Wrist & Hand
Assessment and General View
Done by;
Mshari S. Alghadier
BSc Physical Therapy
RHPT 366
m.alghadier@sau.edu.sa
http://faculty.sau.edu.sa/m.alghadier/
Wrist and hand, RHPT 366, M.G
1/28/13
Functional anatomy
¤ The hand can be divided into two major
parts:
¤  The wrist.
¤  Five digits.
¤  Composed of eight small bones.
¤  It can accommodate movement in three planes.
¤  The greatest degree of freedom is in;
¤  Flexion–extension plane.
¤  Ulnar–radial deviation.
¤  Rotation about the long axis of the forearm.
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
¤  Because of its vascular supply, fracture of the scpahoid
can lead to avascular necrosis and collapse of the
proximal half of that bone.
¤  This damage leads to impairment of wrist function and
progressive osteoarthritis of the wrist joint.
¤  The carpal tunnel, which contains the median nerve
together with the flexor tendons of the digits, and the
tunnel of Guyon, which contains the ulnar nerve.
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
¤  Compression injury of the ulnar nerve will affect the
medial aspect of the hand, with the ulnar intrinsic
muscles of the hand.
¤  This muscular compromise will lead to classic posturing of
the digits called the benediction hand, referring to the
appearance of a priest’s hand when giving a blessing.
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
The benediction hand
deformity results from
damage to the ulnar
nerve. There is wasting
of the interosseous
muscles, the
hypothenar muscles,
and the two medial
lumbrical muscles.
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Wrist and hand, RHPT 366, M.G
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Functional anatomy
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Wrist and hand, RHPT 366, M.G
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Observation
¤ The examination should begin in the waiting
room.
¤ Is the arm relaxed at the side or is the patient
cradling it for protection?
¤  Note whether the wrist or hand is edematous.
¤  Note the shape of the hand and if there are any
changes in contour.
¤  Any deformity.
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Wrist and hand, RHPT 366, M.G
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Observation
The patient may have a swan neck, boutonni`ere
deformity, or claw fingers
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Wrist and hand, RHPT 366, M.G
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Observation
¤  Compare one hand to the other, remembering that the
dominant hand may be larger in the normal individual.
¤  Will he or she allow you to shake their hand?
¤  Is the movement effortless and coordinated or stiff and
uncoordinated?
¤  Watch the patient if he/she push ups and use his hands
to stand from sitting.
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Wrist and hand, RHPT 366, M.G
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Observation
Clubbing and cyanosis of the nails may be
secondary to pulmonary disease.
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Wrist and hand, RHPT 366, M.G
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Observation
¤  Posture and standing position.
¤  Note the height of the shoulders and their relative
positions.
¤  Arm swing can be limited by either loss of motion, pain, or
neurological damage.
¤  Observe for symmetry of bony structures.
¤  Observe for areas of muscle wasting that may be
secondary to peripheral nerve lesions.
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Wrist and hand, RHPT 366, M.G
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Subjective Examination
¤  The wrist and hand are extremely active structures and
complicated.
¤  Non-weightbearing, problems are;
¤  Overuse syndromes, inflammation, and trauma.
¤  Nature and behavior, location and onset of pain.
¤  Functional limitation and what is the dominant hand.
¤  Does the patient regularly participate in any vigorous
sport activity that would stress the wrist or hand?
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Wrist and hand, RHPT 366, M.G
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Subjective Examination
¤  What is the patient’s occupation “computer”??
¤  If there is a trauma?
¤
¤
¤
¤
What was the mechanism of the injury?
The direction of the force.
The position of the upper extremity.
The activity the patient was participating in at the time of
the injury.
¤  Previous history of the same injury?
¤  The most common nerve roots that refer pain are
C6, C7, C8, and T1.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
¤ The palpatory examination is started with the
patient in the sitting position.
¤ You should first examine for areas of;
¤  Localized effusion, discoloration, birthmarks, open sinuses or
drainage, incisions, bony contours, muscle girth and
symmetry, and skinfolds.
¤ Use firm and gentle pressure to allocate the
malposition or deformities.
¤ If you harm the Pt in this part of examination the
Pt will be afraid and you’ll lose his confidence.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
¤  The sitting position with the extremity supported on a
table is preferred for ease of examination of the wrist and
hand.
¤  For palpation, the hand should be in the anatomical
position.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
A.  Anterior (palmar) aspect;
1.  Boney Structures;
¤  Thick skin and fascia covered the palm.
2.  Soft-Tissue Structures;
¤  Many sweat glands but free of hair.
¤  Medial (Ulnar) Compartment;
¤  Flexor Carpi Ulnaris.
¤  Ulnar Artery.
¤  Ulnar Nerve.
¤  Hypothenar Eminence.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
¤  Middle compartment;
¤  Palmaris Longus.
¤  Flexor Digitorum Profundus and Superficialis.
¤  Carpal Tunnel.
¤  Palmar Aponeurosis.
