Examination, evaluation & Assessment of Wrist and Hand

1. Examination, evaluation & Assessment
of Hand and Wrist
Dr. Abid Ullah PT
Lecturer FIMS
Abbottabad
Email:
dr.abidullahpt@yahoo.com

2. 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

3. 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

4. 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

5.  wrist consist of the distal radius,
 scaphoid (S)
 lunate (L)
 triquetrum (Tri)
 pisiform (P)
 trapezium (Tm)
 trapezoid (Tz)
 capitate (C) and
 hamate (H).
she
Looks
Too
Pretty
Try
To
Catch
her

7. Bony Anatomy
 Phalanges: 14
 Sesamoids: 2
 Metacarpals: 5
 Carpals
 Proximal row: 4
 Distal row: 4
 Radius and Ulna
Lister’s tubercle

8. Radiocarpal Joint
 (RC) joint is enclosed in a loose but strong capsule.
 The biconcave articulating surface is the distal end of
the radius and radioulnar disk; it is angled slightly
volarward and ulnarward.
 The biconvex articulating surface is the combined
proximal surface of the scaphoid, lunate, and
triquetrum.
 the convex proximal row of carpals slides in the
direction opposite the physiological motion of the
hand.

9. Bony Anatomy

10. Midcarpal Joint
 a compound joint between the two rows of carpals.
 The combined distal surfaces of the scaphoid, lunate,
and triquetrum articulate with the combined proximal
surfaces of the trapezium, trapezoid, capitate, and
hamate.

13. ANATOMY
 Muscles /Tendons
 Volar wrist- 6
 Dorsal wrist- 9
 6 compartments
 Volar hand- 10
 Dorsal hand- dorsal
interossei
 Nerves - 3
 Median
 Ulnar
 Radial
 Arteries - 2

21. HISTORY
 Age
 Handedness
 Chief complaint
 Occupation
 Previous injury
 Previous surgery
 Sx related to specific
activities
 What exacerbates
 What improves
 Frequency
 Duration

22. Range of motion
 The wrist complex is biaxial motions of
extension/flexion around coronal axis
 ulnar deviation/radial deviation around an
anteroposterior axis.
 Pronation / supination may found especially at the
radiocarpal joint
 Normal ranges are
 65 to 85 of flexion (average max 70)
 60 to 85 of extension (ave… 70)
 15 to 21 of radial deviation (ave… 20)
 20 to 45 of ulnar deviation (ave…40)

23. PHYSICAL EXAM
 Inspection
 Palpation
 Range of Motion
 Neurologic Exam
 Special Tests

24. Surface Features of Forearm and Wrist
 Ulna
 Radius
 Brachioradialis muscle
 Flexor carpi radialis muscle
 Palmaris longus muscle
 Flexor digitorum superficialis muscle
 Flexor carpi ulnaris muscle
 Radial artery
 Pisiform bone
 Wrist creases
Copyright 2011, John Wiley & Sons, Inc.

25. Ulnar styloid/distal ulna.
Medial aspect of the distal ulna
Site of attachment of ulnar collateral ligament of the wrist
Fractures of the ulnar styloid can lead to instability of the
distal radioulnar joint (DRUJ).
Palpation, supination, pronation
Radial styloid.
Lateral aspect of distal radius
Site of attachment for the brachioradialis tendon and
radial collateral ligament of the wrist.

26. Surface Features of the Forearm and Wrist
Copyright 2011, John Wiley & Sons, Inc.

27. Copyright 2011, John Wiley & Sons, Inc.
Surface Features of the Forearm and Wrist

28. Copyright 2011, John Wiley & Sons, Inc.
Surface Features of the Forearm and Wrist

29. Surface Features of the Hand
 Knuckles
 Dorsal venous network of the hand (dorsal venous arch).
 Tendon of extensor digiti minimi muscle
 Tendons of extensor digitorum muscle

30. Copyright 2011, John Wiley & Sons, Inc.

31. Surface Features of the Hand

32. Surface Features of the Hand

33. INSPECTION
 Observe upper
extremity as patient
enters room
 Examine hand in
function
 Deformities
 Attitude of the hand

34. INSPECTION
Palmar Surface
 Creases
 Thenar and
Hypothenar Eminence
 Arched Framework
 Hills and Valleys
 Web Spaces

35. Cascade sign
 Assure all fingers point
to scaphoid area when
flexed at PIPs

36. Volar Wrist Musculature
 Six muscles have
tendons crossing
the volar aspect of
the wrist and,
therefore, are
capable of creating
a
 wrist flexion
movement

37.  These are
 Palmaris longus (PL),
 flexor carpi radialis (FCR),
 Flexor carpi ulnaris (FCU),
 the flexor digitorum superficialis (FDS),
 flexor digitorum profundus (FDP),
 the flexor pollicis longus (FPL) muscles.
 first three of these muscles are primary wrist muscles.
 last three are flexors of digits with secondary actions
at wrist

38. Figure 9-13 ■ The dorsally
located extensor tendons pass
beneath the extensor
retinaculum, where the tendons
are compartmentalizd. From the
radial to the ulnar side, APL, EPB
muscles share a compartment;
ECRB ,ECRL muscles share a
compartment (EPL) muscle has a
compartment of its own; the four
tendons of (EDC)
share a compartment with the
extensor (EIP) (EDM) and the
extensor carpi ulnaris (ECU) has
its own compartment

