June 20, 2024

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
Hand examination
Hand examination

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)

Hand deformity in RA

Rheumatoid hand

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
Hand and wrist examination
Tuck’s finger

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

For Flexon tendon Injuries

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

  1. Piano Key test
  2. Grind test: Pushing wrist medially and flexing and extending it under tension
  3. Fovea sign

Details are on this link

Hand and wrist examination adduction
Adduction

Thumb movements

Holding patient hard flat on the table

  1. Flexion: sideways movement across the palm
  2. Extension: ask to stretch to the side
  3. Abduction: Point to ceiling
  4. Adduction: Pinch my finger
  5. Opposition: Touch the little finger
  6. 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

  1. Little finger sometimes –> No independent FDS
  2. 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.

Neurological Examination