Clinical Examination
of the
Hand and Wrist
A.Mazaherinezhad
MD. Sportsmedicine Department,
Assistant professor, IUMS
IUMS
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
IUMS
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
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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
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Bony
Anatomy
Phalanges: 14
Sesamoids: 2
Metacarpals: 5
Carpals
Proximal row: 4
Distal row: 4
Radius and Ulna
Lister’s
tubercle
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HISTORY
Age
Handedness
Chief complaint
Occupation
Previous injury
Previous surgery
Sx related to
specific activities
What exacerbates
What improves
Frequency
Duration
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HISTORY
4 principle
mechanisms of injury
Throwing
Weight bearing
Twisting
Impact
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EXAMINATION OF THE HANDS, FINGERS
AND WRIST
INITIAL STEPS
INSPECTION
SWELLING
REDNESS
ATROPHY
PALPATION
TENDERNESS
WARMTH
RANGE OF MOTION
FLEXION
EXTENSION
COMPARE OPPOSITE SIDE
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PHYSICAL EXAM
Inspection
Palpation
Range of Motion
Neurologic Exam
Special Tests
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INSPECTION
Observe upper
extremity as patient
enters room
Examine hand in
function
Deformities
Attitude of the hand
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INSPECTION
Palmar Surface
Creases
Thenar and
Hypothenar
Eminence
Arched Framework
Hills and Valleys
Web Spaces
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Cascade sign
Assure all fingers
point to scaphoid
area when flexed at
PIPs
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INSPECTION of Dorsal
Hand and Wrist
Hills and Valleys
Height of metacarpal heads
Finger nails
Pale or white=anemia or circulatory
Spoon shaped=fungal infection
Clubbed=respiratory or congenital heart
Deformities
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Ganglion
Cystic structure
that arises from
synovial sheath
Discrete mass
Dull ache
Dorsal or Volar
aspect
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Boutonniere Deformity
Tear or stretch of
the central
extensor tendon at
PIP
Note: unopposed
flexion at PIP
Extension at DIP
Trauma or
inflammatory
arthritis
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Swan Neck Deformity
Contraction of
intrinsic muscles
(trauma, RA)
NOTE: Extension at
PIP
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Osteoarthritis
Heberden’s nodes:
DIP
Bouchard’s nodes:
PIP
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Rheumatoid Arthritis
MCP swelling
Swan neck
deformities
Ulnar deviation
at MCP joints
Nodules along
tendon sheaths
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Mallet Finger
Hyperflexion injury
Ruptured terminal
extensor mechanism
at DIP
Incomplete
extension of DIP
joint or extensor lag
Treatment:
stack splint
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Dupuytren’s Contractures
Palmar or digital
fibromatosis
Flexion contracture
Painless nodules near
palmar crease
Male> Female
Epilepsy, diabetes,
pulmonary dz,
alcoholism
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RANGE OF MOTION
Active range of motion
Passive range of motion if unable to
actively move joint
Bliateral comparison
To determine degrees of restriction
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RANGE OF MOTION
Wrist
Flexion
Extension
Radial deviation
Ulnar deviation
Ulnar deviation is
greater than radial
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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°.
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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.
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Figure 2:
Measurement of
supination.
The horizontal
arm is placed on
the volar surface
of the wrist.
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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°.
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Figure 4:
Masurement of extension:
The goniometer is placed
anteriorly on the wrist.
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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.
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The dominant hand is usually 5 to 10%
stronger than the non-dominant hand.
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RANGE OF MOTION
Fingers
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
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CLINICAL EXAMINATION OF
THE WRIST
The 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
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PALPATION of Skin
Warmth?
Dryness?
Anhydrosis= nerve damage
Scars
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PALPATION of Wrist
Dorsum
Radial Styloid
Scaphoid
1st MC/Trapezium
jt
Lunate
Lister’s Tubercle
Ulnar Styloid
TFCC
Triquetrum
Pisiform
Hook of Hamate
Guyon’s Tunnel
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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
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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.
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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.
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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 Lister`s 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.
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Ulnar Styloid palpation
Lister’s Tubercle palpation
Ulnar
styloid
Figure 6:
Figure 7:
Main palpable bony
structures on the
dorsal surface of the
wrist (redrawn
after.)
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To examine a
wrist
correctly, one
should
mentally
project the
bones onto
the skin.
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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.
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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
.
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Radial Styloid palpation
Scaphoid Bone palpation
Radial
styloid
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1
MC/Trapezium joint
palpation
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Figure 8:
Figure 9:
The cutaneous projection of
the anatomical snuffbox.
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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.
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The radial part of this groove, just
ulnar to the extensor pollicis longus
tendon, is what is termed the STT
entry point
(scaphotrapeziotrapezoidal) for midcarpal arthroscopy.
Figure 10:
The midcarpal joint can be palpated
through the groove between the
scaphoid and the trapezium and
trapezoid bones.
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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 Lister`s 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.
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Lunate Bone palpation
IUMS
Ulnar and distal to the scapholunate
space lies a concavity which
corresponds to the neck of the
capitate .
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.
Figure 11:
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IUMS
(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.
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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.
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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
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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 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.
Figure 11:
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The midcarpal joint
can be palpated
through the groove
between the scaphoid
and the trapezium
and trapezoid bones.
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Triquetrum Bone palpation
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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).
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Figure 13:
The ulnar "anatomical snuffbox".
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PALPATION
Palmar Aspect
Pisiform and Hamate
Tunnel of Guyon
Ulnar Artery
Carpal Tunnel
Flexor Carpi Radialis
Flexor Carpi Ulnaris
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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.