39. 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

40. Ganglion
 Cystic structure that
arises from synovial
sheath
 Discrete mass
 Dull ache
 Dorsal or Volar aspect

41. Boutonniere Deformity
 Tear or stretch of the
central extensor
tendon at PIP
 Note: unopposed
flexion at PIP
 Extension at DIP
 Trauma or
inflammatory
arthritis

42. Osteoarthritis
 Heberden’s nodes:
DIP
 Bouchard’s nodes:
PIP

43. Rheumatoid Arthritis
 MCP swelling
 Swan neck deformities
 Ulnar deviation at MCP
joints
 Nodules along tendon
sheaths

44. Mallet Finger
 Hyperflexion injury
 Ruptured terminal
extensor mechanism at
DIP
 Incomplete extension
of DIP joint or extensor
lag
 Treatment:
 stack splint

45. Dupuytren’s Contractures
 Palmar or digital
fibromatosis
 Flexion contracture
 Painless nodules near
palmar crease
 Male> Female
 Epilepsy, diabetes,
pulmonary dz,
alcoholism

46. Carpal Tunnel
 The median nerve and the finger flexion tendons lie
within the carpal tunnel.
 This is a common site of compression neuropathy.

47. Carpal Tunnel

48. Guyon’s Canal
(Ulnar Tunnel)
 The ulnar nerve and artery lie within Guyon’s tunnel.
 This is also a common site of compression neuropathy.

49. Guyon’s Canal
(Ulnar Tunnel)

50. Carpal Tunnel Syndrome
 Carpal tunnel syndrome is a compression neuropathy
of the median nerve.
 Compression occurs under the flexor retinaculum at
the wrist.

51. Carpal Tunnel Syndrome

52. Carpal Tunnel Syndrome
 Clinical Signs and Symptoms
 Loss of sensation of the tips of the first three fingers
 Hand and wrist pain
 Weakness of grip

53. Tinel’s Wrist Sign
 Procedure: Patient’s hand supinated. Stabilize the
wrist with one hand. With your opposite hand, tap the
palmar surface of the wrist with a neurological reflex
hammer.
 Rationale: Tingling along the distribution of the
medial nerve indicates carpal tunnel syndrome. The
cause could be any of the following: inflammation of
the flexor retinaculum, anterior dislocation of the
lunate bone, arthritic changes, or tenosynovitis of the
flexor digitorum tendons.

54. Tinel’s Wrist Sign

55. Phalen’s Test
 Procedure: Flex both wrist and approximate them
towards each other. Hold for 60 seconds.
 Rationale: When both wrists are flexed, the flexor
retinaculum provides increased compression of the
medial nerve in the carpal tunnel. Tingling in the
distribution of the median nerve (thumb, index finger,
middle finger, and medial half of ring finger) indicates
carpal tunnel syndrome.

56. Phalen’s Test

57. Reverse Phalen’s Test
 Procedure: Instruct the patient to extend the affected
wrist and have him grip your hand. With your
opposite thumb, press on the carpal tunnel.
 Rationale: Extending the hand and providing pressure
over the carpal tunnel further constricts the tunnel.
Tingling may indicate compression of the medial
nerve.

58. Reverse Phalen’s Test

59. Ulnar Tunnel Syndrome
 The ulnar nerve travels through the tunnel of Guyon
and innervates the muscles of the little and ring
fingers.
 Ulnar nerve syndrome is a compression neuropathy of
the ulnar nerve.

60. Guyon’s Canal (Ulnar Tunnel)

61. Ulnar Tunnel Syndrome
 Clinical Signs and Symptoms
 Pain over the little and ring finger
 Weakness of grip
 Difficulty with finger spreading
 Claw hand

62. Ulnar Tunnel Triad
 Procedure: Inspect and palpate the patient’s wrist,
looking for tenderness over the ulnar tunnel, clawing
of the ring finger, and hypothenar wasting.
 Rationale: All of these signs are indicative of ulnar
nerve compression possibly in the tunnel of Guyon.

63. Ulnar Tunnel Triad

64. Stenosing Tenosynovitis
 Stenosing tenosynovitis in the wrist affects the tendon
and sheath of the abductor pollicis longus and
extensor pollicis brevis.
 It is also termed de Quervain’s or Hoffman’s disease.
 Swelling of the tendons and thickening of the sheaths
that they pass through is due to an overuse condition
of the wrist and thumb.

65. Stenosing Tenosynovitis
 Clinical Signs and Symptoms
 Painful wrist and thumb during movement
 Swelling over the radial styloid
 Tendons and sheath tender to palpation

66. Stenosing Tenosynovitis

67. Finkelstein’s Test
 Procedure: Instruct the patient to make a fist with the
thumb across the palmar surface of the hand and to
stress the wrist medially.
 Rationale: Making a fist and stressing it medially will
stress the abductor pollicis longus and extensor
pollicis brevis tendons. Pain in the distal styloid
process of the radius indicates stenosing tenosynovitis
of the tendons (de Quervain’s disease).

68. Finkelstein’s Test