercle tenderness; Axial loading of the thumb)
Neurodynamic tests
- Median nerve bias (Upper limb tension test 1 [ULTT] /UpperLimb Tension Test 2a)
- Radial nerve bias (ULTT2b)
- Ulnar nerve bias (ULTT3)
Carpal tunnel syndrome (Carpal compression test; Tinel’s test; Wrist-ratio index)
Scapholunate instability (Scaphoid Shift test)
DeQuervain’s syndrome (Finkelstein Test)
Red Flags[edit | edit source]
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.[5] - Localized tenderness, Pain on active motion, Pain on passive motion, Pain on grip, Pain on supination
Any one of the above findings associated with a history of trauma should be sent for radiographs
Additional potentially serious conditions
- Scapholunate instability
- Arthritedes
- Rheumatoid Arthritis
- Lyme disease
- Tuberculosis
- Peripheral Vascular Disease
- Peripheral Neuropathy
- Hx of trauma, fall on outstretched hand (FOOSH). Older age, >65. The risk is same for men/women
- Upper extremity nerve injuries involving :Median; Radial; Ulnar
Possible Diagnosis Examples from Examination[edit | edit source]
- Carpal Tunnel Syndrome
- Anterior Interosseous Syndrome
- Posterior Interousseous Syndrome
- Distal Radial Fractures
- Osteoarthritis
- First Carpometacarpal Osteoarthritis
- Hand and Wrist Osteoarthritis
- DeQuervain Syndrome
- Radial Tunnel Syndrome
- Compression of the Ulnar nerve at Guyon’s canal
- Non-specific wrist pain (mechanical wrist pain)
- Trigger Finger
- Complex Regional Pain Syndrome
- Triangular Fibrocartilaginous Complex
- Dupuytren’s Contracture
Outcome Measures[edit | edit source]
- DASH:
- Grip Strength, functional test.
- Quick DASH
- Symptom Severity Scale
- Patient Specific Functional Scale
Conclusion[edit | edit source]
Hand and wrist complaints are common presentations to physiotherapy clinics. Some practices are special "hand" clinics. Being able to perform a thorough examination is vital.
- Common acute problems include fractures, tendonitis and trigger finger.
- Common chronic problems include carpal tunnel syndrome, ganglions and arthritis.
- There are three main conditions commonly examined on in this station – osteoarthritis, rheumatoid arthritis and psoriatic arthritis.
- You should therefore be familiar with the changes that each of these conditions can cause.[6]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 Shane Cass, DO UNM Primary Care Sports Medicine Clinical Examination of the Hand and Wrist Available from:http://unmfm.pbworks.com/w/file/fetch/50237999/HandandWristExammaster.pdf
- ↑ Ascension Via Christi Joint-by-Joint Musculoskeletal Physical Exam: Hand and Wrist Available from:https://www.youtube.com/watch?v=DxW0rodKOGs (last accessed 29.3.2020)
- ↑ Wikimedia commons Wrist extensor compartments Available from:https://commons.wikimedia.org/wiki/File:Wrist_extensor_compartments_(numbered).PNG
- ↑ Schmid AB, Brunner F, Luomajoki H, et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord. 2009;10:11.
- ↑ Cevik AA, Gunal I, Manisali M, et al. Evaluation of physical findings in acute wrist trauma in the emergency department. Ulus Travma Acil Cerrahi Derg. 2003;9(4):257-261.
- ↑ Medistudents Wrist and hand examination Available from:https://www.medistudents.com/en/learning/osce-skills/musculoskeletal/hand-wrist-examination/ (last accessed 29.3.2020)
1. Cevik AA, Gunal I, Manisali M, et al. Evaluation of physical findings in acute wrist trauma in the emergency department. Ulus Travma Acil Cerrahi Derg. 2003;9(4):257-261.
2. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976). 2003;28(1):52-62.
3. Schmid AB, Brunner F, Luomajoki H, et al. Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskelet Disord. 2009;10:11.