Hand and Wrist Examination is done to identify the different pathologies in hand and wrist like nerve, tendon injuries, deformities, contractures, and many more.
IMPORTANT CASES in Hand and Wrist
- Medial/ Radial/ Ulnar Nerve Injuries
- Untreated Tendon Injuries
- Malunited Distal Radius Fractures
- Volkmann’s Ischemic contracture
- Madelung Deformity
- Dupuytren’s contracture
Inspection
See the cascade in resting position: MCP slightly flexed with index finger 30° and little finger 70°
If cascade is normal but the movement is not then there is suspected Nerve Injury
Expose from the arm to the hand
Both upper limbs should be examined side by side in a similar fashion from the dorsal, volar, radial, and ulnar surfaces.
Put hand over the clear background(pillow).
Look shape of the Hand and its size proportional to the rest of the patient.
Look for Nail changes and orientation
Examples:
- Achondroplasia: Finger short/ stumpy
- Acromegaly: Large/ course
- Marfans: Long proximal phallanges
- Turners: Ring metacarpal is short
- Hyperparathyroidism: Fingertips short/ bulbous
- Down and Hurlers: Little finger incurved
- Paget disease/ Neurofibromatosis: Hypertrophy of fingers
Fusiform swelling at IP joints= RA, collateral tears, Gout, TB, etc
Mallet finger/ thumb:- Rupture of EPL (a late complication of Colles fracture)
Flexion of the finger at PIP/ DIP with nodular thickening in palm and finger –> Dupuytren’s contracture
Flexion at PIP joint with nodular thickening (palpable)= Trigger finger
Intrinsic Hand (+/-)
Ulnar deviation of hand/ Hypothenar wasting
Look for Heberden’s nodes/ Bouchard’s nodes
Look for Sinus, Scar, Skin condition, Ulnar and venous prominence
Look for Ganglionics
Palpation
Look for Temperature and tenderness
Look for Tenderness:
- Scaphoid: Ulnar deviation of wrist/ waist and palpation on anatomical snuff box, Along FCR tendon-> in the wrist (tubercle), Proximal pole -> Just distal to lister tubercle
- Lunate: Palmer flex wrist = palpate in line of 3rd metacarpal
- Pisiform: Along FCU tendon
- Trapezium: Just below 1st Metacarpal
- Trapezoid: Just below 2nd metacarpal
- Capitate: Just below 3rd metacarpal
- Hamate: Just distal pisiform and in line of 2nd metacarpal head
- Quervain’s Disease: Radial styloid over the tendon of APL/ EPB
- Ulnar styloid: TFCC
- Dorsally in the axis of 3rd finger: Perilunate/ Lunate=> Keinbock’s disease
- The base of 1st Metacarpal: Bennet fracture/ Carpometacarpal OA
Palpate individual finger joints:- Thickening, Tenderness, Edema, Increase Local Heat
Try to tuck each finger into the palm:- Ask the patient to repeat it unaided
Passive loss due to:-Joint, Tendon adhesion, arthritis
Active loss:- Nerve/ tendon discontinuity
DRUJ instability/ subluxation
Joint line Palpation in hand and wrist areas
Palpate in sequential order:
Patient elbow flexed and forearm pronated
Use the dominant hand to hold the patient palm
Put:
- Thump in dorsum
- Index in forearm
- 3/4/5 finger => Supporting thenar and hypothenar
Then use a non-dominant hand:- 2,3,4 finger tip=> Start palpating the base of metacarpal
Gradually moving proximally
While your dominant hand alternatively dorsiflex and palmer flex
At the inter-styloid line, we will feel a gap that opens and close with wrist movements
Movements
Normal MCP Joint movement (0-90°) But passively hyperextended up to 45°
PIP Joint: 0-100°
DIP Joint: 0-80°
Mould: A length of malleable wire over fingers ( approx 2 mm diameter)
Wire transferred to the case record and outline drawn around it
Measure with Goniometer
Ask the patient to make a fist: Normally distal phalanges should tuck in; touching the palm at the right angle
( Greater reduction of movement will prevent the finger from reaching the palm)–> Impair ability to grasp/ hold
Distance may be measured by noting the distance that the finger stands proud of the palm in maximum flexion.