¤  Lateral (Radial) Compartment;
¤  Flexor Carpi Radialis.
¤  Radial Artery.
¤  Thenar Eminence.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
B.  Medial (Ulnar) Aspect;
1.  Bony Structures;
¤
¤
¤
¤
Ulna Styloid Process.
Triquetrum.
Pisiform.
Hamate.
2.  Soft-Tissue Structures;
¤  Triangular Fibrocartilaginous Complex.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
C.  Lateral (Radial) Aspect;
1.  Bony Structures;
¤  Radial Styloid Process.
¤  Scaphoid (Navicular).
¤  Trapezium and Trapezoid (Greater and Lesser
Multangular).
¤  First Metacarpal.
2.  Soft-Tissue Structures;
¤  Anatomical Snuffbox.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
D.  Posterior (Dorsal) Aspect;
1.  Bony Structures;
¤
¤
¤
¤
¤
¤
¤
Dorsal Tubercle of the Radius (Lister’s Tubercle).
Lunate.
Capitate.
Metacarpals.
Metacarpophalangeal Joints.
Phalanges and Interphalangeal Joints.
Nails.
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Wrist and hand, RHPT 366, M.G
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Gentle palpation
2.  Soft-Tissue Structures;
¤
¤
¤
¤
¤
¤
¤
Extensor Retinaculum.
Compartment I.
Compartment II.
Compartment III.
Compartment IV.
Compartment V.
Compartment VI.
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Wrist and hand, RHPT 366, M.G
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Special Tests
A.  Tests for ligament, capsule & joint
instability;
¤  Watson’s (Scaphoid shift) Test;
¤
¤
¤
¤
This test is used to diagnose abnormal separation of the
lunate and scaphoid bones.
The examiner takes the patient wrist into ulnar deviation
and slight extension with one hand.
The examiner presses the thumb of the other hand against
the scaphoid to prevent it from moving toward the palm.
With other hand, examiner radially deviates and slightly
flexes the patient’s hand while maintain the pressure on
scaphoid.
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Wrist and hand, RHPT 366, M.G
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The Watson’s Test
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Wrist and hand, RHPT 366, M.G
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Special Tests
B.  Tests Tendons and Muscles;
1)  Bunnel–Littler Test (Intrinsic Muscles Versus
Contracture);
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¤
¤
¤
¤
¤
Tests the structures around the matacarpophalangeal joint.
Meatacarpophalangeal joint held slightly extended while the
examiner moves the proximal interphalangeal joint into flexion.
Positive; inability to flex the proximal interphalangeal joint, due
to tight intrinsic muscle or contracture of the joint capsule.
If the metacarpophalangeal joints are slightly flexed, the
proximal interphalageal joints flexes fully if the intrinsic muscle
are tight.
But it dose not flex fully if the capsule is tight.
http://www.youtube.com/watch?v=ClhZtaDxExs
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Wrist and hand, RHPT 366, M.G
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Special Tests
2)  Finkelstein’s Test (de Quervain’s or Hoffmann’s
Syndrome);
¤  This test is used to diagnose tenosynovitis of the first
dorsal compartment of the wrist, which contains the
tendons of the abductor pollicis longus and extensor
pollicis brevis muscles.
¤  Having the patient place the thumb inside the closed
fist.
¤  Take the patient’s hand and deviate the hand and
wrist in the ulnar direction to stretch the tendons of the
first extensor compartment.
¤  Pain over the radial styloid process is pathognomonic
of de Quervain’s syndrome.
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Wrist and hand, RHPT 366, M.G
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Special Tests
C.  Tests for neurological
dysfunction;
1)  Tinel’s Sign (at the wrist);
The examiner taps over the carpal
tunnel over the wrist, positive test
cause tingling or paresthesia into the
thumb and index finger, and middle
and lateral half of the ring finger.
¤  Its indicative for carpal tunnel
syndrome.
¤  It should be distally to the point
being pressed.
¤
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Wrist and hand, RHPT 366, M.G
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Special Tests
D.  Tests for circulation and swelling;
¤  Allen’s Test;
¤
¤
Used to check the patency of the radial and ulnar arteries
at the level of the wrist.
http://www.youtube.com/watch
v=oYCRz1VAEhI&feature=related
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Wrist and hand, RHPT 366, M.G
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Special Tests
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Wrist and hand, RHPT 366, M.G
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Want to do!
1.
Tennis elbow.
2.
Golfer elbow.
3.
Carpal Tunnel syndrome.
4.
Major hand deformity.
5.
De Quervain’s Syndrome
6.
Medial & Lateral Epicondlytis.
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Wrist and hand, RHPT 366, M.G
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Thank you
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Wrist and hand, RHPT 366, M.G
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References,
¤  Musculoskeletal Examination, 3rd Edition Jeffrey M. Gross,
chapter 10.
¤  Orthopedic Physical Assessment, 5th edition, David J.
Magee, chapter 7.
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