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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)
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Tunnn
el of
Guyon
Pisiform
and Hamate
palpation
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
Figure 16:
The hamulus ossi hamatum (hook of the
of the distal flexion wrist
hamate) is palpated deeply, 2 cm below
crease.
the pisiform bone, on a line joining the
pisiform to the head of the second
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metacarpal bone.
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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
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Flexor carpi
ulnaris
Palmaris longus
Flexor carpi
radialis
Volar flexor
tendons
Thumb CMC Joint Arthritis
Painful pinch or
grasp
“Grind Test”
Axial pressure to
thumb while
palpating CMC joint
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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
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Triangular Fibro-Cartilage
Complex palpation (TFCC)
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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
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PALPATION of HAND
Bone
Metacarpals - 5
Phalanges - 14
Palpate for swelling, tenderness
Assess for symmetry
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PALPATION
Soft tissue
6 Dorsal
Compartments
Transport extensor
tendons
2 Palmar Tunnels
Transport nerves,
arteries, flexor
tendons
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1st Dorsal Compartment
Abductor Pollicis Longus and
Extensor Pollicis Brevis
Radial border of Anatomic
Snuff Box
Site of stenosing
tenosynovitis
De Quervain’s Tenosynovitis
Finkelstein’s Test
IUMS
DeQuervain’s Tenosynovitis
Inflammation of
EXT Pollicis Brevis
and ABD Pollicis
Longus tendons
Tenderness 1st Dorsal
Compartment
Finkelstein’s Test
5 FINKELSTEINS TEST.mpg
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DeQuervain’s Tenosynovitis
2nd Dorsal Compartment
Extensor Carpi Radialis
Longus and Extensor Carpi
Radialis Brevis
Make fist—becomes
prominent
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Intersection Syndrome
(Squeaker Wrist)
Similar to DeQuervain’s
tenosynovitis
Peritendinitis related to
bursal inflammation at the
junction of the 1st and 2nd
dorsal compartments
Overuse of the radial
extensor of the wrist
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Intersection Syndrome
(Squeaker Wrist)
Seen in gymnasts, rowers,
weightlifters, racket sports
Proximal to DeQuervain’s- 4-6 cm
from radiocarpal joint
Crepitation or squeaking can be heard
with passive or active ROM
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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
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4th Dorsal Compartment
Extensor Digitorum
Communis and Extensor
Indicis
Palpate from the carpus to
the metacarpophalangeal
joints
Frequent site of ganglion
cysts
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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
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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
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Carpal Tunnel
Deep to palmaris
longus
Contains median
nerve and finger
flexor tendons
Most common
overuse injury of
the wrist
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Carpal Tunnel Syndrome
Entrapment of the median nerve
Phalen’s and Tinel’s Test
2 point discrimination
Symptoms
Aching in hand and arm
Nocturnal or AM paresthesias
“Shaking” to obtain relief
IUMS
Carpal Tunnel Tests
Neurologic exam
Median nerve
sensation and motor
Phalen’s Test:
both wrists
maximally flexed for
1 minute
Tinel’s Test
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PALPATION
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
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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
IUMS
SPECIAL TESTS
Long 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
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Flexor Tendon Injury
“Jersey Finger”
Avulsion injury
from rapid passive
extension of the
clenched fist
Loss of flexion at
PIP and/or DIP
“+” sublimus or
profundus tests
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Trigger Finger
Stenosing flexor
tenosynovitis
Painful snap or lock
Palpate nodule as
digit flexed and
extended
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Flexor Tenosynovitis
Tendon sheath infection
Usually due to a puncture wound
Bacterial skin flora
Relative surgical emergency
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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
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RANGE OF MOTION
Thumb
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
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Skier’s Thumb
Gamekeeper’s Thumb
Ulnar Collateral
Ligament rupture
of the thumb MCP
joint
Instability, weak
and ineffective
pinch
Radially directed
stress at MCP
joint-stable if
opens <35 degrees
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NEUROLOGIC EXAM
Muscular assessment using grading
system
Sensation testing
Bilateral comparison
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NEUROLOGIC EXAM
Muscle Testing
WRIST
EXT C6
FLEX C7
FINGERS
EXT C7
FLEX C8
ABD T1
ADD T1
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Sensation Testing
Dorsal hand
Radial hand
C-5 NEUROLOGIC LEVEL
SHOULDER
ABDUCTION
BICEPS
LATERAL ARM
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C-6 NEUROLOGIC LEVEL
WRIST
EXTENSION
BRACHIORADIALIS
LATERAL FOREARM
108
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C-7 NEUROLOGIC LEVEL
WRIST FLEXION
FINGER EXTENSION
TRICEPS
MIDDLE FINGER
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C-8 NEUROLOGIC LEVEL
FINGER FLEXION
MEDIAL FOREARM
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T-1 NEUROLOGIC LEVEL
FINGER ABUCTION
MEDIAL ARM
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THE ALLEN TEST
1
2
3
4
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)
IUMS
RADIOLOGIC STUDIES
AP and Lateral of
hand and wrist
Consider Obliques
and special views if
fracture suspected
but not seen on AP
and Lateral
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EXAMINATION OF RELATED
AREAS
Referred pain can be
due to:
Herniated cervical
discs
Osteoarthritis
Brachial plexus outlet
syndrome
Elbow and shoulder
entrapment syndrome
IUMS
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 .
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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.
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(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 .
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(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.
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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.
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(4) The wrist-flexion fingerextension
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.
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(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.
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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)
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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.
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Figure 22: The Watson's test.
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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 .
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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.
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Figure 23:
The lunotriquetral
ballottement test
(Reagan's test)
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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.
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Figure 24:
The Kleinman's
test.
147
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.
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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].
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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.
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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.
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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.
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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.
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Figure 29:
The radioulnar ballottement
test.
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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.
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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.
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QUESTIONS
IUMS