Thump
IP joint (N) flexion = 80°, (N) Hyperextension = 20° ( total range 100°)
MP Joint (N) flexion = 55°, (N) Hyperextension = 5° (total range 60°)
1st CMC Joint (N) flexion =15°, (N) extension = 20°
Abduction of thump= Place of the right angle to palm ( Patient attempts to point thumb to ceiling); Normal=60°
Opposition: Normal thumb should be able to touch the little finger. Loss of opposition may be assessed by the distance between thumb and little finger
Wrist
PASSIVE MOVEMENTS
Wrist dorsiflexion:- Namaste position , Normal=0-75°
Palmer flexion:- Reverse Namaste, Normal = 75°
Check for hypermobility:
Radial Deviation: Angle formed by the forearm and middle metacarpal [ Normal= 20°]
Ulnar Deviation: Same way [ Normal=35°]
Pronation (75°)/ Supination (80°)
ACTIVE MOVEMENTS
Pull hand backward (extension), forward as possible (flexion), deviations, active pronations, and supination
Measurements
Length of forearm
Girth or wrist and joint line and forearm
Joint thickening (Circumferential)
Special Tests in Hand and Wrist
Tendon Injuries
FDL/EPL: Grasp patient just below IP joint:- Immobile
Repeat patient to flex and extend
Extensor tendons
- Ask the patient to extend the fingers
- Any posterior tendons divided into the dorsum of the hand/ finger will be obvious by the lack of extension into the fingers
- To access the distal slip
- Grasp the middle phalanx and ask the patient to try to extend the DIP joint
- Details in Extensor Tendon
Elson’s’ middle Slip test
- Flex PIP joint over the edge of the table
- PIP extension occurs in the middle slip is intact
- If middle slip rupture–> Extension of PIP does not occur
Assessment of hand function
Pinch Grip
- Pick a small object between the tip of your thumb and index
- The intact sensation is necessary for it
- Ask to repeat the test with eyes closed
- If the tip of the adjacent middle finger can assist (Chuck grip)
Key Grip
- Grip a key between the thump and side of the index in a normal fashion
- Test the firmness of the grip by attempting to withdraw the key using your own pinch
Grasp
- Ask patients to grasp a pen firmly in hand
- Attempt to withdraw pen and note resistance offered
Palmar Grasp
- Test cupping action of the hand
- Grasp small ball in hand
- Check patient ability to resist ball being withdrawal
Grasp Wrist
- Flex and extend fingers actively by patients
- Crepitus is fine in character in tenosynovitis of extensor tendons
Ausculatation of tendon=> Grating sound=> De Quervian tenosynovitis
De Quervian tenosynovitis= Finkelstein test
Carpal tunnel syndrome
Important tests
Durkan’s test
Phalen test
Reverse Phalen test
Tinel’s sign
Sensory distribution over the thenar
The tone of thenar muscle
Slide the tip of the index finger across the palm:- Noting frictional resistance and temperature
An increase in thenar resistance ( from lack of sweating) and temperature rise (vasodilation) may occur with median nerve involvement
Details on Carpal Tunnel Syndrome and tests
Ulnar Tunnel Syndrome
Signs:
- Abduction of the little finger
- Tenderness over tunnel
- Clawing of ring/ middle finger
Examination:
Tenderness over tunnel
- Weakness of adduction with normal abduction (CARD TEST)
- Sensory impairment in hypothenar aspects
Details on Ulnar Nerve Examination
Carpal Instability
Watson test
Scapholunate instability
Press with your thumb the tubercle of the scaphoid
And with another hand, Palmer flex and radially deviate the patient’s wrist
Click should be felt if scaphoid subluxed over distal radius and reduction should occur if the pressure of thumb is released
Accompany pain: Confirmatory
Ballottement test
Lunotriquetral instability
Triquetral and lunate are grasped between the thumb and index of the examiner’s hand ( 2 Hands)
Attempts were made to displace them relative to one another (dorsally/ volar)
Pain/ Crepitus => (+)
Mid-carpal Instability (Pivot Shift Test)
One hand steadily distal forearm
Other grasping patient hands
Push carpus against radius and gently swing from full radial deviation to ulnar deviation
The test is positive if normal smooth movement is irregular with for example accompanying clucking sensation
DRUJ Injury
- Piano Key test
- Grind test: Pushing wrist medially and flexing and extending it under tension
- Fovea sign
Thumb movements
Holding patient hard flat on the table
- Flexion: sideways movement across the palm
- Extension: ask to stretch to the side
- Abduction: Point to ceiling
- Adduction: Pinch my finger
- Opposition: Touch the little finger
- Retroposition: Lifting thumb backward
Test for Muscle and Tendon
Assist in flexion of MCP joint:
- Flexor digitorium profundus (FDP)
- Flexor digitorium superficialis (FDS)
Intrinsic muscle: Main MCP flexors
To test FDP–> PIP Joint is held immobilized in extension and the patient is asked to bend the finger
To test FDS–> FDP is 1st Inactivated; otherwise one cannot tell which tendon is flexing PIP
This is done by grasping all the fingers, except the now being examined, and holding them firmly in full extension because profundus tendons share a common muscle belly
So, this maneuver automatically prevents all the profundus tendons particularly in finger flexion
TWO EXCEPTIONS
- Little finger sometimes –> No independent FDS
- Index finger –> Often has entirely separate FDP
Which cannot be inactivated by the usual mass action maneuver instead
Flexor superficialis is tested by asking the patient to pinch the hand with the DIP joint in full extension and PIP in full flexion.
Position can be maintained only if the superficial is active and intact.
